Patients with uveitis who require cataract surgery present challenges to the surgeon at every stage of care. The uveitis must be controlled carefully preoperatively, small pupils are especially problematic during surgery, and inflammation must be controlled postoperatively.
Baltimore-Surgeons must consider several factors when treating patients with uveitis and cataracts. James P. Dunn, MD, explained how best to manage those complicated cases during a talk at the Current Concepts in Ophthalmology meeting. "Without proper planning, you can end up with a disaster- uncontrolled uveitis and a dense papillary membrane over an IOL. That can happen with any uveitic cataract surgery but is most common in patients with juvenile idiopathic arthritis," said Dr. Dunn, associate professor of ophthalmology
Some relevant factors to remember when treating those patients, he noted, are that both uveitis and corticosteroid therapy are cataractogenic.Cataracts are a particular problemin children with uveitis because of the resultant lack of accommodation and the greater risks of IOL-induced uveitis in those patients. Use of steroidsparing therapy, i.e., immunosuppressive drugs, may reduce progression of cataract; however, when it is indicated, corticosteroid therapy should not be avoided simply to prevent the development of a cataract.
Important preoperative factors
Several preoperative factors are critical in assessing the risk of cataract surgery in these patients. Those factors include the degree of dilation of the pupil; the status of the fellow eye; the need for chronic topical steroids to control the uveitis; whether the uveitis is inactive, chronic, or recurrent; whether the uveitis is granulomatous; the presence of inflammation that may be sufficient to warrant concurrent vitrectomy; glaucoma; cystoid macular edema; zonular dehiscence; and how well the patient can tolerate aphakia.
When considering implantation of an IOL, surgeons should be aware of some relative contraindications, the first being the presence of active uveitis (except traumatic or phacoanaphylactic). Patient age less than 12 years is another consideration; IOLs are being implanted more frequently in this age group, but the risks of capsular opacification, chronic uveitis, and glaucoma may be particularly high in such patients, according to Dr. Dunn. Finally, juvenile idiopathic (rheumatoid) arthritis is a relative contraindication, especially in patients with bilateral uveitis who might be better off with aphakia.
"The preoperative goals are to maintain a quiet eye, minimize or eliminate cystoid macular edema, have a firm idea of the surgical approach, and educate the patient to establish realistic expectations of the surgery," he stated.
Regarding the surgical expectations, the goal with those patients may not be to improve the visual acuity from counting fingers to 20/15, but rather to 20/40 or 20/50, given the possibility of such factors as an epiretinal membrane or photoreceptor damage fromchronic macular edema.Discussing those expectations with patients before surgery is an important step, he said.
The most important preoperative consideration, however, Dr. Dunn said, is the achievement of absolute control of the uveitis for at least 3 months preoperatively with the use of immunosuppressive drugs if necessary."That is critical," he stated.
Once the uveitis has been controlled, the preoperative regimen may include administration of high-dose oral steroids for 2 to 7 days preoperatively and intensive topical steroids for 1 week preoperatively. Some clinicians are proponents of topical or oral nonsteroidal anti-inflammatory agents for 1 to 3 weeks preoperatively, but Dr.Dunn said that he does not usually use this regimen himself.
Small pupils are often the biggest problem intraoperatively, but their impact can be reduced by adequately controlling the uveitis before surgery, avoiding miotics to control glaucoma, avoiding the use of cycloplegics on the day before surgery, and using topical nonsteroidal anti-inflammatory drugs on the day of surgery.
Cystoid macular edema (CME) can be addressed with aggressive preoperative use of oral, periocular, or topical steroids, Dr. Dunn advised.
"In general, topical nonsteroidal anti-inflammatory drugs are usually not helpful in endogenous uveitis-associated CME but may help maintain pupil dilation intraoperatively," he said. Regarding glaucoma, the surgeon should consider whether the patient will need glaucoma surgery and whether that surgery should be performed concurrently or sequentially with the cataract surgery. The type of surgery-filtering or a tube shunt-also must be considered.