Management of coincident cataract and uveitis

Visual outcomes and risk factors of uveitis cataract eyes after phacoemulsification and manual small-incision cataract surgery

PURPOSE

To examine the visual outcomes and risk factors of uveitis cataract eyes after phacoemulsification and manual small-incision cataract surgery (MSICS).

SETTING

Tertiary-care eye hospital in southern India.

DESIGN

Retrospective interventional case series.

METHODS

Of the uveitis eyes operated for cataract surgery between 2017 and 2020, eyes with a minimum of 6 months postoperative follow-up were included. Eyes with ocular trauma, lens subluxation, lens-induced uveitis, or retinal detachment-induced uveitis were excluded. Demography, visual acuity, intraoperative and postoperative records, and surgical outcomes were analyzed.

RESULTS

191 eyes of 191 patients with a mean age of 51.7 ± 14.4 years were included. Phacoemulsification was performed in 134 eyes, and 57 eyes underwent MSICS. Synechiolysis and pupil-expanding maneuvers were required in 74 eyes (38.7%). No differences were noted in the rates of complications between phacoemulsification and MSICS eyes, except at 1 year, where higher rates of posterior capsular opacification and vitritis were noted in MSICS eyes ( P = .018). The visual outcomes of eyes that underwent MSICS and phacoemulsification were comparable ( P = .463). In 12 eyes (13.5%), improvement in vision was not significant.

CONCLUSIONS

This study shows phacoemulsification may be a preferred technique in uveitis cataracts, given the lesser incidence of postoperative complications. Patients should be counseled for realistic expectations.

Uveitis Associated with Juvenile Idiopathic Arthritis

Juvenile idiopathic arthritis (JIA) is the most common cause of uveitis in children. While symptoms are usually mild, persistent eye inflammation could lead to severe complications and impaired vision. It is essential that JIA patients at risk are diagnosed with uveitis early, receive adequate treatment, and avoid developing complications, such as cataract, glaucoma, and amblyopia. The purpose of this mini-review is to summarize the screening strategies and clinical management for JIA-associated uveitis (JIA-U) as well as the current state of molecular markers linked to this condition. Because glaucoma is one of the most common causes of visual loss in JIA-U, special focus will be put on this serious complication. We conclude by describing the current evidence regarding the long-standing question of whether chronic anterior uveitis without arthritis may be the same disease entity as JIA-U.

Early and Late Complications after Cataract Surgery in Patients with Uveitis

Background and Objectives: Uveitis, a prevalent eye disorder characterized by inflammatory processes, often leads to cataract formation and significant visual impairment. This study aimed to evaluate preoperative conditions and postoperative outcomes following cataract surgery in uveitis patients. Materials and Methods: A retrospective study was conducted at the University Hospital Center Rebro Zagreb, Croatia, involving uveitis patients who underwent cataract surgery between 2013 and 2022. Eligible patients had uveitic cataracts affecting visual acuity or posterior segment visualization in a "quiet eye" and were disease-inactive for at least three months. Patients with certain pre-existing ocular conditions were excluded. The data collected included patient demographics, uveitis type, preoperative therapy, preexisting lesions, and postoperative outcomes such as visual acuity, intraocular pressure, central macular thickness, and complications. Statistical analysis was performed to identify risk factors associated with complications. Results: This study included 105 patients. The most common uveitis types were idiopathic uveitis, HLA-B27-associated uveitis, and JIA uveitis. After cataract surgery, there was a significant improvement in visual acuity at various time points, with 90% of eyes showing improvement. Intraocular pressure decreased over time. Central macular thickness increased at three months post-surgery but remained stable thereafter. Early and late complications were observed in 52.4% and 63.8% of eyes, respectively. The most common complications were posterior capsular opacification (53.3%), macular edema (26.6%), and epiretinal membrane formation (9.52%). The factors associated with complications varied between early and late stages but included age, age at the onset of uveitis, and the uveitis type. Conclusions: In patients with quiescent uveitis undergoing cataract surgery, significant visual improvement was achieved. This study highlights the importance of careful patient selection, preoperative and postoperative inflammation management, and precise surgical techniques. Although complications were common, the risk of capsular opacification, macular edema, and epiretinal membrane formation after surgery increased. However, future investigations should address this study's limitations and further refine perioperative strategies.

