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158 INDIAN JOURNAL OF OPHTHALMOLOGY
Late Recurrent Uveitis after
Phacoemulsification
Pradeep K Saraf, MS
It is now assumed that recurrent late onset uveitis after
phacoemulsification with intraocular lens (IOL) is
due to indolent infection. Fifteen such cases were
observed after uncomplicated phacoemulsification
with-in-the-bag IOL implant. These cases were
considered noninfective and treated medically with
good visual recovery.
Key Words: Late onset uveitis, phacoemulsification,
endophthalmitis
Indian J Ophthalmol 2004;52:158-59
Any intraocular procedure causes postoperative
inflammation. This is usually treated with topical
corticosteroids and nonsteroidal anti-inflammatory
drugs (NSAIDs). These are generally tapered over a few
weeks depending on the individual situation. Sulcus
fixated posterior chamber intraocular lens (IOL), iris
fixated intraocular lens (IOL) and poorly designed and
manufactured anterior chamber lenses with rough
edges, are known to cause chronic iris irritation. This
results in chronic uveitis, glaucoma, and hyphaema
(UGH syndrome). This responds only to removal and
replacement of the offending IOL. With capsular bag
IOL fixation, this syndrome is now rarely, if ever seen.1,2
Late onset uveitis is presently considered to be due
to indolent infection. Diagnosis can be made by culture
of material from the capsular bag. Treatment consists of
antibiotics in the capsular bag vitrectomy, and more
commonly requires removal of both the IOL and
capsular bag. These steps are recommended in the early
stages to avoid chronic cystoid macular oedema .1
This retrospective study looks at cases of late onset
recurrent uveitis after phacoemulsification and IOL
implant treatment only with topical corticosteroids.
Case report
Six hundred and seventy six uncomplicated
phacoemulsification surgeries done by the author
between September 1995 and March 2001 were
reviewed. Twelve cases with posterior capsular rupture
with or without nucleus dislocation were excluded from
the study. One surgeon performed all surgeries in the
same operating room. Preoperatively all patients had
Shivam Nethralaya, Kolkata, India
Proprietary Interest: None
Reprint rquests to Dr. Pradeep Kumar Saraf, Shivam
Nethralaya, 51/1A Sarat Bose Road, Kolkata – 700 025, India.
E-mail: <pksaraf@vsnl.com>
Manuscript Received: 16.9.02; Revision Accepted: 25.4.03
Brief_Reports.p65 158
Vol. 52 No. 2
complete cataract work up. All preoperative and
postoperative medicines used were similar. All cases
were done under peribulbar anaesthesia. A scleral
tunnel was used for rigid IOLs and a clear corneal
incision was used for foldable IOLs. The anterior
chamber was filled with viscoelastic
(hydroxypropylmethylcellulose-HPMC), and a
capsulorhexis was made. After hydrodissection, the
nucleus was removed using the “divide-and-conquer”
technique in the first 287 cases and by the stop-and-chop
technique in the remaining cases. Cortical cleaning was
done by the bimanual technique through two side ports.
A foldable acrylic lens was used in 97 cases and 567
cases had implantation of a rigid single piece IOL. The
anterior chamber was filled with HPMC before IOL
implantation in the bag. HPMC was thoroughly
aspirated after IOL implantation from the anterior
chamber and not from the back of the IOL. No sutures
were used. All patients received subconjuctival
gentamicin 10mg and dexamethasone 1mg. The eye was
patched until the next day. Only topical betamethasone
0.1% was given. The dosage schedule was 8 times a day
for 2 weeks, 6 times a day for 2 weeks, 4 times a day for
2 weeks, after which it was discontinued.
All the patients were asymptomatic for a month,
without inflammation after a week. Fifteen patients
developed anterior uveitis 4 – 6 weeks after surgery
when topical betamethasone was tapered to twice a day
or discontinued. The symptoms included decrease in
vision, redness, pain and photophobia. Examination
showed vision reduced by 2 to 5 lines, no lid oedema,
mild conjunctival congestion and minimal aqueous flare
and cells. There were no keratic precipitates, hypopyon
or vitreous opacities.
Vitreous tap was done in one case and the specimen
was sent for microscopy and was cultured for bacteria
and fungus. The patient was also given intraocular
vancomycin (1.0mg) and cefotoxim (0.25mg). There was
no growth on culture. In the remaining 14 cases vitreous
tap or culture was not done. They were treated only
with topical betamethasone 0.1%. The topical
medication was increased to 4 times a day and tapered
each week, over a month. If symptoms recurred topical
betamethasone was given 4 times daily for 2 weeks and
tapered over 2 months. In case of further recurrence
topical fluoromethalone was given for a month and
tapered over 4 months. The duration of treatment is
given in Table 1. Follow-up was 3 months in 4 cases, up
to 1 year in 3 cases and up to 4 years in 8 cases.
