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Cataract Cataract Surgery and The Patient with UveitisThe second of two articles focusing on the effective prevention and management of postoperative inflammation.Nick Mamalis, MD
When assessing patients with uveitis and cataracts, you look for essentially the same indicators for surgery as you do in patients without uveitis. For instance, there must be a visually significant cataract, as well as the potential to improve vision postoperatively. In addition, a cataract may have to be removed to allow the examination and treatment of posterior pole disease. Sometimes, though, we are forced to remove a cataract from a patient with uveitis because the cataract is contributing to the inflammation. For example, a hypermature cataract can leak protein and incite inflammation or uveitis. We call this phacotoxic or phacoantigenic uveitis. In other patients, we remove the cataract because it results in a swollen lens, which can lead to the formation of synechia and potential problems with narrow angles. In the July issue of Review, I provided advice on diagnosing and treating unexplained postoperative inflammation. In this follow-up article, I will explain how best to approach cataract surgery and manage inflammation in patients with uveitis. Preoperative Management When contemplating performing cataract surgery in a patient with uveitis, preoperative management is paramount. Your primary objective when treating the patient preoperatively is to control any acute inflammation, because the eye must be quiet prior to surgery. Be aggressive. Use whatever treatment is necessary, whether topical corticosteroids, topical non-steroidal  anti-inflammatories (NSAIDs),
systemic steroids or systemic NSAIDs. Some uveitis specialists advocate what
they call a “stepladder approach.” By this, they mean using simple
topical medications first, followed eventually by subconjunctival injections
and regional medication, and finally, if those do not work, systemic
medications. In patients with severe inflammation that cannot be controlled,
these physicians have even resorted to systemic immunosuppressive therapy or
systemic chemotherapy. Figure 1. Dense posterior subcapsular cataract in a patient with uveitis and previous steroid treatment. Preoperative management is paramount to a good surgical outcome in patients with uveitis. Your primary objective is to control any acute inflammation so that the eye is quiet at the time of surgery. The eye should be calm for about three to four months preoperatively. Keep in mind that it is exceedingly difficult to eliminate all signs of inflammation. Patients with chronic uveitis will always have low-grade flare, but you do not want to have cells in the anterior chamber. Concern yourself with controlling active inflammation. One week prior to surgery, begin the patient on a preoperative regimen. The aim here is to minimize the flare-up of inflammation that follows a surgical procedure. I prescribe a topical corticosteroid drop, usually prednisolone acetate, and a non-steroidal anti-inflammatory drop, such as diclofenac or ketorolac, both q.i.d. It’s also a good idea to put the patient on a short course of oral corticosteroids, like oral prednisone, at a dosage of anywhere from 20 to 60 mg per day, depending on the patient’s weight and the preoperative intensity of his inflammation. Surgical Technique  Particularly in patients with
uveitis, we want to manipulate the eye as little as possible in order to
minimize postoperative inflammation. For this reason, a small incision
phacoemulsification technique with in-the-bag placement of the intraocular lens
(IOL) tends to work best in these cases and actually can hasten patient
recovery. Past reports of relatively poor surgical results in patients with
uveitis and cataracts involved extracapsular cataract extraction and large
incisions, which triggered intense inflammation. I like to use a clear corneal
incision, and I try to leave the conjunctiva and sclera alone. Figure 2. Patient with juvenile rheumatoid arthritis and extensive posterior synechia. In cases with synechia formation, the pupil may be smaller or bound down to the lens. Although manipulation should be minimal, you will have to free up those synechia in order to get an adequate view and remove the cataract thoroughly. A continuous curvilinear capsulorhexis will enable you to place the implant within the capsular bag. It will also allow you to remove as much cortex as possible. In addition to a good capsulorhexis, you will need adequate hydrodissection to further facilitate cortical cleanup. Remember, cortex itself can induce postop inflammation, so you want a pristine capsular bag. Polishing the capsule’s anterior surface can certainly be helpful when it comes to removing residual lens epithelial cells. In terms of the posterior capsule, patients with uveitis often have a posterior subcapsular cataract with some significant plaque. You will want to peel that off as much as you can and vacuum the capsule, but you definitely do not want to break the capsule. Vigorous polishing may increase the risk of capsular rupture.
