Hindawi Publishing Corporation

International Journal of Inflammation
Volume 2012, Article ID 548453, 16 pages
doi:10.1155/2012/548453

Review Article
Cataract Surgery in Uveitis

Rupesh Agrawal,1 Somashiela Murthy,2 Sudha K. Ganesh,3 Chee Soon Phaik,4
Virender Sangwan,2 and Jyotimai Biswas3
1 Tan Tock Seng Hospital, Singapore 308433
2 L.V. Prasad Eye Institute, Andhra Pradesh, Hyderabad 500034, India
3 Medical Research Foundation, 18 College Road, Tamil Nadu, Chennai 600006, India
4 Uveitis and Cataract, Singapore National Eye Centre, Singapore 168751

Correspondence should be addressed to Rupesh Agrawal, rupesh agrawal@ttsh.com.sg

Received 21 September 2011; Accepted 28 October 2011

Academic Editor: Mark Willcox

Copyright © 2012 Rupesh Agrawal et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.

Cataract surgery in uveitic eyes is often challenging and can result in intraoperative and postoperative complications. Most
uveitic patients enjoy good vision despite potentially sight-threatening complications, including cataract development. In those
patients who develop cataracts, successful surgery stems from educated patient selection, careful surgical technique, and aggressive
preoperative and postoperative control of inflammation. With improved understanding of the disease processes, pre- and
perioperative control of inflammation, modern surgical techniques, availability of biocompatible intraocular lens material and
design, surgical experience in performing complicated cataract surgeries, and efficient management of postoperative complications
have led to much better outcome. Preoperative factors include proper patient selection and counseling and preoperative control
of inflammation. Meticulous and careful cataract surgery in uveitic cataract is essential in optimizing the postoperative outcome.
Management of postoperative complications, especially inflammation and glaucoma, earlier rather than later, has also contributed
to improved outcomes. This manuscript is review of the existing literature and highlights the management pearls in tackling
complicated cataract based on medline search of literature and experience of the authors.

1. Introduction surgical techniques, availability of biocompatible intraocular
lens material and design and surgeons trained in performing
One of the most daunting tasks for an ophthalmic surgeon is complicated cataract surgeries and anticipatory management
the management of complicated cataracts. Cataract in uveitis of postoperative complications [4], the outcome has been
may develop as a result of the intraocular inflammation per maximized. Ocular morbidity in patients undergoing com-
se, from chronic corticosteroid usage or more often from plicated cataract surgery is now limited to those cases that
both [1]. The incidence of cataract in uveitis varies from have pre-existing changes in the retina or optic nerve such
57% in pars planitis [2] to 78% in Fuchs heterochromic as irreversible macular scarring or optic nerve atrophy. The
iridocyclitis (FHI) [3]. fundamentals of cataract surgery in patients with different
Cataract surgery in uveitic eyes is challenging and can forms of uveitis have been recently reviewed by numerous
present with many unforeseen intraoperative complications. authors [1, 4–17]. This paper presents a review of the existing
Two decades ago, the outcome of surgery in these eyes was literature on this topic and proposes a set of management
guarded and often confounded by postoperative complica- pearls in tackling complicated cataract based on the literature
tions such as severe inflammation, hypotony, and even phthi- review and authors’ combined experience.
sis bulbi. However, with modern day cataract surgical tech- Extensive literature search using OVID medline search
niques, this is seldom the case. With improved understanding engine and all available library databases was employed with
of disease processes, optimization of immunosuppression for references cross-matching to obtain all peer reviewed articles
perioperative control of inflammation, minimally invasive published on cataract surgery in uveitis. The literature search

