Seminars in Ophthalmology

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Cataract Surgery Complications in Uveitis Patients:

A Review Article

Stephanie M. Llop & George N. Papaliodis

To cite this article: Stephanie M. Llop & George N. Papaliodis (2018) Cataract Surgery
Complications in Uveitis Patients: A Review Article, Seminars in Ophthalmology, 33:1, 64-69, DOI:
10.1080/08820538.2017.1353815

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Published online: 29 Nov 2017.

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Seminars in Ophthalmology, 2018; 33(1): 64–69
© Taylor & Francis
ISSN: 0882-0538 print / 1744-5205 online
DOI: https://doi.org/10.1080/08820538.2017.1353815

Cataract Surgery Complications in Uveitis Patients:

A Review Article
Stephanie M. Llop and George N. Papaliodis

Uveitis and Ocular Immunology Service, Department of Ophthalmology, Massachusetts Eye and Ear, Harvard
Medical School, Boston, MA, USA

ABSTRACT
Uveitis is a leading causes of blindness worldwide, and the development of cataracts is common due to both the
presence of intraocular inflammation and the most commonly employed treatment with corticosteroids. The
management of these cataracts can be very challenging and often requires additional procedures that can
compromise surgical results. The underlying disease affects a relatively young population at higher risk of
complications. Preoperative control of inflammation/quiescent disease for at least three months is generally
accepted as the minimum amount of time prior to surgical intervention. Phacoemulsification with intraocular
lens is the preferred method for surgery, with some studies showing improvement in visual acuity in over 90% of
patients. The most common postoperative complications include macular edema, posterior capsule opacification,
recurrent or persistent inflammation, glaucoma, epiretinal membrane and IOL deposits, or dislocation. Despite
the potential complications, cataract surgery in uveitis patients is considered a safe and successful procedure.
Keywords: Cataracta complicata, cataract complications, cataract extraction, phacoemulsificationuveitis

INTRODUCTION membranes, and bleeding from fragile vessels pose

The development of cataracts is a known complication
in patients with uveitis due to the presence of intrao-
cular inflammation and/or its treatment with topical,
regional, and systemic steroids.1–8 Previous studies
have demonstrated the incidence of cataracts in uveitis
varies from 57% in pars planitis to 78% in Fuchs het-
erochromic cyclitis.5,9–13 The most common type are
posterior sub-capsular cataracts,14,15 and their progres-
sion depends on the duration, intensity, and treatment
of inflammation.16 A recent study in 1,173 eyes with
uveitis showed that, compared to non-uveitic catar-
acts, eyes with uveitis are from younger patients who
have worse preoperative and postoperative visual
acuity at all visits.17
The management of cataracts in these patients with
ocular inflammation has historically been a challenge,
being technically more difficult and providing less
reliable outcomes than the management of age-
related cataracts.18 Poor pupillary dilatation and
intraoperative complications due to posterior synechia,
poor stability of the capsule or zonules, pupillary
surgical challenges for the cataract surgeon that
usually require additional procedures and result in
more complications.6,11,19–22
Preoperative Management
Due to the lack of studies that show good evidence in
terms of preoperative management, there is no consen-
sus on the ideal treatment to prepare eyes with uveitis for
cataract surgery. Most authors agree that a period of
three months of quiescence is necessary, but some
patients with recurrent or chronic uveitis may undergo
surgery during a “window of opportunity” when
inflammation appears to be better controlled.18
Certainly, there is significant variability in the type of
preoperative steroids used, but some type of preparation
before cataract surgery is imperative. Bhargava et al.
found in two publications that patients who were treated
with preoperative oral corticosteroids had significantly
better final visual acuity than patients who did not used
preoperative corticosteroids (P < 0.001).9,22

Correspondence: George N. Papaliodis, M.D., 243 Charles St., Boston, MA 02114, USA. E-mail: george_papaliodis@meei.harvard.edu