Cataract surgery in patients with uveitis: Data from the Swedish National Cataract Register

PURPOSE

To investigate the surgical and pharmacological management and outcomes of patients with cataract and concurrent uveitis.

METHODS

Data from the Swedish National Cataract Register, 2018-2019, were collected and analysed. Uveitic eyes were identified and eyes without uveitis were used as controls. Generalized estimating equations were used to adjust for intra-individual correlation.

RESULTS

The study included 719 eyes with and 256 360 without uveitis. The mean age was 66.0 ± 13.5 (standard deviation [SD]) years in the uveitis group and 74.3 ± 8.7 years in the control group (p < 0.001). Surgery was associated with more intraoperative difficulties in eyes with uveitis (27.0%) than in control eyes (7.1%; p < 0.001). Posterior capsule rupture/zonular complications were registered in nine eyes with uveitis (1.3%) and in 1464 eyes without uveitis (0.6%; p = 0.02). Hydrophilic acrylic intraocular lenses (uveitis 3.6%, controls 1.2%) and subconjunctival steroids (uveitis 17.4%, controls 6.1%) were more frequently used in eyes with uveitis (p < 0.001). post-operative best-corrected visual acuity (BCVA) was 0.16 ± 0.38 logarithm of the minimum angle of resolution (logMAR, mean ± SD) in eyes with uveitis (n = 52) and 0.08 ± 0.20 in control eyes (n = 14 489; p = 0.008).

CONCLUSION

In this large registry-based Swedish cohort study, the findings demonstrate that cataract surgery in patients with uveitis poses more challenges and requires special surgical precautions. Eyes with concurrent uveitis had worse BCVA prior to and following surgery. Despite the intraoperative challenges, the visual improvement was greater in the uveitic group.

Cataract Surgery in Uveitis: Risk Factors, Outcomes, and Complications

PURPOSE

To determine the outcomes of cataract surgery in eyes with uveitis, including the rates of intraoperative and postoperative complications, as well as predictors of visual outcomes.

DESIGN

Retrospective observational cohort study.

METHODS

Setting: Tertiary public hospital setting in Auckland, New Zealand, between 2008 and 2020.

STUDY POPULATION

Patients who underwent cataract surgery following a diagnosis of uveitis.Main observation Procedures: Additional intraoperative procedures, intraoperative and postoperative complications, and postoperative visual outcomes and complications.

RESULTS

471 eyes of 371 subjects were included. Median duration of uveitis prior to cataract surgery was 3.0 years (interquartile range [IQR] 5.2) and median period of quiescence prior to surgery was 1.0 years (IQR 1.5). Additional procedures (posterior synechiae peel [32.3%] and vision blue [18.1%]) were common. Intraoperative complications occurred in 32 eyes (6.8%). Consultants were the primary surgeons in the majority (82.5%) of operations. By 12 months, visual acuity was 20/50 or better in 248 eyes (79.7%). The most common postoperative complication was uveitis flare, occurring in 56.5%. On Cox proportional hazards analysis, time quiescent was associated with reduced risk of flare (HR 0.794, P = .003). Postoperative cystoid macular edema (CME) developed in 45 eyes (9.6%), with no significant predictors identified on multivariate analysis.

CONCLUSIONS

Cataract surgery in uveitis is complex. In the hands of the surgically experienced, rates of intraoperative complications are low. The primary challenge is managing postoperative care as we report a high rate of uveitis relapse and CME. Careful monitoring is important as complications can be unpredictable and occur later than expected.

Relationship between the higher inflammatory cytokines level in the aqueous humor of Fuchs uveitis syndrome and the presence of cataract

BACKGROUND

This study aims to compare the levels of intraocular cytokines between Fuchs uveitis syndrome (FUS) eyes and the senile cataract eyes. The association between inflammatory cytokine levels and cataract severity in FUS is evaluated to find the possible mechanism of cataract in FUS eyes.

