EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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42 EW CATARACT September 2012 Complicated cataract cases Uveitis: Posterior synechiae, lens deposits, CME, prolonged post-op inflammation, and secondary glaucoma by James P. Dunn, M.D. U T his month's "Complicated cataract cases" column takes a look at the subject of uveitis, which is an inflammation of the uveal tract including the iris, ciliary body, and choroid. Uveitis is a common problem in general ophthalmic practice. In addition to cataract development, it predisposes to complications such as anterior and poste- rior synechiae, glaucoma, cystoid macular edema, and reduced visual potential. The surgeon must be ready to manage these problems pre-operatively, intraoperatively, and post-operatively. Pre-op management consists of quieting these eyes in advance of surgery and counseling patients on possible post-op problems, which include pupil irregularity, optic capture, lenticular inflam- matory deposits, glaucoma from either the underlying uveitis or the corticosteroid medications used to treat it, epiretinal membrane development, cystoid macular edema, and less-than-perfect visual acuity after surgery. Intraoperative management may entail managing synechiae, miotic pupils, and posterior capsule plaques. Placement of the intraocular lens is an important intraoperative consideration. In synechiae formers, serious consideration should be given to sulcus placement of an appropri- ately designed lens to keep adhesions from developing post-op between the iris and the residual anterior lens capsule. Post-op management consists of quieting inflammation and handling any complications that may arise in the days, weeks, and months that follow. Typical post-op problems include keratic precipi- tates, lenticular precipitates, recurrent synechiae, lens decentration, optic capture, posterior capsule opacification, and cystoid macular edema. In addition to patients who come to cataract surgery with a known history of uveitis, there are patients who will develop uveitis either de novo or as a complication of surgery. The cataract surgeon must be prepared to handle these eyes as well. In this issue, James P. Dunn, M.D., shares some study information, clinical pearls, and case examples that ophthal- mologists will find useful for brushing up on this very important subject. Kevin Miller, M.D., Complicated cataract cases editor Figure 2A (Case 1). CME in left eye associated with active sarcoid uveitis Figure 2B (Case 1). Resolution of CME following sub-Tenon's triamcinolone acetonide injection Figure 3C (Case 2). Post-op slit lamp photograph of left eye showing resolution of iris bombe veitis following cataract surgery increases the risk of cystoid macular edema (CME), posterior synechiae, and secondary glaucoma, all of which may lead to delayed visual recovery or perma- nent visual loss. It is important to make the distinction between patients with pre-existing uveitis who undergo cataract surgery and those with no history of intraocular inflammation who develop uveitis after surgery. In the latter group, there typically has been some type of intraoperative complication, al- though it may not be recognized at the time of surgery, such as a small nuclear fragment that is not aspi- rated and lodges itself in the angle. A careful clinical examination is essential if such complications are to be identified and treated success- fully. Foster and colleagues popular- ized the concept of aggressive pre-op suppression of uveitis for at least several months prior to cataract sur- gery.1 While there are a variety of published regimens using a combi- nation of topical, oral, and periocu- lar corticosteroids as well as oral or topical nonsteroidal anti-inflamma- tory drugs (NSAIDs), the fundamen- tal principle is to minimize the risk of recurrent uveitis and its sequelae by complete control of inflamma- tion. With uncommon exceptions such as traumatic or phacolytic cataract, cataract surgery should never be performed in an actively inflamed eye. Furthermore, CME should be eliminated or minimized; the same regimen that treats uveitis will often accomplish this goal. A recent report showed patients with posterior uveitis who had undergone placement of an intravitreal fluoci- nolone implant prior to cataract sur- gery had better visual outcomes and less uveitis (but also more glaucoma) after surgery compared to eyes undergoing cataract surgery with no fluocinolone implant.2 At the time of surgery, intra- venous methylprednisolone 125-500 mg or hydrocortisone 100-400 mg at the start of surgery is given if there are no medical contraindications. Principles of uveitic cataract surgery include minimization of iris trauma (which compromises the blood aqueous barrier and tends to lead to iridocapsular adhesions after sur- gery), meticulous cortical removal, and careful placement of the in- traocular lens within the capsular bag. The literature regarding which IOL material is preferable in such cases is inconclusive, and there are advocates for one-piece or three- piece acrylic lenses as well as three- piece silicone lenses. Intraocular lens deposits following uveitic cataract surgery appear to be less common with hydrophobic acrylic lenses than other lens types, but some clinicians feel that the pre- and post-op medical management of the uveitis and meticulous intraopera- tive technique are more important factors in the outcome of surgery. continued on page 44 Figure 3A (Case 2). Iris bombe due to extensive posterior synechiae Figure 1. Inflammatory deposits on the anterior surface of the IOL following uveitic cataract surgery as seen with direct illumination (left) and retroillumination (right) Figure 3B (Case 2). Extensive iris pigment deposits on anterior lens surface caused by recurrent acute anterior uveitis