Eyeworld

28 | EYEWORLD | SUMMER 2025 ATARACT C Relevant disclosures Galor: None Kedhar: None Larochelle: None uses oral prednisone, starting 2 or 3 days before surgery and tapering over 3 weeks. Additionally, if a patient has known macular edema that's recurred in the past and they require an intravitreal injection, such as Ozurdex (dexamethasone, AbbVie), Dr. Laro- chelle will make sure the patient has a fresh injection on board or consider intraoperative at the time of surgery to give them extra coverage. Dr. Larochelle added that things like herpet- ic uveitis may flare around cataract surgery, so if you know someone has a history of herpetic eye disease, it's important to ensure they're back on an oral antiviral around the time of surgery. Surgery and lens considerations Dr. Kedhar recommends that patients under- go small incision phaco. "In terms of the lens choice, generally we recommend acrylic lenses for these patients," he said. "Those seem to be well tolerated without any increased risk of inflammation." Dr. Kedhar advised having a frank discus- sion with full explanation of the risks of certain premium lenses. "Usually, I don't recommend multifocal lenses because of the risk of macular changes afterward, which might make the pa- tient dissatisfied later." He also said it's import- ant to try to place the lens in the capsular bag as opposed to in the sulcus because leaving the posterior capsule intact is important. He said to ensure that the capsulorhexis is sufficiently large. Typically, you want a 5–6 mm capsulorhexis because these patients tend to have phimosis or contraction of the anterior capsule, so by keeping it 5–6 mm, that usual- ly minimizes the contraction. The lenses can decenter when that does occur. These patients also tend to have weaker zonules, so with any kind of premium lens where it needs to be well centered, there's a risk for decentration, Dr. Kedhar said. "During surgery, we may have to deal with pupillary membranes and posterior synechiae, so that can make the case longer, and it's more uncomfortable to be manipulating the iris, so we'll use more anesthesia, whether it's a sub-Tenon's or retrobulbar block," Dr. Larochelle said. She will not hesitate to do general anes- thesia in patients who are adolescents or even also recommend if there's any CME present that it be maximally treated for 90 days before sur- gery and that patients are treated with periop- erative corticosteroids." This can range from topical steroids beginning 3–7 days before sur- gery to systemic oral steroids, and that would be determined on a case-by-case basis depending on the severity of the inflammation. Dr. Kedhar said it may make sense to treat preoperatively with topical NSAIDs because these patients have a higher risk of CME after surgery. If the patient has any infectious causes for their uveitis, like herpes simplex or herpes zoster, it generally makes sense to treat with an antiviral prior to surgery and through the postop course to minimize risk of recurrence, he added. Dr. Larochelle will treat aggressively with steroids to try to prevent an exacerbation of uveitis from the surgery itself. "I typically have a regimen of starting a topical steroid like prednisolone as well as a topical NSAID 1 week ahead of surgery, each drop 4 times a day," she said. This continues into the postop period with an extended taper. Dr. Larochelle also generally continued from page 27 continued on page 30 Band keratopathy, posterior synechiae, and uveitic cataract in a patient with a history of juvenile idiopathic arthritis-associated iritis Source: Sanjay Kedhar, MD

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