A history of uveitis can hasten a patient's development of cataracts and complicate cataract surgery. The crystalline lens changes due to the intraocular inflammation as well as the topical steroids used to treat the uveitis. Even with an anatomically successful cataract procedure, patients are at increased risk of postoperative complications that could limit their recovery of vision.PREOPERATIVE PLANNING
Although uveitis can affect any part of the uveal tissue from the front of the eye to the back, the most commonly encountered form of the condition is anterior uveitis, the focus of this article. The list of the potential causes of acute anterior uveitis is long, but ophthalmologists are usually unable to pinpoint the origin of the inflammation. Before phacoemulsification, it is imperative that the uveitis be controlled and the eye be quiet. This requirement means that, for at least a few weeks if not months, the anterior chamber should be free of cells. A minor degree of baseline flare is permissible, because complete resolution is often nearly impossible.
To blunt the postoperative inflammatory response, patients begin using topical steroids and nonsteroidal anti-inflammatory drugs (NSAIDs) days to weeks prior to cataract surgery. Uveitic eyes are prone to a pronounced postoperative inflammation as well as to complications such as cystoid macular edema. Subconjunctival, sub- Tenon, or even intravitreal injections of steroids can be administered prior to surgery, although they are not generally required. Systemic steroids or other immunosuppressive drugs are sometimes prescribed in cases of particularly aggressive uveitis.
Many eyes with anterior uveitis have posterior synechiae. These adhesions and any pupillary membrane can limit pupillary dilation and the surgeon's access to the cataract. He or she can dissect the membrane and synechiae with a forceps, a blunt spatula, or even viscoelastic solutions. The pupil can then be expanded mechanically and, if necessary, held in position with iris hooks or other devices for expansion. A sufficiently large capsulorhexis (at least 5 mm in diameter) is needed, because the iris tends to adhere to the anterior lens capsule, which will lead to further synechiae formation during the postoperative period.
Some surgeons advocate implanting a three-piece IOL in the sulcus in order to prevent the iris from contacting the anterior lens capsule, but this positioning may lead to chafing of the iris and additional inflammation. A monofocal lens design is recommended to maximize image quality, as spectacle independence tends not to be a priority for these patients. The commonly used IOL materials are hydrophobic acrylic or silicone polymer. Both are reasonable choices, but some surgeons believe that the former is generally quieter in the eye.
Ophthalmologists can use their standard surgical technique for the cataract procedure, but they should consider additional steps to help control postoperative inflammation. The injection of preservative-free triamcinolone into the anterior chamber or vitreous cavity can be a powerful adjunctive therapy. A subconjunctival or sub-Tenon injection of triamcinolone or other steroids can further enhance the anti-inflammatory effect. In some cases, systemic steroids are administered as an intravenous infusion during surgery and are then continued orally in the postoperative period (Figure).
The patient's use of topical steroids and NSAIDs should be prolonged to ensure that inflammation is completely controlled after surgery. Although prednisolone acetate 1% ophthalmic suspension is commonly prescribed after cataract surgery, stronger medications such as difluprednate 0.05% ophthalmic emulsion may be a better choice.1 When discontinuing steroids, a slow taper helps to prevent rebound inflammation. Continuing NSAIDs for at least 6 weeks may help to prevent cystoid macular edema. The ophthalmologist can follow serial optical coherence tomography measurements of the macula to watch for edema at the postoperative visits.
Once the eye has recovered from cataract surgery and is free of inflammation, the patient should have a relatively routine postoperative course. There is always the chance, however, that uveitis will recur in the future.
Uday Devgan, MD, FRCS, is in private practice at Devgan Eye Surgery in Los Angeles and Beverly Hills, California. He is chief of ophthalmology at Olive View UCLA Medical Center and an associate clinical professor at the Jules Stein Eye Institute at the UCLA School of Medicine. Dr. Devgan may be reached at (800) 337-1969; email@example.com.
- 1. Foster CS, Davanzo R, Flynn TE, et al. Durezol (difluprednate ophthalmic emulsion 0.05%) compared with Pred Forte 1% ophthalmic suspension in the treatment of endogenous anterior uveitis. J Ocul Pharmacol Ther. 2010;26(5):475-483.