Eyeworld

EW FEATURE 82 Challenging cataract cases • October 2017 AT A GLANCE • Preoperative and intraoperative management strategies can provide optimal outcomes in cataract patients with uveitis. • Patients with uveitis should have a quiet eye for 3–6 months before cataract surgery. • The main concern in uveitis patients is managing the pupil during cataract surgery. Enlarge the pupil only as much as needed for a safe surgery. • A large rhexis is also important for an optimal outcome. by Michelle Stephenson EyeWorld Contributing Writer Proper management of inflammation and surgical technique are the keys to success C ataract surgery in patients with uveitis poses a chal- lenge. However, preoper- ative and intraoperative management strategies can help provide an optimal outcome in these patients. Cataract surgery in patients with uveitis continued on page 84 to be free of inflammation for 6 months prior to cataract surgery. However, there are exceptions to this rule. "Sometimes you cannot completely quiet the eye. Some- times the cataract is the cause of the chronic inflammation, so the lens must be removed to help control the inflammation," he said. Several associated issues make cataract surgery in the setting of chronic inflammation more of a challenge. For example, weak zonules are common with chronic inflammation, even with the very mild inflammation of retinitis pigmentosa. The surgeon should be prepared to place capsular tension segments and capsular tension rings if needed. "Capsular support systems, such as MST [MicroSurgical Technology, Redmond, Washington] capsule support hooks, can be very useful to hold the capsule during nucleofractis. Even if the actual cataract surgery is uneventful, the surgeon should think about the long-term possibility of progressive zonular weakness and should try to prevent capsular phimosis (from weak zonules) with placement of a capsular tension ring, fashioning a large anterior capsulotomy, and using traditional optic capture with a three-piece IOL," Dr. Oetting said. "In children with severe inflamma- tion, I learned from Lisa Arbisser, MD, to consider performing a posterior capsulotomy, then plac- ing the haptics in the sulcus and prolapsing the optic all the way back to capture by the posterior capsule to prevent posterior capsular opacity and phimosis." Small pupils are not uncom- mon, so surgeons should be pre- pared to use iris hooks or other devices. The most common cause of small pupils in patients with uveitis is central posterior synechiae. "I typically will lyse these synechiae with iris hooks to simultaneously break the synechiae and widen the pupil. I typically will do this with no OVD and use trypan blue to stain following iris hook placement, as these lenses are typically very opaque," Dr. Oetting said. "I like to use a diamond configuration of the iris hooks. With severe inflammation and posterior synechiae, especially in children, I will place the three- piece haptics in the bag and the optic anterior (reverse optic capture), so the optic and not the synechiae generating capsule is adjacent to the patients with ocular surface disease with corneal staining. She will see such patients in 3 weeks for a follow-up appointment with repeat cataract diagnostics preoperatively. If they're not quite ready for surgery, she'll use the extra time for corneal treatments and may stretch out sur- gery for the second eye to provide a bit more time for ocular surface treatment and recovery. However, patients with moder- ate to severe disease often require even more time before cataract surgery. One resource Dr. Yeu has found helpful is self-retaining am- niotic membrane therapy. It can be uncomfortable for a patient for 3 to 4 days, but it helps improve the corneal surface rapidly, allowing for more accurate diagnostic imaging, she said. Corneal, cataract surgery timing If a patient requires endothelial keratoplasty and cataract surgery, surgeons carefully weigh how to time the procedures. "For a surgeon just starting out with Descemet's membrane endothelial keratoplas- ty [DMEK] or Descemet's stripping endothelial keratoplasty [DSEK], staging the phaco first is helpful so that when the corneal graft is being done, that's all the surgeon has to focus on," Dr. Chan said. "In DMEK, it is helpful for the pupil to be con- stricted, and if done in combination with phaco, where the pupil has to be dilated, it can make the DMEK more challenging." However, if a patient has morn- ing blur complaints and known Fuchs' dystrophy with cataract, she recommends a combination surgery. Dr. Yeu agreed. "The more that they're having clinical signs of corneal edema, the more likely it is I'll do a combined procedure versus cataract surgery alone," Dr. Yeu said. "If it's a gradual decline in vision, and corneal disease is not as severe based on the clinical exam, I lean toward cataract surgery only," Dr. Mian said. "This is where [ob- taining] endothelial cell density may be helpful." If corneal endothelial disease is less severe, Dr. Mian prefers to perform DMEK; in advanced cases with moderate to severe edema or scarring, his choice is DSEK. Although there has been a lot of buzz about femtosecond laser-as- sisted cataract surgery (FLACS), its advantages are not necessarily as valuable in patients with concurrent endothelial disease. "It could minimize ultrasound energy use, but it depends on the density of the lens," Dr. Mian said. "Femtosecond phaco is not covered by any insurance, so cost becomes a factor. I do use a dispersive viscoelas- tic to protect the endothelium." If a patient has some endo- thelial dysfunction but can have cataract surgery alone, Dr. Yeu will use FLACS. However, if combining cataract surgery with an EK, she will use manual cataract surgery. Dr. Chan also sees the advan- tage of using less phaco energy to emulsify a cataract, especially a dense one, thereby helping to preserve the corneal endothelium. However, "Femto wounds can cause more endothelial apoptosis, so I would not use the femto laser to create incisions in patients with a compromised corneal endothelium," she said. EW Editors' note: The physicians have no financial interests related to their comments. Contact information Chan: clarachanmd@gmail.com Mian: smian@umich.edu Yeu: eyeulin@gmail.com Ensure continued from page 80 Preoperative considerations According to Michael Raizman, MD, Boston, a patient's eye should be quiet for a minimum of 3 months before undergoing cataract surgery. "The exact time depends on the severity of the uveitis. There are patients with recurrent anterior nongranulomatous uveitis, which is perhaps the most common type, without many synechiae, and these patients tend to do better and don't necessarily have to be as quiet as those with a more chronic uveitis with a lot of synechiae," he said. "For example, sarcoidosis patients tends to have a lot of synechiae and small pupils. I would wait a minimum of 3 months for all of them, and for a patient with chronic disease, I might want the eye to be quiet a little bit longer." If uveitis is discovered when a patient presents for cataract surgery but there is no history of uveitis, a tailored workup is required. "I tend to do a very limited workup relative to others in that I direct patients to lab testing based on the type of uve- itis they present with," Dr. Raizman said. Thomas Oetting, MD, Iowa City, Iowa, prefers for the patient

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