METHODS

A retrospective study of 28 eyes with FUS was performed. Auxiliary examinations were performed, including ophthalmic examinations, laser flare-cell photometry, and levels of inflammatory cytokines in the aqueous humor were measured. The control group included 25 eyes with senile cataract. Data on the aqueous humor inflammatory cytokines were compared between the two groups. The association between the aqueous humor cytokine levels and severity of posterior subcapsular cataract was assessed.

RESULTS

There were 28 eyes with FUS in 27 patients. Unilateral involvement was noted in 26 patients (96.30%). Stellate keratic precipitates (KPs) were noted in 16 eyes (57.14%). Heterochromia was observed in 21.43% of affected eyes. Posterior subcapsular cataract (PSC) was observed in 16 of the 28 eyes. Eyes with FUS had significantly higher aqueous humor (AH) cytokine levels (VEGF, bFGF, IL-6, IL-8 and IL-10) compared with the control eyes (P < 0.05). There was a statistically significant positive correlation between the severity of cataract and IL-6 and IL-8 levels in the AH (τ = 0.664 and 0.634, respectively; P = 0.001, P = 0.002, respectively).

CONCLUSIONS

Expression of VEGF, bFGF, IL-6, IL-8 and IL-10 in the AH of FUS patients was significantly higher than in senile cataract eyes, and the aqueous humor levels of IL-6 and IL-8 were significantly positively associated with the severity of posterior subcapsular cataract. Our results imply that an inflammation mechanism may be involved in the early development of cataract in FUS.

Effect of hypothermic perfusion on phacoemulsification in cataract patients complicated with uveitis: a randomised trial

Background

To evaluate the effectiveness and safety of hypothermic perfusion in the phacoemulsification of cataract caused by uveitis.

Methods

This was a prospective, single-masked, randomised, controlled clinical trial. One hundred and six patients with uveitis-associated cataract underwent phacoemulsification with perfusion fluid temperature at 4 °C (treatment group) or 24 °C (control group). Anterior chamber inflammation grade, corneal endothelial cell count, corneal thickness, macular fovea thickness, and intraocular pressure (IOP) were observed on the 1st day and 7th day after operation.

Results

The aqueous flare score was 0.83 ± 0.76 in the 4 °C group, which was lower than that in the 24 °C group (1.51 ± 1.02, p = 0.006) on the first day after operation. The aqueous cells score was lower in the 4 °C group (0.17 ± 0.38) than that in the 24 °C group (0.62 ± 0.94, p = 0.025). The mean corneal thickness of incision in the 4 °C group (907.66 ± 85.37 μm) was thinner than that in the 24 °C group (963.75 ± 103.81 μm, p = 0.005). Corneal endothelial cells density, macular fovea thickness, or percentage of transiently increased IOP showed no difference between the two groups (p > 0.05). There was no significant difference in all the main outcome parameters between the two groups on the 7th day after operation (p > 0.05).

Conclusions

Hypothermic perfusion in the phacoemulsification of uveitis-associated cataract is safe, and it can effectively inhibit anterior chamber inflammation and reduce the incisional corneal edema in the early postoperative stage.

Trial registration

The study was registered with the Chinese Clinical Trial Registry. (http://www.chictr.org.cn/, Registration Number: ChiCTR1800016145).

Uveitis and deficient lens capsules: Effect of glued intraocular lens on the visual outcome and the reactivation of inflammation

Purpose:

To evaluate the visual outcome and complication profile after glued intraocular lens (IOL) in post uveitic eyes.

Methods:

Patients with history of uveitis who had glued IOL with 3 months antecedent quiet anterior chamber (AC) were included in this prospective observational case series. Visual acuity, slit-lamp examination, fundus evaluation, optical coherence tomography, intraocular pressure, specular count and AC inflammation were analyzed before and after glued IOL procedure. Glued IOL eyes were also compared with their fellow normal capsular bag IOL.