cataract is considerably more difficult than that in eyes with FHI [20–31].1. and patients are often the cataract removed by needling and aspiration.2. the complications resulted in marked significant complication of cataract extraction in FHI eyes reduction of vision or even loss of the eye [11]. synechiae. Out of 162 eyes. Most cataracts are of the posterior subcapsular type. operative hemorrhage varied from 3. 19]. and better than 20/60 in symptoms at the time of presentation are blurred vision 56%. Cataract Surgery in Patients with Fuchs Heterochromic operative outcome of conventional cataract extraction even Iridocyclitis (FHI).1. occurred in recent years. Foster described the inten- Numerous studies of cataract extraction in FHI have sive use of preoperative and postoperative corticosteroids reported insignificant intraoperative and postoperative com. and corneal edema were is recommended during the perioperative period for all reported by some authors [3. initially. successful postoperative outcome with limited complications glaucoma. rhage. the literature on cataract extraction in patients with uveitis. with perioperative and postoperative immunosuppression. the increased ability to control inflammation perioperatively but eventually up to 70% of these patients will require and the rapid evolution in microsurgical techniques that has filtering surgery [13]. in order of reported complications [22]. The reported incidence of cataract formation in FHI immunosuppression aimed at zero tolerance of inflamma- syndrome ranges from 15% to 75%. by Kanski and Shun-Shin [32]. If patients are symptomatic. achieving a post of corticosteroids in the early 1960s. 12]. The most The review of the literature reveals that. and hypotony or glaucoma. Vision was inflammation is discovered during a routine eye examination hand motion or less in l5% of the lensectomized eyes. By far the largest volume of information without intraocular lens implantation. with JIA undergoing cataract surgery saw better visual with the remainder being cortical or mixed [18]. However.7 months. in addition to dromes. 33] that patients 18. In his landmark paper. To summarize. In the follow-up period reported a high incidence of severe complications [4. Several ment inflammation associated with this condition is often factors must be kept in mind when assessing the current asymptomatic until complications supervene. eyes with uveitis associated with JIA that undergo cataract . Review of Current Literature pathic Arthritis (JIA). It was not until the important concept of adequate 19]. during cataract extraction in uveitis [4–7. Treatment with systemic. with the vast majority tion and abolishment of every cell was strongly advocated of series reporting an incidence of around 50% [3. were hyphema. progressive vitreous opacification. 18. It is therefore important to consider each syndrome cataract. and spontaneously resolving vitreous hemor. Historical Perspective improved microsurgical techniques. ocular inflammation operative visual acuity of 20/40 or better in all 41 eyes in their was difficult and often impossible to control.8 ± 8.1. 11. Recent articles report a much lower incidence of hyphema than was recorded previously. the two most common 20/400 to count fingers in 30%. complications arising from this syndrome are more severe. control of likely reasons for this vast improvement would appear to be intraocular pressure can be achieved by medication alone. The uveitis tends to be low grade and chronic. 61 had posterior synechiae rarely form. the only complication was PCO. However. Subsequently several studies reported frequency. 13. 19]. 10]. extensive posterior 17]. as a result of cataract formation and vitreous floaters [18. Vitreous haze was the major cause of postoperative discussing the results of cataract extraction in inflamed eyes visual acuity of less than 20/20. the chronic nongranulomatous anterior seg- 3. outcomes. The most visually In many cases. More recent appears to be the development of glaucoma. Numerous studies have reported the poor post 3. Permanent publications have reported a considerable decrease in the elevation of IOP was reported to develop at some time incidence of intraoperative and postoperative complications following the operation in 3% to 35% of these eyes [13].2 International Journal of Inflammation included all relevant published studies on cataract surgery in The reported incidence of intraoperative and post- uveitis since 1960 in English language. [18].1. Inflammatory squealae may develop at relatively predictable The literature indicates that commonly encountered com- rates in eyes with a given inflammatory syndrome [4–7.6%) eyes [18]. these rates do vary markedly among syn. and 101 unaware of the disorder until complications develop or the had lensectomy and limited anterior vitrectomy. and supported by clinical studies [22. Other complications such as retinal detachment. Javadi and colleagues had safe outcomes with phacoemulsification and in-the- Evolution of cataract surgery in uveitis. and articles series. 4. 7. Until the advent bag intraocular lens implantation in FHI. of 17. and reported visual acuities of 20/40 or better in 67% plications. topical. and periocular steroids extensive synechiae formation.6% to 76%. 11– plications include band keratopathy. 3. 6. separately when assessing the results and complications Rehabilitation of 40–60% eyes with JIA that develop encountered following cataract extraction. Cataract Surgery in Patients with Juvenile Idio- 3. The largest series of regarding cataract surgery in uveitis patients concerns those patients with JIA who had cataract extraction was reported with FHI. which developed in six (14. Not unlike inflammation associated with FHI. the recurring complications seen of patients and no major intraoperative or postoperative following cataract surgery in FHI. Cataract Extraction in Different Uveitic Entities. perhaps a result of the use of 2.

there is still controversy surrounding the implantation of lar lens implantation in patients with juvenile idiopathic an IOL at the time of surgery [29]. and band keratopathy in 3. even with successful cataract surgery. traction [35]. In addition patients were operated at around a mean age of twelve years. These complications arthritis-associated uveitis where cataract surgery with are still very real despite the development of biocompatible intraocular lens implantation was performed in 36 eyes and IOL materials. cystoid macular edema in 16 eyes. There have been a few studies into the capsular bag at the time of cataract removal often which showed good postoperative outcome with vitrectomy . 38–42].3 years. to making surgery technically more difficult. although mild anterior chamber al. Surgery should be delayed until the anterior results in reformation of posterior synechiae and develop- chamber is free of inflammatory cells (“flare” will persist). ment of membranes over the IOL. 4. With cyclitic membrane formation.3. with a reported incidence of about 25% average follow-up period of 17. important cause of poor vision. reported good postoperative outcome following intraocu. only half of surface modified IOL was used in 7 eyes and a foldable acrylic the cataracts in one large series eventually became visually IOL was used in 3 eyes. and poor (0. retinal detachment in 2 eyes. however the study in most studies. effusion. cataract than 20/40 vision.5) limited by the state of the optic nerve and the macula and in 11%. Posterior capsular opacification was found in following surgery in pars planitis patients and is the most 2 eyes and anterior capsular fibrosis in 1 eye [37]. Thus. Implantation of an IOL prognosis despite therapy. primary capsulotomy with limited surgery in uveitis averages around 10%.5 months. Generally. As chronic inflammation years [33]. The cataract extraction is contemplated [22. 12 eyes [36]. few other complications are surgery cannot be withheld or delayed for too long whilst seen. Furthermore. This contrasts markedly uveitis with 21 out of 34 children having JIA reported with the inflammation seen in Fuchs syndrome or JIA- good tolerance of intraocular lens in JIA patients and associated uveitis. some eyes are hypotonous by the time was limited by very small number of patients [26].3–0. A heparin percentage of the cataracts remain at this stage.1. A possible reason for the varied outcomes is that A number of factors combine to make cataract surgery intermediate uveitis can take on a variable clinical course. 24].International Journal of Inflammation 3 extraction. Cataract Surgery in Patients with Intermediate Uveitis. looking at cataract extraction in children with chronic activity is present in some cases. and phthisis. resulting in cocooning The addition of a limited vitrectomy in combination of the IOL [26]. Inflammation in eyes with pars planitis is limited primarily Another major study published in 2009 by Quiñones et to the posterior segment. age of six to eight years as performing YAG capsulotomy in Numerous studies have reported varying results of cataract the postoperative period for posterior capsular opacification extraction in patients with intermediate uveitis [2. 20. For this reason. secondary pupil Another similar study revealed the beneficial outcome with block glaucoma develops warranting a surgical peripheral vitrectomy in patients with JIA-associated uveitic cataract iridectomy [26]. synechiae seldom develop and the average followup reported in this study was more than four incidence of glaucoma is low [2]. Secondary cataract may be compromised by the presence of band keratopathy developed in 16 eyes but in none of the eyes with primary [21.5) in 64%. visual acuity of 20/40 or better and 30% had improved visual Macular edema is the major complication encountered acuity to 20/60. hypotony is which was almost five years after the diagnosis of JIA in this associated with an increased risk of postoperative choroidal study as against the midteens in other studies. The incidence of glaucoma after cataract operation. phthisis from 25% to 2% in a series described by Kanski [34]. The in intermediate uveitis. Secondary glaucoma developed in 18 eyes. moderate (0. the mean postoperative follow-up period was 3. The the outcome of cataract surgery in JIA patients is often visual result was good (>0. 70% of eyes had a significant [2]. These eyes have a marked with approximately a third of all patients having a severe tendency to form synechiae [22]. It has been seen to some Most JIA patients are in the amblyogenic age when they degree in almost half of the eyes that undergo cataract develop cataracts and the surgeon must bear this in mind extraction and is responsible for 80% of the eyes with less when planning cataract surgery. Lens opacities first develop analysed ten eyes of 7 patients who had phacoemulsification as a diffuse haze in the posterior subcapsular region. which is located primarily anterior to the good postoperative visual outcome with optimal control lens.3) in 25% eyes. posterior capsulotomy and anterior vitrectomy. which closely anterior vitrectomy may be considered in children under the parallels the natural rate of glaucoma in this syndrome [7]. persists in close proximity to the lens. cataracts eventually Recently published study by Ganesh and colleagues develop in 40% of patients [2]. Although was reported by Probst and Holland in 1996 wherein visual glaucoma is common in this syndrome due to the chronicity acuity of 20/40 or better was achieved in eight eyes at an of inflammation. At final followup. may be difficult in a very young child. more hazardous in these patients. If seclusion or occlusion pupillae occur. and inflammation appears to remain under control battling to keep the eye quiescent in preparation for the following surgery. This may results in malignant glaucoma with lens removal resulted in a decrease in the incidence of if the iris is plastered back onto the anterior capsule. 35]. of the ciliary processes and ciliary body result in hypotony Successful use of intraocular lens implantation in uveitis and phthisis bulbi if surgery is not done early. As the anterior chamber is largely free of inflammation of inflammation with immunomodulatory therapy. As a result of the high A more recent study by Kotaniemi and Penttilä in 2006 risk of complications that may develop following surgery. A large with IOL implantation done by a single surgeon. macular edema. 22.

