Eyeworld

C is a need for a better understanding of PAU following uncomplicated phacoemulsification cataract extraction in patients without a history of uveitis or autoimmune disease. "In my own experience, I have seen nu- merous patients with suspected PAU, some of whom have a negative laboratory workup and some of whom are subsequently diagnosed with an underlying autoimmune condition," Dr. Thomas said. "It is well documented in the lit- erature that some of our patients with idiopath- ic uveitis may actually have sarcoidosis-related uveitis, and this discrepancy is due to a lack of standardized imaging/lab protocols for patients with uveitis. 2 " Dr. Thomas cited the example of patients not necessarily having clear evidence of sar- coidosis on chest x-rays but possibly suggestive findings on a CT scan of the chest. Additionally, Dr. Thomas warned that the extent of inflammation in a postop uveitis may be underestimated; if OCT is not being rou- tinely performed, prevalence of CME may be underestimated. Additional imaging may reveal inflammation beyond the anterior chamber and macula. For example, a patient with PAU who Dr. Thomas recently evaluated also was found to have mild retinal vasculitis. Significance of the findings The finding that African Americans have a higher risk of developing PAU following uncomplicated phacoemulsification cataract extraction was "quite significant," Dr. Thomas said. Equally significant was the percentage of African American patients that had bilateral PAU. "While the hypothesis of the role of melanin in the pathogenesis of PAU is appro- priate, I wonder whether patients with bilateral PAU and those with inflammation exceeding 12 months following cataract surgery have some underlying predisposition to autoimmunity," Dr. Thomas said. "Given the greater prevalence of sarcoidosis in African American patients and the challenges with diagnosis that I mentioned previously, it would be interesting to investigate this point further." Also important was the finding that there was no association with worse VA or IOP com- pared to others who also developed PAU. Such information should be available for patients. "It is important, however, to note that OCT was not routinely performed on all patients with PAU," Dr. Thomas said. "Thus, is it plausible that the prevalence of CME, and its effect on VA outcomes, was underestimated." The findings should impact ophthalmolo- gists' clinical approach. "I would implore any ophthalmologist assessing a patient with suspected PAU to have a standardized approach to the diagnosis of this condition," Dr. Thomas said. "That is, first rule out any lens-related uveitides, then consider a standard panel of laboratory and radiographic tests." Additionally, it would be worthwhile for an- terior segment surgeons to consider waiting for resolution of anterior chamber inflammation and/or CME in the first eye prior to performing cataract surgery on the fellow eye, especially in African American patients, Dr. Thomas said. JUNE 2019 | EYEWORLD | 37 And more from the 2019 ASCRS ASOA Annual Meeting GEORGE WARING IV, MD References 1. Reddy AK, et al. Risk factors associated with persistent ante- rior uveitis after cataract surgery. Am J Ophthalmol. 2019. Epub ahead of print. 2. Han YS, et al. Distinguishing uveitis secondary to sarcoidosis from idiopathic disease: cardiac implications. JAMA Ophthalmol. 2018;136:109–115. Financial interests Thomas: None

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