Results:

Overall 17 eyes (50.7 ± 16.1 years) were analyzed. It included 41.8%, 23.5%, and 35.29% anterior, posterior, and pan uveitis, respectively. The etiologies were tuberculosis (23.53%), toxoplasmosis (11.77%), Fuch's heterochromic cyclitis (5.88%), HLA B27 (11.77%), psoriatic arthritis (5.88%), Rheumatoid arthritis (5.8%), sarcoidosis (11.77%), herpetic kerato-uveitis (5.88%), and idiopathic (17.65%). Cataractous subluxated lens (35.3%), aphakia (23.5%), decentered IOL (23.5%) and intraoperative capsular rupture (17.6%) were the surgical indications. A significant improvement in the mean uncorrected and best corrected visual acuity (P < 0.001) was recorded. The complications were IOL pigment dispersion (47%), macular edema (41%), and epiretinal membrane (24%). There was significant rise in AC reaction on day 1 (P < 0.001) and normal AC was attained by 88.2% eyes at 6 months. AC inflammation reactivation was noted in 11.7% of eyes. Though inflammatory reactivation was similar to the normal IOL, macular edema was higher in glued IOL.

Conclusion:

Glued IOL can cause inflammation in uveitis eyes which can be managed medically with minimal complications.

An objective evaluation of crystalline lens density using Scheimpflug lens densitometry in different uveitis entities

AIM

To measure lens densities with a Pentacam HR device in patients with active uveitis. Measurements were taken at the onset of the attack and after the treatment of inflammation.

METHODS

The study included 51 eyes with different anterior uveitis aetiologies and a control group of 48 eyes of age- and gender-matched healthy subjects. Lens densitometry measurements were taken with a Scheimpflug camera on a Pentacam HR device. All the examinations and measurements were performed on the first presentation with the onset of the attack and were repeated at 1st and 3rd months after treatment. Lens densitometry measurements were compared with those of the healthy control group and the healthy fellow eyes of the uveitic patients.

RESULTS

No statistically significant difference was determined between the groups in respect of age and gender (p > 0.05). At 3 months, Pentacam densitometry of zones 3 value was determined to be significantly high in the uveitic eyes compared to the healthy eyes (p = 0.018). The average lens density value (ALD) at 1 month was statistically significantly higher than the baseline value in the uveitic eyes (p = 0.034). There was no significant change in the ALD value at 3 months compared to the baseline and 1-month values (p = 0.386, p = 0.736, respectively).

CONCLUSION

Even if there is no cataract development that can be clinically observed in eyes with anterior uveitis, lens density in zone 3 showed a significant increase at the end of 3 months compared to the baseline value. This change can be evaluated objectively with Scheimpflug imaging.

Ultrastructural Analysis of the Anterior Lens Epithelium in Cataracts Associated with Uveitis

PURPOSE

To investigate the transmission electron microscopic findings of lens epithelial cells (LECs) in patients with different subtypes of uveitis and to compare the findings with those in age-matched controls.

METHODS

In this prospective case-control study, the anterior lens capsules were taken from 47 eyes of 47 patients with uveitis of different subtypes (17 with Fuchs uveitis syndrome [FUS], 13 with -Behçet's uveitis, 10 with idiopathic uveitis, and 7 with herpetic keratouveitis) and from 15 eyes of 15 control patients.

RESULTS

In the FUS group, the LECs had homogeneous thickening and irregularity, with some small vacuoles and widespread, oval-shaped pigment clusters in some areas. In the Behçet uveitis group, there was evident thinning in the lens epithelium. The subepithelial tissue under the epithelium was thickened, and edematous areas were detected. In the idiopathic uveitis group, the LECs were thinner with small vacuoles, and the cubic structure of the LECs was transformed into a squamous one. Moreover, the LECs included some small vacuoles, similar to those in the FUS group. In the herpetic keratouveitis group, two prominent cell types were observed: (1) completely normal LECs and (2) degenerated-type LECs with pyknotic nuclei, condensation of chromatin, swelling in the cytoplasm, membrane ruptures, and intra-cytoplasmic inclusion bodies. In the control group, the LECs and all of their elements occurred in normal ultrastructural patterns, with the exception of a few small intraepithelial vacuoles, which were fewer in number and smaller than those in the FUS and idiopathic uveitis groups.