which ranged from one to 23 years. minimum of 3 months. the vision got worse in 17. all the eyes required steroid treatment implantation in eyes with pars planitis was safe and led to during followup to control recurrences of inflammation. in. All eyes showed min- 29%. IOL deposits in patients with sympathetic ophthalmia. therapy. Current Guidelines for the Management of 72. Moorthy et al. Reynard and Meckler [53] reported the capsular opacification which occurred in 10%. [23] described 16 patients with various types uveitis has been previously reviewed by Foster and associates of uveitis associated with ankylosing spondylitis in 5 and [8]. Vogt-Koyanagi. Their recommendations for a successful cataract surgery inflammatory bowel disease in two. and optic atrophy were also perioperative management and meticulous surgery.1. submacular fibrosis. This group includes patients with uveitis Diseases that spare the posterior segment generally have associated with sarcoidosis. Most 4. It was reported that the postoperative visual acuity sarcoidosis.5% of eyes. the authors reported results of phacoemulsification and intraocular lens implan- tation in patients with Behcet’s disease [49]. JIA patients. one eye. two eyes under- 14%. mainly optic atrophy [48]. namely the uveitic diagnosis. [55] reported results of cataract surgery those with idiopathic uveitis because of the severe posterior in 59 eyes of VKH and found BCVA improvement by one segment complications. Vision postoperatively. Acute uveitic syndromes tend to be associated other types of uveitis. Cataract Surgery in Patients with Idiopathic and Other whether an intraocular lens should be implanted or not.4. Other complications attributable to cataract formation is most likely to benefit were posterior seynchiae and severe inflammation. after recurrent inflammation. They attributed the Uncontrolled inflammation led to the formation of cyclitic success to control of inflammation. and anterior capsule fibrosis in imal inflammation at the time of surgery. complete removal of cortical material should take better visual acuity. . [52] performed lens implantation in 100 eyes with intermediate uveitis.4 International Journal of Inflammation along with cataract extraction in patients with chronic Nozik [51] both reported based on anecdotal evidence that intermediate uveitis [43–47]. IOL decentration in 1%. Clinical Evaluation of Complicated Cataract and Asso- frequent complication reported by them was posterior ciated Uveitis. three extracapsular were CME. proper tion.. or more lines on Snellen’s chart in 40 (67.79%) eyes.67 months. with chronic tion is the most common anterior segment complication inflammation and macular edema. good visual outcomes in most cases. such as determining 3. They reported 4. its risks. The three most frequent causes of poor visual recovery went intracapsular cataract extraction. Two eyes achieved visual acuity better than 20/40 during the follow-up period.5% of the eyes. 68% of eyes had best this study. retained 20/100 vision. The reported by the authors. toxoplasmosis. The eye in which visual loss is mainly capsular opacification in 37. as A large study by Ganesh and colleagues in 2004 [38] ana. Cataract Surgery in Behcet’s Disease. In another paper by Berker et al. and optic nerve. In cataract surgery in 19 eyes of VKH. Few complications were noted. and vigilant postoperative care. 91% of eyes showed a favorable visual outcome at corrected visual acuity (BCVA) of >6/12. and the prognosis seen postoperatively. including phacoemulsification. Thus. and epiretinal membrane. and in one case the cataract was needled. systemic and topical steroids should be used techniques. In 1983. and 14/16 eyes prophylactically for 1 week preoperatively and continued had posterior chamber intraocular lenses implanted.5. The three eyes with severe postoperative inflammation 3. long as inflammation has been absent for at least two to lyzed the outcome of phacoemulsification with intraocular three months preoperatively. Operating on eyes with cataract and Fox et al. CME in 50%. PCO Surgery is indicated whenever visual improvement can was seen in 38 (76%) eyes. All patients had less and for minimizing the postoperative uveitis are as follows. specific uveitic diagnosis is of paramount importance also when planning the surgical strategy [4]. Posterior from cataract surgery. membranes or phthisis in three eyes in spite of corticosteroid the-bag IOL implantation.1. than 0–2 anterior chamber cells for at least three months Uveitis should be inactive for at least 3 months pre- preceding surgery. sympathetic ophthalmia. for success. and one-piece PMMA posterior chamber intraocular most serious appeared to be the development of posterior lens should be used if the patient and the surgeon understand synechiae and in 6/14 eyes (43%). cataract extraction. Duke-Elder [50] and Smith and with better outcomes than chronic uveitis. followed by optic atrophy and be expected and the eye has been free of inflammation for a subretinal gliosis. The authors concluded that phacoemulsification with IOL Following surgery. such patients do well following conventional surgery.5% of eyes had improvement in vision after surgery. a better prognosis than those that affect the macular and/or Harada (VKH) syndrome. meticulous surgery. The major complications reason for BCVA <6/12 was pigmentary disturbance in reported by authors in this study were significant posterior macula.1. Cataracts were removed by extracapsular operatively. with most eyes achieving 20/40 or tinued. immunosuppressive drugs should be con- improved in all cases. 61% eyes achieved a stable visual acuity of >6/12. cystoid macular edema. Uveitic Cataract However. The most common average followup of 19. macular pathology was the special nature of this surgery. the place. occurring in up to 36% of Akova and Foster [54] analyzed results in 21 eyes of cases [1]. The outcome of surgery depends segment complications such as epiretinal membrane forma- upon several factors. Cataract forma- retained only light perception vision. Forms of Uveitis. results of cataract extraction in six sympathizing eyes of reactivation of intermediate uveitis in 51%. was found to be significantly lower in eyes with BD than in In 2004 Ganesh et al.

