Combining Cataract and Uveitis Care

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 postoperatively.

• 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 affectsurgical planning. For example, fluctuating macular edemacan alter axial length measurements and intraocular lens (IOL) calculations. The presence of band keratopathy can block thevisual axis and the surgeon’s view. Removal with chelationshould be considered, with adequate time to allow for cornealstabilization 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.

SELECTED UVEITIS DIVISION PUBLICATIONS 2020

• Bilateral Placoid Choroiditis in an HIV patient with Cryptococcus Neoformans Meningitis and Disseminated Cryptococcal Disease Larochelle RD, Larochelle MB, Aung YY, Linn T, Heiden D, Vitale AT. Journal of VitreoRetinal Diseases (In Press). July 2020.

• Single-Nuclei RNA-Seq Provides Comprehensive Transcriptomic Classification of Human Retinal Cell Types Xuesen Cheng, Qingnan Liang, Leah A. Owen, Akbar Shakoor, Albert T. Vitale, Ivana K Kim, Denise J. Morgan, Yumei Li, Margaret M. DeAngelis, Rui Chen. Investigative Ophthalmology & Visual Science. June 2020, Vol.61, 1956.

• Prevalence of Retinal Diseases and Associated Risk Factors in an African Population from Mwanza, Tanzania Bradley H. Jacobsen, Avni A. Shah, Sahil Aggarwal, Christopher Mwanansao, Molly McFadden, Moussa A. Zouache, Akbar Shakoor. Ophthalmic Surgery, Lasers and Imaging Retina. 2020.

• Efficacy of Adalimumab in Non-Infectious Uveitis Across Different Etiologies: A Post Hoc Analysis of the VISUAL I and VISUAL II Trials Pauline T. Merrill, Albert T. Vitale, Manfred Zierhut, Hiroshi Goto, Martina Kron, Alexandra P. Song, Sophia Pathai, Eric Fortin. Ocular Immunology and Inflammation. 2020 May 29;1-7. Online ahead of print.

• Surgery in Uveitis Christopher D. Conrady, Lynn Hassman, Akbar Shakoor. Uveitis. 2020 - Springer; pp 181-198.

• Long-term Visual Outcomes of Endophthalmitis and the Role of Systemic Steroids in Addition to Intravitreal Dexamethasone Christopher D. Conrady, Richard M. Feist Jr., Albert T. Vitale, Akbar Shakoor. BMC Ophthalmology. 2020; 20:181.

• Not All That Flickers Is Snow Rachel C. Patel, Albert T. Vitale, Donnell J. Creel, Kathleen B. Digre. Journal of Neuro-Ophthalmology. 23 March 2020.

• The Clinical Characteristics of Unilateral Placoid Pigment Epitheliopathies Isil Kutluturk, Aniruddha Agarwal, Shiri Shulman, Albert T. Vitale, Maurizio B. Parodi, Christoph D. Conrady, et al. Ocular Immunology and Inflammation. Published online: 20 Feb. 2020.