Of the 15 cases with chronic uveitis, 4 were male and
11 were female. In total, there were 351 male and 325
female patients, ranging in age from 51 to 77, averaging
65.3. (The average age for the cohort study was 64.7)
One case had diabetes. There was no case history of
uveitis. Preoperative visual acuity was 6/36 or more in
10 cases and less in 5 cases. No case had mature cataract.
Three cases had foldable acrylic IOL and 12 had single
piece PMMA IOL. In all cases, symptoms resolved
rapidly after restarting or increasing the dose of topical
corticosteroid. Vision was felt to be consistent with
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June 2004 Brief Reports
Table 1. Duration of treatment
Months Number of cases
2 months 5 specific IOL type . Madhavan7 reported a mild but
2-4 months 4 significant toxic effect on cell cultures with some
More than 4 months 6 viscoelastics. It may be assumed that viscoelastics
preoperative macular status in all cases – 12 were 6/9
or better, 2 were 6/12 and one was 3/60 due to the
presence of a macular hole preoperatively. There was
no case of steroid-induced glaucoma and no cystoid
macular oedema.
Discussion
Uncomplicated phacoemulsification and extracapsular
cataract surgery with or without IOL usually result in
very little intraocular inflammation that could last from a
few days to weeks. Late onset intraocular inflammatory
reaction in these eyes is mostly suspected to be due to an
indolent infection.1 Wenkel3 reported 9 cases of chronic
postoperative endophthalmitis after cataract extraction
and IOL implantation. In these cases the main clinical
findings were hypopyon and infiltrates in the capsule
bag. Chronic and recurrent endophthalmitis has also been
reported due to contaminated viscoelastic.4
Jalali et al5 reported two such cases wherein one
patient who had recurrent hypopyon; vitrectomy after 7
months showed Propionibacterium acnes.
In the present series of 15 patients, intraocular
antibiotics and vitrectomy were not required and the
patient was cured by topical corticosteroids only,
suggesting a noninfectious pathology. The cause of
recurrent anterior uveitis in the present cases is unclear.
The review of 2000 extracapsular cataract extractions
with IOL done by the author previously did not show
any such incidence (Unpublished data). So it is
presumed to be a complication specific to
phacoemulsification. One cause for chronic inflamma-
tion is nucleus dislocation into the vitreous. These cases
were excluded from this study; however, it is possible
that a small nuclear chip could have been present
behind the iris and could not be removed even after
good clearing.
Jehan et al 6 have reported 10 cases of severe
intraocular inflammation associated with Memory Lens.
These happened on an average of 7.8 days post-op, and
Brief_Reports.p65 159
159
were presumed to be sterile. A definite aetiology was
not determined, though they were felt to be due to
residual polishing compound on the IOL. The cases in
this series were random and could not be related to any
entrapped behind the IOL in capsular bag may be a
cause for recurrent uveitis and it abates after some time
when the viscoelastic is cleared.
Metallic dust from the phaco needle is occasionally
seen on the iris postoperatively, but appears to be totally
inert. It is presumed that it could induce uveitis in some
cases.
All the above causes including entrapment of small
nucleus piece, viscoelastics and metallic dust from
phaco tip, are specific to phacoemulsification and need
further study.
To summarise, cases with late recurrent anterior
uveitis after phacoemulsification are frequently not of
infective origin, and can be reasonably safely treated
with topical corticosteroids and careful observation.
More invasive procedures, such as vitreous tap and
culture, intraocular antibiotics, vitrectomy or IOL
explantation can be deferred as long as there is
satisfactory resolution. This observation warrants
further prospective study.
References
1. Schmitz K. Postsurgery Intraocular inflammation. BenEzra. D,
editor. Uveitis Update. Dev Ophthalmol. Basel: Karger.1999. Vol 31,
pp.175-91
2. Benjamin FB. Highlights of ophthalmology (Letter) 1987, Vol XV,
No 9.
3. Wenkel H, Rummelt V, Knorr H, Naumann GO.Chronic
postoperative endophthalmitis following cataract extraction and
intraocular lens implantation. Report on nine patients. Ger J
Ophthalmol 1993: 2: 419-25
4. John CC, Mili R. Epidemic bacillus endophthalmitis after cataract
surgery II. Chronic and recurrent presentation and outcome.
Ophthalmology 2000; 107: 1038-41
5. Jalali S, Das T, Gupta S. Presumed non-infectious endophthalmitis
after cataract surgery. J Cataract Refract Surg 1996;22: 1492-97.
6. Jehan FS, Mamalis N, Spencer TS, Fry LL, Kerstine RS, Olson RJ.
Postoperative sterile endophthalmitis (TASS) associated with the
memorylens. J Cataract Refract Surg 2000 26:1773-77
7. Madhavan HN, Sara R. Effects of viscoelastic ophthalmic solution
on cell cultures. Indian J Opthalmology 1998;46:37-40
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