Toxoplasmic retinochoroiditis is associated with inflammatory therapy to prevent damage to ocular structures a 36% risk of reactivation following surgery [63]. This may result from the hypermature state can be given. The state of the macula to protect against recurrence of macular swelling. eyes with chronic retinal complications. possibly the cataract if there are no contraindications to periocular steroid surgery may not result in optimal and desirable visual injections. such as ocular toxoplasmosis and 4. whilst maintaining the dose of detachment which may complicate the eye with uveitis. Similarly.International Journal of Inflammation 5 (a) (b) Figure 1: A 54-year-old farmer gave history of loss of vision and repeated episodes of redness and pain in the left eye following injury 40 years ago. whereby lens proteins leak out of the capsular literature. Furthermore. such as documented steroid response or infectious outcome and such cases are left to the discretion of surgeon uveitis. such as that resulting from for example. infection. the authors favour an intravitreal injection of bag through an intact capsule. In eyes with types of infectious uveitis that have a propensity to recur. tapering the steroid dose according to the state of the retina must also be carefully examined for amount of inflammation postoperatively. are at risk of developing macular edema postoperatively. the oral evidence of ischemia. should be carefully determined or eyes with previous episodes of CME (e. for example in poorly controlled compromise the visual outcome. and optic nerve should be thoroughly examined for during steroid prophylaxis should be administered in eyes at risk of the preoperative assessment. optic atrophy and severe cupping of the form of oral steroids 1 mg per kg/day starting 3 days the optic disc are bad prognostic signs. Generally. Jancevski and Foster be considered as surgery may trigger reactivation of the recommended the use of supplementary perioperative anti. manent structure damage. atrophy. leading to persistence the conclusion of cataract surgery [60–62]. In presence of dense lens opacity. Note the polychromatic crystals (cholesterolosis) deposited on the iris. Since visual acuity was doubtful perception of light. Diffuse (a) and slit (b) photographs show the left eye with peripheral corneal scar and peripheral anterior synechiae and total posterior synechia with cataract. together with for cataract removal in an eye that is not blind. Behcet’s disease a choroidal neovascular membrane.2. The visual potential of the eye. B steroids are tapered or reduced to the preoperative levels scan ultrasonography should be done to rule out retinal over the subsequent month. In addition. where preservative-free triamcinolone acetonide 4 mg in 0. such as triamcinolone acetonide 40 mg/1 mL may (Figures 1(a) and 1(b)). the preoperatively. especially those with anterior uveitis in the pediatric age essential to good vision [58]. Similarly. is phacoanti. surgery was not advised for him. Less disabling abnormalities such as be given. Alternatively. or scar. chronic macular edema. an orbital floor or sub-tenon’s injection of depot to operate under nil visual prognosis or for cosmetic reasons steroid. for optimal surgical and visual outcome (Figures 2(a) and 2(b)). This has been of intraocular inflammation. In eyes which ankylosing spondylitis and anterior uveitis. are poor prognostic and birdshot choroidopathy.1 mL at the lens capsule has been breached. especially in patients where high doses of oral pre-existing corneal scars and severe iris atrophy may also steroid are contraindicated. Supported by encouraging results in the recent of a cataract. Control of Pre Operative Inflammation. B scan of the left eye showed findings suggestive of old vitreous hemorrhage and retinal detachment. developing recurrence of uveitis following cataract surgery. or in cases of trauma. a definite indication hourly administered 2 days prior to surgery. such as chronic anterior uveitis secondary to sarcoidosis. to name a few. intermediate before planning cataract surgery as this will have a direct uveitis). diabetics. Herpes . an oral and topical non-steroidal anti-inflammatory agent. Similarly. determined by prior per. At the temporal periphery. guttae prednisolone acetate 1% 2 Regardless of the guarded prognosis.g. This has been shown to group [56] have more poor outcome than patients with reduce the risk of postoperative CME [59]. genic uveitis. preoperative prophylaxis should also reactivation of uveitis must be assessed. This may take factors. The risk of herpes simplex uveitis. optimal control of periocular segment for appropriate medical or surgical management of inflammation is imperative in cases with sclerokeratouveitis the eye [57].. Vogt-Koyanagi Harada disease. there is an incidental conjunctival lesion suggestive of actinic keratosis. Cataract surgery may also be shown to be as effective as prescribing systemic steroids indicated to permit better visualization of the posterior perioperatively. steroid prophylaxis should be given perioperatively impact on the visual outcome. In other concurrent immunosuppressive therapy. Macular ischemia.

