Eyeworld

EW FEATURE 84 Challenging cataract cases • October 2017 He said that patients who are on systemic therapy for uveitis or for systemic immune disease should remain on it. "I often do not supple- ment that around the surgery. I will watch these patients a little more closely postoperatively. Routine cat- aract surgery patients are seen 1 day after surgery and then 3 to 4 weeks later. Uveitis patients are seen 1 day and 1 week after surgery, and some- times in between if I'm concerned about the level of inflammation at day 1," Dr. Raizman said. Some patients who have never previously had uveitis develop it postoperatively. This can be caused by a number of factors. "Certain- ly, any complications during the surgery, especially related to the iris, can cause uveitis," Dr. Raizman said. "Another high-risk scenario is an im- plant that's not in the capsular bag and might be in contact with the iris or ciliary body. This can predis- pose to postoperative inflammation. Retained lens fragments can be hard to diagnose. Additionally, we always need to consider endophthalmitis if a cataract patient develops uveitis postoperatively but did not have uveitis prior to surgery." According to Dr. Oetting, in pa- tients with a history of mild inflam- mation (those who have never need- ed anything stronger than drops to control their inflammation), wait several months while patients are quiet on no drops. Use topical pred- nisolone acetate and a nonsteroidal for a week preoperatively, then use a very slow, 2- to 3-month taper after surgery. Follow these patients a bit more closely, and watch for cystoid macular edema. iris, which seems to lessen postoper- ative synechiae." He said that anterior synechiae from the iris to the cornea are partic- ularly tricky and should be avoided near the main wound and in the angle where anterior chamber IOL haptics are placed. Additionally, iatrogenic capsule damage from injections (or past vit- rectomy) is an increasing problem. Patients with uveitis are increasingly getting injections of steroids and devices with steroids to help control inflammation. Lateral and posterior capsule damage is a rare but noted complication of these procedures. "If you suspect damage from past injec- tions, be very careful or avoid hydro- dissection, such as when operating with a posterior polar cataract," Dr. Oetting said. Patients with past inflamma- tion, especially herpetic-related, can have corneal edema lessening the surgeon's view during surgery. "The primary strategy is to use trypan blue and generous lubrica- tion to maximize contrast and view. Occasionally, side illumination with a light pipe or scraping the corneal surface is used to increase our view," Dr. Oetting said. Controlling inflammation pre- and postoperatively "For patients who have been con- trolled with topical therapy alone, I will often maintain the topical therapy even though the eye is quiet for a month or 2 prior to surgery," Dr. Raizman said. "Three days before surgery, I will begin 0.75 mg to 1 mg/kg/day of oral prednisone. I will continue this for approximately 1 week after surgery." Cataract continued from page 82 In patients with a history of moderate inflammation (those who have needed oral steroids or injec- tions briefly in the past), wait several months with patients on no drops or other agents. Then use oral pred- nisone and a topical nonsteroidal for 3 days preoperatively. "The typical oral dose would be 30 to 40 mg with a quick taper off after a week follow- ing surgery. The prednisolone and nonsteroidal drops are very slowly tapered over 2 months following surgery," Dr. Oetting said. In those patients with a history of severe inflammation, rheuma- tology and retinal specialists may be needed. "These patients often require steroid-sparing agents chronically to remain quiet. They will need an oral steroid, typical- ly around the time of surgery, as described previously, although they may need a longer course," Dr. Oetting said. "They will also need a topical steroid and a nonsteroidal, and they may need injections of intravitreal agents to control cystoid macular edema." Dr. Oetting added that early intervention and close collaboration with rheumatology is critical in any patient who requires oral prednisone to control inflammation and to help rule out systemic inflammatory con- ditions affecting the eye. "I person- ally defer the management of these agents to the rheumatologist." Surgical tips According to Dr. Raizman, the main concern in uveitis patients is managing the pupil. If a patient has posterior synechiae, especially if he or she has a small pupil, extra care needs to be taken. "On the one hand, excessive manipulation of the iris can lead to more inflam- mation after surgery. On the other hand, you must get the pupil to an adequate size to safely perform the surgery. I try to enlarge the pupil only as much as needed for a safe surgery," he said. Additionally, many of these pa- tients have fibrosis of the pupil mar- gin. If the surgeon simply stretches the pupil with a pupil expander or iris hooks, the fibrotic part of the pupil tends to stay intact, while the rest of the pupil stretches unaccept- ably. "This can result in a severely distorted pupil postoperatively. I recommend cutting the pupillary membrane with scissors prior to enlarging the pupil by making radial snips in the membrane every one or two clock hours prior to enlarg- ing the pupil. This tends to create a rounder pupil postoperatively," Dr. Raizman said. Another pearl is to make the rhexis at least 5 mm. In this sce- nario, a 6-mm or 6.5-mm rhexis is sometimes even better. "If the rhexis is too small, the iris may adhere to the edge of the rhexis with posterior synechiae after surgery and create a pupil that's smaller than desired to observe the posterior segment," Dr. Raizman said. EW Editors' note: The physicians have no financial interests related to their comments. Contact information Oetting: thomas-oetting@uiowa.edu Raizman: mbraizman@eyeboston.com Inflammatory deposits on the anterior surface of the IOL following uveitic cataract surgery as seen with direct illumination (left) and retroillumination (right) Source: James Dunn, MD

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