CONCLUSION

The electron microscopic analysis of LECs of patients with different subtypes of uveitis revealed significant ultrastructural alterations, which may be related to the summation of oxidative stress and intraocular inflammation.

Intravitreal dexamethasone implant as an alternative to systemic steroids as prophylaxis for uveitic cataract surgery: a randomized trial

PURPOSE

To determine the utility of the dexamethasone implant (IVD) as an alternative to systemic steroids as prophylaxis against cystoid macular edema (CMO) in patients with chronic, recurrent CMO associated intermediate or posterior uveitis (IU/PU), and cataract undergoing cataract surgery.

METHODS

This was a randomized, parallel design, and clinical trial. Patients with IU/PU and cataract scheduled for cataract surgery were randomly assigned to receive the IVD concurrently with cataract surgery (Group 1: 20 patients) or systemic steroids (Group 2: 23 patients) tapered over 4-6 weeks along with uneventful cataract surgery and routine postoperative care. Patients with glaucoma/contraindications to steroids were excluded. All patients were followed up for 6 months.

OUTCOME MEASURE

Primary-incidence of postoperative CMO. Secondary-the change in BCVA (corrected distance visual acuity) and Central Subfield thickness (CST) and complications. Appropriate statistical analysis was done.

RESULTS

The median age was 47.3 ± 4.23 years (group 1) and 49.12 ± 5.32 years (Group 2). One patient (Group 1) and two (Group 2) developed CMO. The BCVA improved significantly in both groups (p = 0.013). The CST change was insignificant. Four patients (Group 1) required intraocular pressure (IOP) lowering medications. Three patients (Group 2) required early steroid taper.

CONCLUSIONS

IVD is a good alternative as prophylaxis in IU/PU and cataract in preventing postoperative CMO.

Efficacy of Intravitreal Dexamethasone Implant in Patients of Uveitis Undergoing Cataract Surgery

Purpose: To assess postoperative inflammation using laser flare photometer, following phacoemulsification with or without single intraoperative intravitreal dexamethasone implant in addition to standard of care, in patients of uveitis with cataract.Methods: Prospectively, 30 eyes with uveitic cataract were randomized into 2 groups (i) standard of care (SOC group) (ii) Dexamethasone implant (DEXA group). Both the groups underwent phacoemulsification with intraocular lens implantation and standard of care treatment for uveitis, but DEXA group additionally received intraoperative intravitreal dexamethasone implant. Patients were followed at least till 6 months.Results: DEXA group had significantly less postoperative flare (LFP values) (P<0.05) as compared to SOC group and also recovery of flare to preoperative value occurred much early in DEXA group. 37.5% cases developed CME in SOC group but none in DEXA group. Mean CMT (267.81±34.26μm) and final logMar BCVA (0.036±0.063) was significantly better in DEXA group (p<0.04).Conclusions: Intraoperative intravitreal dexamethasone implant is a safe and effective option for preventing and managing the postoperative inflammation in uveitic cataract.

Cataract development in children with Coats disease: risk factors and outcome

PURPOSE

To describe the clinical features of cataract during the course of Coats disease and to determine its risk factors and effects on the long-term visual outcome.

METHODS

The medical records of consecutive patients with Coats disease followed for at least 2 years were analyzed retrospectively. Ophthalmological examination, ancillary tests, and treatment modalities were reviewed. The time of cataract diagnosis and its management were recorded. Parameters influencing cataract development and final visual outcome were investigated using uni- and multivariate analysis.

RESULTS

A total of 57 patients (mean age, 5.0 ± 4.0 years; 51 males) were included; cataract formation was observed in 16 (28%) during a mean follow-up of 7.1 ± 3.7 years. The mean time from diagnosis of Coats disease to cataract detection was 25 ± 22 months. Total white cataract developed in 12 patients (75%); posterior subcapsular cataract, in 4 (25%). Cataracts were surgically removed in 10 patients to improve fundus visualization and clinical follow-up. Presence of exudative retinal detachment at diagnosis was an independent risk factor for cataract formation (P = 0.031). Cataract development was associated with more advanced disease stages (P < 0.001). History of cataract was a significant predictor for worse final visual outcome (P < 0.001), independent of disease stage (P = 0.003) and presence of macular complication, such as atrophy, fibrosis, or tractional retinal detachment (P < 0.001, adjusted R² = 0.83).