Complications of Uveitis Adversely Affecting Surgical if the eye is quiet. and a complicated cataract. during the postoperative period [69]. despite heavy immunosuppression. the laser flare meter is a useful tool to measure flare in the anterior chamber and may be used to determine 4. such as infection and other intraoperative complications 4. the patient may be administered intravenous phy or diffusely thickened choroid is a poor prognostic sign. Eyes in which [59]. Optimal Time for Cataract Surgery.3. biomicroscopy can also aid preoperative surgical planning [65]. (b) Shows the left eye two months postoperatively. In cases where. Furthermore. limited by the presence of a central corneal scar. such as the presence of synechiae. Diagnostic Aids. Finally. She underwent cataract surgery in the left eye with a preoperative visual acuity of counting fingers. such as in an intumes- The presence of choroidal effusion on B scan ultrasonogra. Postoperatively. Apart from the standard means of will also need to be thoroughly explained. body is found to be detached and processes appear under traction from a ciliary (cyclitic) membrane. (a) Shows the right eye showing evidence of healed scleritis. methylprednisolone 1 g one day before surgery.5. espe- cially readings of 6 mmHg or less even when quiescent. topical NSAID and rule out cyclitic membrane preoperatively in chronic uveitic prednisolone acetate 1% or even oral NSAID may help cases with bound pupils as described above. cataract surgery 4. Determining the surgical to monitor the level of inflammation in the anterior chamber risk is a very important aspect of preoperative assessment. In addition. Counselling of the Patient for Uveitic Cataract Surgery. cent cataract. She was investigated extensively and had a positive Mantoux test. Eyes which have generally low intraocular pressures. the risk of hypotony is high. should be combined with vitrectomy and trimming of the The most important aspect of counselling when planning ciliary membrane aided by indentation of sclera to relieve to perform cataract surgery for the uveitic eye is explaining ciliary body traction and to restore normal IOP. it or hole [66].4. with complicated cataract. her visual acuity improved to 20/125. retinal ischemia. If the ciliary cataract surgery [70]. simplex is also associated with reactivation following the demonstrate macular ischemia or edema. Other warning signs such as seclusio papillae surgery. ultrasound control postoperative inflammation [64]. If the ciliary body has risk is higher if attacks have occurred within 12 months of undergone atrophy. especially if assessing macular. membranes. corectopia. stress of surgery.6 International Journal of Inflammation (a) (b) Figure 2: A 48-year-old lady was diagnosed as bilateral sclera-keratouveitis. for which she received anti-tubercular therapy. A study from Conducting a careful ultrasonic biomicroscopy is essential Japan suggests that in patients with Behcet’s disease the eye in eyes with relative hypotony [65] to assess the state of should be inactive for a minimum of 6 months and that the the ciliary body and its processes. . colour perception and B scan ultrasonography.6. It also helps guide therapy as it can be used Outcome: High-Risk Surgical Cases. one may there is phacodonesis. A fundus fluorescein angiogram may also anatomy. or glaucoma. improve the visual outcome is important. optic nerve and retinal function. the visual prognosis. Performing a macular potential test using laser is important to explain that surgery may be complicated interferometry may help in determining minimum visual and possibly take longer than usual because of abnormal potential [67].5 g qd active posterior segment disease. before surgery to minimise the chance of recurrence and or an attempted OCT in looking for macular atrophy. Emphasizing apply additional methods such as pupillary response. the the uveitis is difficult to control are also at high risk of severe intraocular inflammation is still not completely abolished postoperative inflammation and hypotony or phthisis bulbi. including disc leakage [68]. hypotony. light that the eye will need a minimum period of quiescence projection. Before scheduling phthisis bulbi. The general risks involved in surgery. are at high risk of developing postoperative hypotony or even 4. the ophthalmologist should attempt to ensure that with normal intraocular pressure reading and apparent the eye has been quiescent for at least 3 months [11]. and acyclovir 400 mg bid or valtrex 0. edema. preoperatively and for 2 to 3 weeks postoperatively may Considering the risk of post operative hypotony and to help prevent recurrence. and surgery is urgently required. This phacodonesis without evident zonulysis are important poor has been shown to reduce the risk of postoperative CME prognostic signs for postoperative hypotony.

