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By Marissa B. Larochelle, MD

Cataract surgery in uveitis patients requires special consider­ation. Both intraocular inflammation and its first-line treatment (steroids) contribute to cataract progression, and cataracts are a main cause of decreased vision in uveitis patients. With careful perioperative planning and management, cataract surgery can be safe and effective in this patient population. 

Perioperative Planning

The most important aspect of successful cataract surgery in a uveitis patient is control of inflammation in the perioperative period. In general, surgery should only be considered when inflammation has been quiescent for a minimum of three months, ideally on an anti-inflammatory regimen with or without steroid-sparing immunomodulatory therapy (IMT), on acceptably safe doses of systemic corticosteroids (≤10 mg/daily). Several regimens involving a combination of topical, periocular, and/or systemic steroids exist to control inflammation in the perioperative cataract setting. 

Examples:

• Oral prednisone 60 mg daily (or 1 mg/kg/day for patients weighing less than 60 kg) starting two or three days before surgery and tapering over approximately three weeks post-operatively.
• Initiation of topical steroid (prednisolone acetate 1%) and topical nonsteroidal anti-inflammatory drugs (NSAIDs) one week before surgery.
• Use of intravitreal implant (0.7 mg dexamethasone implant – Ozurdex) or subtenon’s injection of triamcinolone before surgery in patients with a history of recurrent macular edema.
• Pulse dose of intravenous methylprednisolone (ranging from 125-1000 mg) at the time of surgery.
• Subconjunctival or intracameral triamcinolone at the conclusion of the case.

Structural complications associated with uveitis can affect surgical planning. For example, fluctuating macular edema can alter axial length measurements and intraocular lens (IOL) calculations. The presence of band keratopathy can block the visual axis and the surgeon’s view. Removal with chelation should be considered, with adequate time to allow for corneal stabilization before biometry. 

Intraoperative Considerations

Currently, phacoemulsification is the mainstay of cataract surgery for uveitic eyes, with IOL placement in the capsular bag when possible. Uveitic structural complications can pose challenges intraoperatively. Lysis of posterior synechiae or pupillary membranes is often required and can be accomplished with a viscoelastic cannula, Sinskey hook, or micro scissors. The creation of a continuous curvilinear capsulorhexis can be challenging in the case of a fibrotic capsule from chronic inflammation. Capsular hooks or tension rings may be required to stabilize the capsular bag in cases of zonular weakness. 

Children with Uveitis

Uveitic cataracts in the pediatric population present a unique challenge. Cataracts occur in approximately 35% of those with juvenile idiopathic arthritis-associated uveitis. Timing of cataract surgery is especially important in children in the amblyopic age range. Post-operative inflammation in children with uveitis can be particularly robust, resulting in fibrin and formation of pupillary membranes. Uveitis is no longer an absolute contrain­dication to IOL implantation in children, but special attention is required to minimize complications and optimize outcomes.

Pearls:

• Increase or restart oral antivirals (acyclovir or valacyclovir) before cataract surgery in patients with a history of herpetic ocular disease.
• Treat aggressively with corticosteroids (topical, periocular, or oral) in the perioperative period to prevent severe inflammation.
• Consider prophylaxis with Bactrim DS before cataract surgery in patients with ocular toxoplasmosis
• Avoid multifocal IOLs in patients with uveitis, especially if they have any posterior involvement.

Dr. Larochelle specializes in cataract surgery as well as the diagnosis and management of patients with infectious and inflammatory conditions of the eye.