CONCLUSIONS

Cataract development is frequent in children with Coats disease and aggravates the visual prognosis. Exudative retinal detachment at diagnosis, present in more advanced disease stages, is an independent risk factor for cataract formation.

Cataract Surgery in Exudative Uveitis: Effectiveness of Total Lens Removal, Anterior Vitrectomy, and Scleral Fixation of PC Iols

Purpose

Cataract surgery in exudative uveitis is often followed by severe complications (pupillary seclusion/occlusion, dense posterior capsule/anterior vitreous opacification, cystoid macular edema following repeat YAG laser procedures) which often drastically limit functional recovery Total removal of cataract, anterior vitrectomy, and scleral fixation of a posterior chamber (PC) intraocular lens (IOL) has been tried as a surgical alternative, searching for lessened postsurgical complications and a better outcome.

Methods

Group A was a cohort of 12 patients with cataract after exudative (mostly sarcoidosis and Vogt-Koyanagi-Harada) uveitis, subjected to intracapsular cataract extraction, anterior vitrectomy, and scleral fixation of PC IOLs. Group B was the control group, including 12 patients with a similar clinical condition subjected to phacoemulsification or extracapsular cataract extraction plus in-the-bag or in-the-sulcus IOL implantation. Follow-up time for both groups was at least 7 years.

Results

Postoperative inflammatory signs were substantially less in Group A patients, from 2 days up to >7 years postsurgery Group A patients showed no cells/exudates adhering to the IOL surfaces, no synechiae, minimal (as compared to Group B) vitreous opacifications, and significantly higher visual acuity (p=0.024 at the seventh year control). Group A patients reported less frequent relapses of uveitis postsurgery, but the relevant clinical data did not allow statistical evaluations.

Conclusions

Total removal of cataract in highly exudative uveitic eyes, plus anterior vitrectomy and scleral fixation of PC IOLs, although technically a more demanding surgical procedure, proved to be safe and more effective than classical procedures.

Decision-making and management of uveitic cataract

The visual outcome of uveitic cataract surgery depends on the underlying uveitic diagnosis, the presence of vision-limiting pathology and perioperative optimization of disease control. A comprehensive preoperative ophthalmic assessment for the presence of concomitant ocular pathology, with particular emphasis on macula and optic nerve involvement, is essential to determine which patients will benefit from improved vision after cataract surgery. Meticulous examination in conjunction with adjunct investigations can help in preoperative surgical planning and in determining the need for combined or staged procedures. The eye should be quiescent for a minimum of 3 months before cataract surgery. Perioperative corticosteroid prophylaxis is important to reduce the risk of cystoid macular edema and recurrence of the uveitis. Antimicrobial prophylaxis may also reduce the risk of reactivation in eyes with infectious uveitis. Uveitic cataracts may be surgically demanding due to the presence of synechiae, membranes, and pupil abnormalities that limit access to the cataract. This can be overcome by manual stretching, multiple sphincterotomies or mechanical dilation with pupil dilation devices. In patients <2 years of age and in eyes where the inflammation is poorly controlled, intraocular lens implantation should be deferred. Intensive local and/or oral steroid prophylaxis should be given postoperatively if indicated. Patients must be monitored closely for disease recurrence, excessive inflammation, raised intraocular pressure, hypotony, and other complications. Complications must be treated aggressively to improve visual rehabilitation. With proper patient selection, improved surgical techniques and optimization of peri- and post-operative care, patients with uveitic cataracts can achieve good visual outcomes.

Phacoemulsification with primary implantation of an intraocular lens in patients with uveitis

PURPOSE

To evaluate the outcome of cataract surgery in adult patients with uveitis.