This possibility should be is best secured around the torso to prevent the body from discussed with the patient before surgery. and some surgeons prefer to perform a primary support may need to be stacked up high in order to support posterior capsulorhexis at the time of the cataract surgery the head. shallow cataract formation alone. a strap before implanting the IOL [76]. having excluded steroid Generally. surgery is (d) Incision. the 1% can provide adequate analgesia. Intraoperative Surgical Techniques and Skills [78] accommodative IOLs may not be effective in the long term due to recurrent inflammation and scarring of the ciliary (a) Posture. Where possible. or anterior chamber.International Journal of Inflammation 7 and so forth. Either a scleral or temporal clear corneal preferably not combined with the cataract surgery as the incision may be used. However. the incision should be of . may be combined with vitrectomy. such as epiretinal mem- with medications (systemic immunosuppression may need branes or coexisting retinal detachment. Hazy or scarred vitreous gel contributes The risks and benefits of combining or separating the to poor contrast sensitivity and any previous episode of surgical procedures should be thoroughly explained to the inflammation with macular involvement increases the risk patient. The choice of intraocular lens can be cystoid macular edema. Even 5. As the patient tends to slide down the bed. and frequent followup. The type of IOL intermediate uveitis. Choice of IOL. These patients are best discussed later (see IOL implantation-contraindications and postured in the Trendelenburg position. Choice of Surgery. For children and in anatomy of the anterior segment should be restored to a state patients for whom prolonged surgical time is anticipated. responders and eyes with infectious uveitis. 71–74]. (b) Surgical Challenges. iris prolapse. major retinal problems. thereby reducing vitreous clouding. manipulation of the iris may removal by phacoemulsification is safer for the uveitic induce ocular discomfort or pain. 5. posterior synechiae. advice given regarding their risks and benefits [77]. staged. These include the small pupil. Whilst phacoemulsification surgery may be individual surgeon’s surgical skill and experience. cervical spine is involved. and that these factors may contribute to risk of bleb failure is increased with drainage of post- postoperative inflammation. the need for compliance Regarding retinal complications. At the end of surgery. In cases with patient has difficulty accessing medical care. the eye may be safely rendered These patients are often young. In that was still able to accommodate in exchange for an eyes with intermediate uveitis. These patients do better with a monofocal IOL implant. flexion deformity of the axial spine. as will be operating table for ocular surgery. especially if the may be combined with vitreoretinal surgery. the material. Other factors requiring careful cataract surgery inflammatory exudate through a healing discussion and explanation include the possibility of and bleb. Patients with ankylosing spondylitis with a fixed body. The uveitic eye poses numerous Should the patient have complications other than surgical challenges. The pillow the surgery. cataract surgery to be adjusted). Surgical Technique ative inflammation. especially based on the extensive literature available [39. as in severe zonulolysis requiring modified capsular tension Some uveitic cataract eyes are complicated by glaucoma rings that need suturing. Either regional anesthesia cataract as less inflammation is induced than that by a man. performed to clear Consequently. and design are all important points also controls intraocular inflammation and helps resolve the that need discussion. increased risk of posterior capsular rent. Complications that may arise from the problems include an undersized or incomplete capsulorhexis. especially in view slipping. The choice of cataract surgery tech- nique is best left to the surgeon and depends upon the (c) Anaesthesia. and retinal detachment. is often adequate to outcomes due to the presence of preexisting macular or optic control the postoperative inflammation and prevent CME. or an intracameral injection of preservative-free lignocaine ual extracapsular cataract extraction. have difficulty not only in placing plication encountered postoperatively because of the relative their chin on the slit-lamp rest but also lying flat on the youth of these patients [75]. or retinal problems that may also benefit from surgery. whereby their lower type of IOL). multifocal implants. and surgical technique are major determining limbs are elevated above the level of their head. this often not only improves vision but implant. general anesthesia may be preferred. the option of separate. For eyes with concomitant uveitic glaucoma. whether based on diffrac. or FHI.2. peripheral ante- combined surgery should be discussed with the patient and rior synechiae. reasons for delayed visual recovery. pupillary membranes and even zonulolysis. with combined surgical procedures. an intravitreal tive or refractive principles may compromise the visual injection of triamcinolone acetonide. especially when the Posterior capsule opacification is another frequent com. nerve conditions. they will need to understand and accept the the vitreous gel. of the increased risk of postoperative endophthalmitis. as close to normal as possible. opacities are observed during maintain the plane of the face parallel to the floor. CME. therefore losing a lens aphakic until the retinal problem has been dealt with. Cataract done under topical anesthesia. so as to factors as well. In fact that they will now need reading glasses. and increased postoper- 5. cataract surgery should be done first. increased risk of intraoperative zonular dehiscence. cataract surgery intraocular lens implant means loss of accommodation.1. of poor visual performance with multifocal implants. Occasionally. or slowly progressive fibrosis of the capsular bag. During the surgery.

This (e) Pupil Enlargement. taking care not made by injecting balanced salt solution with adrenaline to detach Descemet’s membrane in the process. tip of the viscoelastic cannula may be used to sweep the iris away from the peripheral cornea as the viscoelastic material is being injected into the angle of the anterior chamber. USA). to adequate length in order to prevent iris prolapse in eyes with physically separate the iris from the cornea. anterior synechiae. this may be done by . and an early cataract and (b) showing presence of 360 degree posterior synechiae. Ill. When both are present. PS may be (1 : 1000 0. An attempt at pupil dilation can be should be done very gently and carefully. PS) (Figures 3(a) and Figure 5: Postoperative slit lamp photograph showing minimally 3(b)) or may form between the peripheral iris and corneal distorted pupil following pupil manipulation intraoperatively to endothelium as a result of previous iris bombe (peripheral negotiate posterior synechiae. Abbott Medical Optics) is useful as this high-molecular- weight sodium hyaluronate can physically roll open the pupil and keep it dilated as long as the aspiration flow rate is kept low.3%. Inc.8 International Journal of Inflammation (a) (b) Figure 3: (a) Showing the eye with synechiae at papillary border.5 mL adrenaline in 500 mL) into eyes with pupils lysed by simply injecting viscoelastic against the adherent that are not bound by synechiae or membranes. iris. such as Healon 5 (Viscoadaptive from Abbott Medical Optics. pigment deposition on the lens. PAS). Alternatively. the PAS should be released before the PS. dilate the pupil only if it is not bound. Preservative. (f) Synechiolysis and Removal of Pupillary Membrane. Abbott Park. Choosing a viscoadap- tive viscoelastic such as Healon 5 (sodium hyaluronate 2. (a) (b) Figure 4: Intraoperative use of Kuglen hooks to stretch and dilate the pupils. allowing the viscoelastic to “bulldoze” the iris away free intracameral lignocaine 1% may also be used to help from the anterior capsule. Release of PAS may be done by injecting viscoelastic. Synechiae may be present between the iris and the anterior lens capsule (posterior synechiae. failing which the small or stretched pupils.