64
 Cataract Surgery Complications in Uveitis Patients
Type of Surgery: Phacoemulsification vs. Small
Incision Cataract Surgery (SICS)
One reason it is difficult to compare previous studies is
because of older surgical techniques compared to
modern phacoemulsification surgery. A study by
Suresh et al. performed phacoemulsification via either
a 5.5 mm scleral tunnel, or a 3.2 mm clear cornea
approach with IOL insertion and an overall immediate
improvement of two or more lines of Snellen VA was
seen in 91% of the eyes and maintained until the latest
follow-up in 87% of cases.18 In another study of 242
eyes with uveitis that underwent phacoemulsification
surgery, 59.9% of eyes had a visual acuity of 20/40 or
better by their last postoperative visit; 68.18% had
anterior uveitis, 7% intermediate, 7% posterior, and
17.76% panuveitis.23 Ram et al. found improvement
in 91.6% of patients after phacoemulsification.24
Estafanous et al. reported 87% of patients with visual
acuity of 20/40 or better.19 A study that compared
phacoemulsification versus small incision cataract sur-
gery (SICS—a form of extracapsular cataract extrac-
tion) showed comparable results with corrected
distance visual acuity (CDVA) of 20/60 or better in
90.0% of patients who had phacoemulsification versus
88.3% in the SICS group.22 Data from Hazari et al.
comparing extracapsular cataract extraction (ECCE),
ECCE with posterior capsule intraocular lens
(PCIOL), and phacoemulsification with PCIOL in uvei-
tis patients showed no statistically significant differ-
ence in the visual acuity at six months between the
three groups.3 These facts seem to be irrelevant in our
modern era of advanced phacoemulsification, but,
unfortunately, there are still countries that do not
have open access to this technology.
COMPLICATIONS
Cystoid Macular Edema
Cystoid macular edema (CME) is the most common
complication of cataract surgery in the general popula-
tion. Because of the different definitions and diagnostic
criteria, the incidence has been reported to be between
1% and 30%, with 1%–2% of patients having no risk
factors. Although, in most cases, the macular edema is
self-limited, in rare cases it can lead to long-term visual
deterioration that is difficult to treat.25
In patients with uveitis undergoing cataract sur-
gery, the reported incidence ranges from 2% by
Suresh et al. to 33% by Estafanous et al. following
phacoemulsification.3,4,6,9,14–20,24,26 Severe uveitis was
associated with an increased incidence of macular
edema. One study published a prevalence of up to
56% of CME when longer follow-up was observed
(mean 81.4 months).27 Comparing phacoemulsification
vs. SICS, patients in the phacoemulsification group
© 2018 Taylor & Francis
65
had a slightly lower incidence of cystoid macular
edema and persistent uveitis.22 Many factors play a
role in the development of macular edema; this
makes it difficult to compare studies and accounts for
such a large variability in the published data. The
etiology of the uveitis has a big impact on the risk of
developing postoperative macular edema, being more
prevalent in intermediate uveitis and very rare in her-
petic infections. This is shown, for example, in studies
specifically on patients with pars planitis, where post-
operative macular edema has a higher impact, affect-
ing up to half of the cases, related to a higher
preoperative incidence of CME.5 The preoperative con-
trol of inflammation is key in predicting recurrent
inflammation after cataract surgery and, consequently,
the development of macular edema. Bhargava et al.
showed that there was a statistically significant reduc-
tion in the rate of macular edema in patients preopera-
tively treated with oral corticosteroids (P < 0.001).9 In a
study of patients with JIA, all eyes had chronic ante-
rior uveitis (45 inflamed eyes) at the time of cataract
surgery; despite ongoing immunosuppressive therapy,
44% developed CME.28 Eventually, chronic macular
edema can result in atrophic macular changes that
could affect vision permanently.14
Posterior Capsular Opacification (PCO)
Another common complication after cataract surgery
is posterior capsule opacification, leading to symptoms
of glare or blurred vision, reduced visual acuity, or
impaired posterior segment exam.20 Some studies
would consider PCO as clinically significant if it
requires yttrium aluminum garnet (YAG) capsulot-
omy. The incidence of PCO varies among studies, in
part due to the definition given or criteria for diagno-
sis. Factors that are critical in the development of PCO
include surgical technique, and preoperative/post-
operative control of uveitis; it is more likely to occur
in eyes with persistent inflammatory activity.10 Kosker
et al. had the lowest PCO rate of 12.7% in a study that
only included quiet eyes (at least three months prior to
surgery) with a diagnosis of anterior uveitis,21
although Okhravi et al. reported that the prevalence
is higher in patients with anterior uveitis compared to
posterior.10 Hazari et al. reported PCO in 14.92%3 of
patients; Bhargava et al. in 16.67%9 of eyes that under-
went SICS, and comparing SICS vs phacoemulsifica-
tion, the incidence was 15% vs 16.7% respectively. In
both groups, YAG laser capsulotomy was performed
in 20 eyes (15.9%) after a quiet postoperative period of
three months.22 In one of these studies in patients who
had SICS, there was no statistically significant correla-
tion between PCO and increased postoperative inflam-