MATERIALS AND METHODS

In this retrospective cohort study, medical charts of patients with uveitis and matched control patients without uveitis who underwent cataract surgery at the Eye Clinic, Sahlgrenska University Hospital, Mölndal, between January 2005 and December 2009 were analyzed.

RESULTS

The study included 58 eyes with and 283 eyes without uveitis. The most common etiologies were idiopathic anterior uveitis and Fuchs' heterochromic uveitis. Postoperative visual acuity at 4 weeks was ≥0.5 decimal (0.3 logMAR) in 48 eyes with uveitis (87.3%) compared to 180 non-uveitic eyes (86.1%). Four eyes with uveitis (7.1%) and one eye without uveitis (0.5%) developed postoperative intraocular hypertension/glaucoma. Posterior capsule opacification developed in 11 eyes (19.0%) with and 28 eyes (12.4%) without uveitis.

CONCLUSION

With appropriate perioperative anti-inflammatory regimen and surveillance, modern cataract surgery using phacoemulsification and primary intraocular lens implantation can be performed in patients with uveitis without greater risk of complications, yielding similar visual outcome as in patients without uveitis.

Phacoemulsification and Core Vitrectomy in Fuchs' Heterochromic Uveitis

OBJECTIVE

To evaluate the efficacy of phacoemulsification combined with posterior capsulorhexis, core vitrectomy and ciliary sulcus intraocular lens (IOL) implantation in patients with Fuchs' heterochromic uveitis (FHU).

MATERIALS AND METHODS

A total of 18 eyes of 18 patients with FHU underwent cataract surgery were included in the study. 18 eyes with FHU underwent posterior capsulorhexis, core vitrectomy and poly (methyl methacrylate) (PMMA) IOL implantation in the ciliary sulcus. Subjects were chosen for this procedure based on an intraoperative vitreous haziness assessment, performed by indirect ophthalmoscopy. Patients with +2 or more vitreous haziness qualified for this procedure.

RESULTS

Of the 83 eyes with FHU that underwent cataract surgery, 18 eyes (21.6%) of 18 patients were employed in the study. There were 11 (61.1%) men and 7 (38.9%) women in the study; ages ranged from 23 to 47, with a mean of 32.06 years. Follow-up ranged from 8 months to 49 months. There were no intraoperative complications except for peripheral iris bleeding in 7 eyes. There was no severe intraocular inflammation in any patient postoperatively. All patients had 0.05 or better logMAR visual acuity after corneal suture removal. Glaucoma developed in 2 patients. For the short term period, the main vision threatening problem was suture-induced astigmatism.

CONCLUSION

Cataract surgery combined with posterior capsulorhexis, core vitrectomy and IOL implantation in the ciliary sulcus is safe and leads to good visual outcome due to the removal of the hazy vitreous in patients with FHU.

Cataract Surgery with Primary Lens Implantation in Children with Chronic Uveitis

PURPOSE

To evaluate the evolution of chronic uveitis in children undergoing cataract surgery with primary intraocular lens (IOL) implantation.

METHODS

Twelve children with chronic uveitis underwent cataract surgery with primary posterior chamber intraocular lens (IOL) implantation.

RESULTS

Fourteen eyes were implanted with a foldable hydrophobic acrylic IOL. The mean follow-up was 35.39 months (8.72-69.57). The mean BCDVA before surgery and at the end of follow-up was 1.11 (0.40-2.30; SD: 0.57) and 0.48 (0-3; SD: 0.77; p=0.007) respectively. The mean oral corticosteroids dosage after surgery and at the end of follow-up was 0.80 mg/kg/day (SD: 0.37) and 0.17 mg/kg/day (SD: 0.24; p=0.001) respectively. All patients except one were treated with methotrexate. Four patients (5 eyes) were additionally treated with anti-tumor necrosis factor agent.

CONCLUSIONS

Cataract surgery with primary posterior chamber hydrophobic IOL implantation is possible and leads to a good visual recovery in cases of pediatric chronic uveitis. This surgery requires aggressive anti-inflammatory management with immunosuppressive drugs to control inflammation and reduce the corticosteroids dosage.