International Journal of Inflammation 9 (a) (b) (c) Figure 6: Intraoperative use of self-retaining iris hooks to dilate the pupils. . (a) (b) (c) Figure 7: Postoperatively removal of self-retaining iris hooks.

it may be safe to implant IOLs in these difficult opposite directions (Figure 4(a)). pupillary membranes were formed only in eyes with silicone Alternative means of opening the pupil include the use IOLs. This also contributes to increased postoperative inflammation. can be removed using a pair Kelman-Mcpherson forceps. USA) has which lens epithelial cells tend to migrate. the posterior capsule. but not so small as to prevent capsular phimosis. Creating the ideal capsulorhexis is also very important in preventing posterior capsule opacification. the capsulorhexis inevitably needs to be larger than the pupil. The most user-friendly instrument for extensive synechiae once an edge of the iris has been viscodissected off the anterior capsule is a bent Kuglen hook. When the pupil size is small. IOLs. The eye PS. The iris hooks are removed at end of surgery (Figures 7(a)– Removal of viscoelastic from under the IOL is an 7(c))).2 mm incision and manoeuvred to expand and single-piece hydrophobic IOL also encourages its adhesion to maintain the pupil open at a 6 or 7 mm diameter. the side port to complete the rhexis. thus stretching technique. More recently a pupil device. and to compromise the anterior capsule. pupillary aperture with the phaco tip kept in view at all times with minimal risk of engaging and traumatizing the iris (Figures 9(a) and 9(b)). but hydrophobic acrylic stretch the pupil in a single injector system. When the pupil has been freed. IOL implant through multiple corneal paracentesis (Figures 6(a)–6(c)). The capsulotomy can be initiated by a 26. The anterior chamber must be kept deep and the anterior capsule flattened using adequate viscoelastic material in order to control the tearing of a capsulorhexis. develop a tear. The review of the literature suggests that while inadequate. If proper execution of pupil manoeuvring square-edged acrylic (either hydrophilic or hydrophobic) is done. silicone IOLs had a higher incidence of terotomies by means of intraocular scissors. the membrane phaco (Figure 10).or 27-gauge bent cystitome and a modified vitreoretinal Figure 8: Intraoperative still video clip demonstrating the step of forceps (pediatric rhexis forceps) can be then inserted from capsulorrhexis. the (k) Intraocular Lens Implantation Contraindications and Type pupil begins to widen with viscoelastic. now with a manner to latch around the pupil edge. once the pupillary membrane has been removed. Alió direction perpendicular to the initial stretch (Figure 4(b)). even when a pupillary membrane is fragments are still lodged in the posterior chamber during present. . ranging from mild to extensive. which may be injected into the anterior chamber Pressing the optic against the posterior capsule when using a through a 2. et al. the pupil may be stretched using a pair of angled earlier. The fication rate was highest (34. Often. In cases where a narrow strip of membrane is present at the site of PS formation. should be deferred.10 International Journal of Inflammation (h) Continuous Circular Capsulorhexis. It is generally prefer- able to keep the size of the capsulorhexis slightly smaller than the pupil so that iris chaffing does not occur and results in progressive intraoperative miosis as nuclear fragments are being moved out of the capsular bag (Figure 8). In small pupils. the Malyugin ring important step in reducing the space behind the IOL into (Microsurgical Technologies. as it enables the surgeon should be rotated to look for residual lens matter and a gentle to push or pull the iris. thereby releasing the iris from the shake given at the end of nucleus removal to ensure that no anterior lens capsule. Disposable iris hooks are easy to place [78]. sweeping the pupil free from the lens capsule with a cannula. In general.2%) in eyes with silicone pupil may then be further enlarged using multiple sphinc. [39. the safest tech- simultaneously nick the membrane to segment and release it nique is the vertical chop employed in the in situ chop from the anterior capsule and release the PS. postoperatively pupil looks relatively round with IOL. been used. Pupil retainers material had lower uveal but better capsular biocompatibility may also be tried. hydrophilic acrylic material has good uveal of a Beehler pupil dilator (2 or 3 pronged) to mechanically but worse capsular biocompatibility. This is then repeated in a case scenarios as long as the uveitis is well under control. used in chronic uveitis was considered a contraindication. In addition. They also found that the posterior capsular opaci- minimal distortion of pupillary margins (Figure 5). thereby reducing the risk of PCO [79]. Redmond. pulling the iris in modern IOLs. Chopping of fragments is done within the the pupil. taking care not postoperative cystoid macular edema and PS formation. However. a 27-gauge needle may be used to (i) Nucleus Management. thus causing PCO. In eyes with chronic uncontrolled uveitis. The capsulorhexis should be centred. 79] showed that the most biocompatible IOL for The surgeon should stop at once should the iris sphincter the anterior chamber and the capsular bag is a single-piece. overlapping the edge of the optic at all times. (g) Pupil Expansion. if this is of IOL. (j) Irrigation and Aspiration. Wash. implantation of IOLs in uveitic eyes with JIA and Kuglen hooks introduced through the main incision. This step must be done thor- This “push-pull” instrument is excellent for the safe release of oughly so as not to leave cortical material behind.

which may Zonulolysis. These small fragments can cause recurrent anterior uveitis when their position in the anterior chamber changes and may also cause localized corneal edema and even localized corneal decompensation in the long term. be treated by controlling the inflammation. have proven ineffective in controlling the uveitis. Retained Lens or Nuclear Fragments. if preoperative prophylactic oral steroids have presence of weak zonules may result in capsular phimosis. Associated with this Zonulolysis. eyes is frequent and has been reported to range from if the overall zonular strength is weak. Early Postoperative Complications 5. An infrequent intraoperative complication is is the development of cystoid macular edema.3. the to the sclera by means of a modified Cionni CTR ensures incidence has been reported to range from 12% to 59% [38]. Intraoperative Complications inflammation (Figures 11(a)–11(g)). This may vary in terms of severity or duration of inflammation. The incidence Insertion of a plain capsular tension ring (CTR) is often of CME following extracapsular cataract surgery in uveitic necessary in order to prevent IOL decentration. This can occur in eyes with chronic uveitis.2. One of the most com- mon postoperative complications is excessive postoperative 5. Due to the small pupil size. 14].3. Figure 10: Intraoperative still surgical video clip showing irrigation and aspiration of the soft lens matter. Any retained soft lens material or nuclear fragment should be removed surgically as soon as possible [80].International Journal of Inflammation 11 (a) (b) (c) Figure 9: Intraoperative still surgical video clip showing the nucleus management in total white uveitic cataract. at the end of phaco. Complications and Postoperative Management Excessive Postoperative Inflammation. small hard nuclear fragments may lodge in the posterior chamber during phacoemulsification. that the IOL remains centred. Hence. 5. only to pop into the anterior chamber months later. been given and maximal topical steroids and cycloplegics due to unopposed capsular bag fibrosis and shrinkage. However.1. Failure to use a CTR in the Generally.3. the eye should be given a gentle shake whilst aspirating to ensure no nuclear fragments are inadvertently left behind. Following phacoemulsification. fixation of the CTR 33% to 56% [10. the dose .