mation (P > 0.05).9 In a large cohort of 242 eyes by
Yamane et al., PCO was documented in 19% of
patients after phacoemulsification.23 PCO requiring
66 S. M. Llop and G. N. Papaliodis
YAG laser capsulotomy was reported in 18.3% by
Yoeruek et al.,16 28.70% eyes by Ram et al.,24 and in
31% of eyes by Estafanous et al.19 Other studies have a
higher incidence, ranging from 37.5% to 58% of eyes,
including a study with 42.3% PCO in patients who
only had intermediate uveitis.4,13,15,27
When comparing IOL materials (polymethyl metha-
crylate [PMMA], silicone and acrylic), PCO after sur-
gery occurred in 23.7% of eyes, but significantly less
frequently in patients with an acrylic IOL than in
patients with IOLs of other materials (P < .001).6
Suresh et al. compared PMMA, heparin surface-
modified and acrylic IOLs, and PCO was seen in
53%, 45%, and 24%, respectively.18 Lower rates were
seen in patients who were given systemic corticoster-
oids preoperatively.20 PMMA lenses have demon-
strated the highest incidence of associated PCO in
normal eyes, so their use is not recommended in
patients with uveitis who are predisposed to increased
inflammation.10 A study by Elgohary et al. using a Cox
multivariate regression model revealed that YAG cap-
sulotomy was required at a higher rate in patients who
had hydrogel IOLs and in patients <55 years old.20
Fogla et al. also described a higher prevalence of
PCO in younger patients <40 years old.15 In a recent
study of cataract surgery in pediatric uveitis (mean age
10.9 years), the percent of PCO was 15/21 eyes or
71%.26
Recurrent or Persistent Inflammation
Some authors clinically define postoperative uveitis as
any inflammatory episode within three months after
surgery that required additional intensive antiinflam-
matory (topical or systemic) or immunosuppressive
treatment in the presence of anterior chamber flare
and/or cells. Studies with lower recurrence of uveitis
have stricter preoperative steroid application and, in
some cases, additional immunosuppressive
treatment.16 As little as 8.3% of patients developing
recurrent inflammation has been reported, but a very
short follow-up period is noticed in that study
(4–8 weeks postsurgery).16 Other studies have shown
an incidence of 12.5% in one month,4 approximately
13% in six months,6,21 and 30% recurrence in
12 months.11 When longer follow-up is provided, the
true incidence might be higher, as suggested by the
findings of Krishna et al., where 53% of eyes devel-
oped clinically significant recurrence or exacerbation
of inflammation.27 In those with anterior disease,
severe uveitis in the first week postoperatively was
found to be associated with an increased incidence of
macular edema, and visual acuity less than 6/12 at
six months’ follow-up.10,13
When comparing ECCE with ECCE + PCIOL, there
was no statistically significant difference in postopera-
tive inflammation, noted in 27.4% of eyes. However,
eyes that underwent phacoemulsification and PCIOL
implantation were associated with significantly lower
incidence of increase inflammation (chi-square test;
P = 0.047).3 Bhargava et al. found a rate of persistent
uveitis in 16.7% of patients who underwent SICS vs.
13.6% after phacoemulsification.22 Studies exclusively
on phacoemulsification in uveitis patients report an
incidence of 21.8% by Elgohary et al.20 and 30.16%
by Yamane et al.23 Abela-Formanek et al. showed
that there were no significant differences in inflamma-
tion after implantation of foldable IOLs in uveitic eyes
(foldable hydrophilic acrylic, hydrophobic acrylic or
silicone).29
Epiretinal Membrane
Epiretinal membrane is another complication after cat-
aract extraction in uveitic patients. The etiology of the
uveitis and the diagnostic modality (clinical exam vs.
use of OCT) may explain the large variability in the
incidence of this complication, which ranges between
4.47% and 56%.3,9,16,19,20,22,23,27
Glaucoma
The coexistence of uveitis and ocular hypertension is
common, and previous studies have found that
increased IOP leads to glaucoma in 9–20% of
patients.30 It is then expected that postoperative devel-
opment of persistently elevated IOP is another com-
mon complication of cataract surgery. There are many
etiologies for uveitis and some are inherently more
associated with glaucoma than others.
Older studies, including a review of the published
data on Fuchs heterochromic iridocyclitis (FHI),
reported that the incidence of glaucoma ranges from
10% to 32% in the years prior to modern phacoemulsi-
fication surgery. This particular subset of patients with
FHI also have a higher frequency of hyphema;5 Suresh
et al. observed the Amsler’s sign in 20/34 eyes with
FHI.18 Studies in juvenile idiopathic arthritis (JIA)
patients show that eyes with active inflammation
developed secondary glaucoma in 50% of cases.28 In
the Fox et al. group, 3/16 eyes with glaucoma preo-
peratively developed loss of visual acuity postopera-
tively because of complications of chronic glaucoma.31
A raise in IOP is usually followed by complete
resolution, but sometimes a reasonable number of
patients require glaucoma surgery. In a study by
Yoeruek et al., a rise in IOP occurred in 41 eyes
(22.8%), but 19 of these eyes had borderline pressure
before cataract surgery. Of these, 2.2% (four eyes)
required glaucoma surgery.16 Similarly, Okhravi et al.
reported 13.3% eyes (12 of 90 eyes) with raised IOP
and two required surgery. Findings were similar for