 I find that an acrylic lens is relatively biocompatible within the eye, and a small clear corneal incision allows me to use a foldable implant. I routinely shy away from silicone implants for uveitic eyes, though, because silicone implants are not as biocompatible as acrylic ones if they are not surface modified. Newer materials, such as the various hydrogels or hydrophilic acrylics, may be better in terms of biocompatability. We do not have enough information on them as yet in terms of their use in patients with uveitis. (See Dr. Zimmerman’s sidebar, bottom.) Figure 3. Intraoperative photograph of a patient undergoing combined phacoemulsification with a posterior chamber IOL and vitrectomy. Postoperative Care You will want to administer some extra corticosteroids right at the conclusion of surgery. You might consider injecting 40 mg triamcinolone sub-Tenon’s posteriorly while the patient is still on the table. I like to make sure patients get a good dose of steroids before they leave the OR. I will put in a collagen shield soaked in dexamethasone, as well as in an antibiotic like cephalexin. Then, I will patch the eye for approximately three hours, after which the patient will remove the patch. At that time, I have the patient begin aggressive corticosteroid and non-steroidal therapy. For the first several days, I have him use topical prednisolone acetate every two to three hours, and I decrease that dosage to approximately four times per day thereafter. Immediately after patch removal, I will also start the patient on a non-steroidal, either diclofenac or ketorolac, four times a day. In addition, I find it helpful to continue patients on a dose of oral prednisone similar to what I had them on during the first preoperative week. I will taper them over the course of two to four weeks postoperatively, depending on how they are tolerating the corticosteroids. We frequently taper the medications of routine cataract patients rapidly. Don’t do so in patients with uveitis, because they can suffer a rebound of their inflammation. Continue them on their steroidal and non-steroidal drops for at least six to eight weeks. Starting and sticking with an aggressive regimen are key to minimizing postoperative problems. These days, we follow up with routine patients at one day postop, again at one to two weeks, and then not for several months. Patients with uveitis require much closer and more frequent attention. I see such patients postoperatively at one day, three or four days, one week and two weeks. In fact, you may want to see these patients weekly until you are certain that their uveitis is neither flaring nor recurring. Complications. There are specific postop complications in patients with uveitis for which you need to watch. • Inflammation. One potential complication, obviously, is a recurrence of the inflammation. If you see any sign of a flare-up of the uveitis, treat the eye aggressively. When tapering medication, watch carefully for signs of a worsening inflammation, which you would treat immediately by increasing the dose of topical corticosteroids and NSAIDs. • Cystoid Macular Edema (CME). In addition to being prone to postop inflammation, these patients are also susceptible to CME or chronic changes in the macula from inflammation. Watch these individuals carefully. If they are developing CME or chronic maculopathy, treat them aggressively with topical steroids and NSAIDs, followed by a sub-Tenon’s steroid injection, when necessary. If these steps do not work, consider other therapies, like systemic acetazolamide. • IOP increase. Some patients are steroid responders, so they will get an increased postoperative pressure as a result of their medications. Certain newly available corticosteroid drops, such as rimexolone and loteprednol etabonate, have a lesser effect on IOP but may not be as strong as prednisolone in treating inflammation. Their clinical use has just begun, so our experience is limited.  Because patients with uveitis are susceptible to rises in IOP, you
must watch them for signs of glaucoma. In cases of increased pressure, treat
patients with aqueous suppressants, beta blockers if the patient can tolerate
them or possibly a carbonic anhydrase inhibitor. • Cornea edema. Naturally, you will want to prevent corneal edema as best you can by controlling the IOP and inflammation; they will affect the endothelial cells that can cause edema. Figure 4. Patient with a posterior chamber IOL showing extensive pupillary capture of the implant with posterior synechia formation and inflammation. I have found that the best preventive measure is to “bounce the pupil.” I give patients a drop of 1% cyclopentolate to use at bedtime. It dilates the pupil for eight or nine hours, and the pupil may then come down during the day. • Synechia. You will want to make sure that the patient’s pupil does not stick down again due to posterior synechia. If the IOL is not perfectly in the capsular bag, you must also watch for pupillary capture of implant (See Figure 4). I find that the best way to prevent the postoperative formation of synechia is to “bounce the pupil.” By that, I mean that I will give patients a drop of 1% cyclopentolate to use at night when they go to bed. This drop will dilate the pupil for eight or nine hours, and then the pupil can come down again during the day. Constant dilation may permit synechia formation, but pupil movement helps to prevent it. Synechia may occur postoperatively in patients with uveitis whether or not they had synechia preoperatively. The pupil should be “bounced” until the postop inflammation has settled down. • Posterior capsular opacification (PCO). The initial postop period has passed, you have tapered the patient’s medication, and the inflammation is under control. Unfortunately, patients with uveitis have a higher incidence of PCO than do those undergoing routine cataract extraction. In a uveitic eye, PCO can opacify the capsule in a matter of several weeks to several months after surgery. Keep the posterior capsule intact for as long as possible after surgery. In patients with visually significant PCO, wait until the eye is completely settled down and the inflammation calm before proceeding with YAG laser treatment. Communication. A good visual outcome does not depend only on excellent preoperative care, surgery and postoperative care. It also relates to the type of uveitis that the patient has (See Figure 5). For example, when treated and followed properly, individuals with Fuchs’ heterochromic iridocyclitis or HLA-B27 uveitis tend to have a fairly good outcome without much postop inflammation.  Those with pars planitis, sarcoid-induced uveitis or uveitis due to
juvenile rheumatoid arthritis usually have more postop inflammation and more
problems with increased IOP and CME. It’s important to counsel your
patients prior to surgery so that they have realistic expectations. Those with
more severe forms of uveitis may not end up with perfect vision and are more
likely to encounter problems postoperatively (See Table 1). Figure 5. Postoperative photograph showing an excellent surgical outcome in a uveitis patient who underwent cataract surgery with a posterior chamber IOL. The outcome depends, in part, on the type of uveitis a patient has. For that reason, it is important to counsel patients before they undergo surgery so that they have realistic expectations. Most people with uveitis are aware of the associated symptoms: pain, light sensitivity, eye redness and decreased vision. Keep in mind that patients with uveitis tend to become somewhat tolerant of these symptoms. In addition to watching them closely, be sure to warn patients to report any changes or increase in symptoms, which might indicate that their inflammation is rebounding or starting up again. In the final analysis, clear communication with your patients is key to their ocular health.
Dr. Mamalis is a professor of ophthalmology and director of the Intermountain Ocular Research Center at the University of Utah.
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