b) show the right and left eye with quiet anterior chambers and nondilating pupil with posterior synechia. . On the first postoperative day. g) Diffuse low and high magnification and slit view of the left eye two days after intensive treatment showing decrease in the inflammation. He returned to the emergency clinic on the next day with loss of vision and showed severe anterior chamber reaction with hypopyon. He improved over the course of one week and regained good vision at the end of one month. a treated case of Hansen’s disease 15 years ago. underwent phacoemulsification with PCIOL in the left eye. Examination showed active anterior uveitis and complicated cataract. the visual acuity has improved to 20/50. (h) The left eye shows near-quiet anterior chamber 2 weeks after treatment. f. (a.12 International Journal of Inflammation (a) (b) (c) (d) (e) (f) (g) (h) Figure 11: A 45-year-old man. (c. presented with progressive visual loss. (e. his visual acuity improved to 20/50 (from preoperative vision of 20/200) with a mild fibrinous reaction in the anterior chamber. d) Diffuse and slit view of the left eye on the second postoperative day shows hypopyon and coagulum around the IOL. Vitreous appeared uninvolved. He was hospitalized and treated with intensive topical steroids and cycloplegics. He was treated with topical steroids and after 4 months.

Removal of intraocular lens in uveitic steroids may be difficult to taper or withdraw and patients eyes is rarely necessary. Stabilisation of the IOP and vision has been successfully chronic low-grade inflammation not responding to anti- treated with an intraocular injection of sodium hyaluronate inflammatory treatment and cyclitic membrane resulting in via a limbal paracentesis in non uveitic eyes [82]. The patient regained visual acuity of 20/25. In severe hypotony and maculopathy [85. [82] 34. posterior capsular opacification is perhaps the Posterior synechiae.6%. [84] 81. reported that their may require long-term topical steroids to maintain the IOP. indications include the formation of perilental membrane. Control of postoperative However. Preventive measures include creating a circular well- Intraocular Pressure (IOP) Abnormalities. [9] reported an incidence of 48. The underlying diagno- cases. In the pediatric eye with chronic uveitis undergoing cataract surgery. Control Rauz et al. most common complication following any type of cataract mation may occur during the postoperative period due to surgery. This is thought to oral pulse of steroids or injection of periocular steroids. The IOP may be centred capsulorhexis which is smaller than the optic size.3. of triamcinolone acetonide [81] if this had not been given stepping up the immunosuppression for the long term may intraoperatively. Foster et al. capsule at the conclusion of surgery. with the shows the presence of ciliary body detachment secondary inflammation centered on the pars plana region. This is often effective in raising the IOP. pupillary or ciliary membrane for. Hence. Examination showed a total cataract in the right eye.7% and Küçükerdönmez et al. 8. and pars planitis. If no prophylactic Recurrence of Uveitis. In the late postoperative postoperative complications and improve surgical outcomes. JIA. were 32. vitrectomy and trimming of ciliary body traction sis for uveitis included sarcoidosis.0%. the patient underwent cataract surgery with synechiolysis. of oral steroids may be sharply increased. which was treated with oral and topical steroids. An be triggered by the intraocular procedure.2%. in membranes and silicone oil filling may be needed if UBM eyes with predominantly intermediate or panuveitis.3%. 3 months postoperatively and is on maintenance with oral methotrexate and topical steroids. the next step is to increase PCO. meticulous removal of viscoelastic from within the capsular This can often be managed with topical and systemic anti. cally after surgery was responsible for the postoperative . temic immunosuppression. After the inflammation subsided. and 3. bag and ensuring the optic is stuck on to the posterior glaucoma medications.International Journal of Inflammation 13 (a) (b) Figure 12: A 36-year-old man presented with a history of redness and pain since two years and decreased vision since one year. the surgeon’s greatest fear is hypotony. (a. whereby various complications are addressed at different sittings [79]. This strategy may avoid Posterior Capsular Opacification. be necessary to prevent further recurrences. raised transiently during the early postoperative period in using an acrylic IOL with a square-edged optic design. but the topical Explanting an IOL. The recurrence alternative means would be to give an intravitreal injection rate has been reported to be as high as 51% [15]. Increased frequency of recurrence oral steroids had been given the patient should be given an following cataract surgery may occur. period. 86]. excessive inflammation (Figures 12(a) and 12(b)). there was increased anterior chamber inflammation. Once inflammation also plays an important role in preventing wound leakage has been ruled out.2% of uveitis and keeping the pupil mobile during this time are at 1 year. with 360 degrees posterior synechiae. Late Postoperative Complications be the safer approach. They believe to tractional membranes not addressed during the cataract that undetected subclinical inflammation present chroni- surgery [83]. Investigations showed HLA-B 27 was positive. a multistage surgery may 5. Okhravi et al. the anti-inflammatory therapy topically and systemically. Postoperatively. Their corresponding Nd:YAG capsulotomy rates important.3. eyes with compromised trabecular meshwork or angles. b) Diffuse and slit photograph of the right eye on the first postoperative day shows a membrane on the IOL which responded to intensive topical steroids and cycloplegics. thus avoiding the need to adjust the sys.

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