phacoemulsification and SICS.22
Seminars in Ophthalmology
 Cataract Surgery Complications in Uveitis Patients
Hypotony
Low IOP or hypotony is an uncommon complication
after cataract extraction. Older studies on patient
with JRA showed higher incidence of hypotony
that is mostly seen in the immediate postoperative
period. Possible explanations include cyclitic mem-
branes, ciliary body detachments, or severe
inflammation.5
IOL Deposition
The standard of care for cataract surgery in uveitis
represents phacoemulsification with in-the-bag place-
ment of an intraocular lens.6,32 The appearance of
deposits in the IOLs is a late complication seen in
uveitis patients. A study from Suresh et al. (2001)
reported that the incidence of giant cell deposition on
the IOL surface was substantial enough to initiate or
enhance topical steroid treatment in 19% of the eyes,
occurring on 7 of 31 heparin surface-modified IOLs
(23%), 6 of 30 PMMA IOLs (20%), and on 3 of 25
acrylic IOLs (12%).18 Yoeruek et al. had 12.8% of 180
eyes develop deposits in the anterior surface of the
lens16 and Elgohary et al. saw 3% anterior lens depos-
its, all in plate-haptic silicone IOLs.20 Silicone has the
worst visual results, according to a meta-analysis by
Mehta et al.7
IOL Dislocation
Another known problem after complicated uveitic cat-
aract surgery is IOL dislocation, with an incidence that
ranges between 0.2% and 3%. Early dislocation has
been attributed to loss of capsular support or zonular
integrity during surgery or uneven placement of the
haptics. However, late dislocation has been reported
many years after an otherwise uncomplicated surgery.
This is believed to be secondary to progressive dehis-
cence of the zonules; per previous studies, uveitis is
among the risk factors for IOL dislocation that also
include pseudoexfoliation, surgical or external trauma,
history of vitrectomy, or eyes with high axial length.33
In a study by Ganesh et al. of 581 eyes with chronic
uveitis that underwent phacoemulsification surgery,
11 eyes had late dislocation of the IOL. Although
most of these patients maintain good vision in the
long term and the prevalence is very low, it certainly
poses special consideration in this high-risk population
in which additional surgery could result in recurrence
of inflammation and elevated IOP. Juroswki et al.
reported lens capsule contraction in 80% of patients
with 40% developing IOL decentration, versus just one
patient (3.3%) developing IOL decentration in the
group with non-uveitic senile cataract.11
© 2018 Taylor & Francis
67
Other Complications
Other complications that occur less frequently but
have been reported include corneal edema, corneal
scars, corneal neovascularization, corneal perforation,
band keratopathy, iris atrophy, anterior synechia, pos-
terior synechia, rubeosis, hypopyon, anterior capsular
opacities, IOL explantation, IOL capture, vitreous opa-
cities, vitreous hemorrhages, macular holes, optic disc
edema, optic disc atrophy, retinal detachments, chor-
oidal detachments, enucleation, evisceration, and
pthisis.23
DISCUSSION
Overall, cataract surgery in uveitis patients is a very
successful procedure that not only improves visual
acuity in most patients, but also provides better visua-
lization of the posterior segment. The evidence demon-
strates that IOL implantation can be done safely in
these patients, and the single most important factor
for successful surgery appears to be good inflamma-
tion control and a quiescent, inflammation-free period
of at least three months prior to surgery. The preva-
lence of complications is slightly higher in studies on
ECCE than phacoemulsification, but overall both
methods are very effective if the inflammation is con-
trolled prior to the procedure. This is still relevant,
because phacoemulsification remains inaccessible in
many countries.
The high variability in the reported incidence of
complications in this article is related to many factors.
Uveitis is a broad category of heterogeneous condi-
tions that involves infectious or non-infectious inflam-
mation of the anterior, intermediate, and/or posterior
segment of the eye. Not all etiologies have the same
implications in terms of the risk of developing certain
complications like macular edema. Also, there are dif-
ferences in the definitions and the criteria authors use
to determine its relevance. For example, there is no
standardized way to diagnose CME, and some studies
would use OCT vs. fluorescein angiography or simply
a clinical exam, which makes it somewhat difficult to
compare results between studies. Moreover, studies
come from different countries with diverse popula-
tions who have risk factors that could influence, either
positively or negatively, the results of cataract surgery.
These and many other aspects account for the inevita-
ble variability in the published data and make com-
parison among studies difficult, preventing the
development of standardized protocols.
Despite the good overall results, it is still important
to be cognizant that uveitis patients are at a higher risk
for complications, so they should be informed about
this risk and establish reasonable expectations for
visual recovery after cataract surgery.
68 S. M. Llop and G. N. Papaliodis
DECLARATION OF INTEREST
The authors report no conflicts of interest. The authors
alone are responsible for the content and writing of
this article.
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