Phacoemulsification Versus Manual Small Incision Cataract Surgery in Patients With Fuchs Heterochromic Iridocyclitis

PURPOSE

To compare the safety and efficacy of phacoemulsification and manual small incision cataract surgery (SICS) to treat cataract in patients with Fuchs heterochromic iridocyclitis (FHI).

DESIGN

A randomized, double-masked, prospective, multicenter study.

METHODS

Consecutive patients with cataract after FHI were randomly assigned to have phacoemulsification or manual SICS by 1 of 2 surgeons experienced in both techniques. Complications (intraoperatively and postoperatively), operative time, visual acuities, endothelial cell counts, and surgically induced astigmatism were compared.

RESULTS

At 6 months, 65 (92.8%) patients in the phacoemulsification group and 70 (92.1%) in the manual SICS group had a corrected distance visual acuity of 20/63 or better (P = 0.974). Surgical time was significantly shorter in the SICS group (11.2 ± 2.4 minutes) than in the phacoemulsification group (14.2 ± 3.1 minutes) (P < 0.001). The mean surgically induced astigmatism was 0.8 ± 0.2 diopters (D) in the phacoemulsification group and 1.16 ± 0.2 D in the SICS group (P < 0.001). Endothelial cell counts at 1 week and at 6 months did not differ significantly in the phacoemulsification and SICS groups (t test; P = 0.133 and P = 0.032, respectively). Intraoperatively, 2 (3%) eyes randomized to receive phacoemulsification and 4 (5.3%) eyes randomized to receive SICS had posterior capsular rent (P = 0.465).

CONCLUSIONS

Both techniques achieved good visual outcomes with low rates of complications. Manual SICS may be a viable alternative for cataract management in patients with FHI in settings with limited access to phacoemulsification.

Cataract Surgery Outcomes in Uveitis: The Multicenter Uveitis Steroid Treatment Trial

PURPOSE

To assess the visual outcomes of cataract surgery in eyes that received fluocinolone acetonide implant or systemic therapy with oral corticosteroids and immunosuppression during the Multicenter Uveitis Steroid Treatment (MUST) Trial.

DESIGN

Nested prospective cohort study of patients enrolled in a randomized clinical trial.

PARTICIPANTS

Patients that underwent cataract surgery during the first 2 years of follow-up in the MUST Trial.

METHODS

Visual outcomes of cataract surgery were evaluated 3, 6, and 9 months after surgery using logarithmic visual acuity charts. Change in visual acuity over time was assessed using a mixed-effects model.

MAIN OUTCOME MEASURES

Best-corrected visual acuity.

RESULTS

After excluding eyes that underwent cataract surgery simultaneously with implant surgery, among the 479 eyes in the MUST Trial, 117 eyes (28 eyes in the systemic, 89 in the implant group) in 82 patients underwent cataract surgery during the first 2 years of follow-up. Overall, visual acuity increased by 23 letters from the preoperative visit to the 3-month visit (95% confidence interval [CI], 17-29 letters; P < 0.001) and was stable through 9 months of follow-up. Eyes presumed to have a more severe cataract, as measured by inability to grade vitreous haze, gained an additional 42 letters (95% CI, 34-56 letters; P < 0.001) beyond the 13-letter gain in eyes that had gradable vitreous haze before surgery (95% CI, 9-18 letters; P < 0.001) 3 months after surgery, making up for an initial difference of -45 letters at the preoperative visit (95% CI, -56 to -34 letters; P < 0.001). Black race, longer time from uveitis onset, and hypotony were associated with worse preoperative visual acuity (P < 0.05), but did not affect postsurgical recovery (P > 0.05, test of interaction). After adjusting for other risk factors, there was no significant difference in the improvement in visual acuity between the 2 treatment groups (implant vs. systemic therapy, 2 letters; 95% CI, -10 to 15 letters; P = 0.70).

CONCLUSIONS

Cataract surgery resulted in substantial, sustained, and similar visual acuity improvement in the eyes of patients with uveitis treated with the fluocinolone acetonide implant or standard systemic therapy.

Phacoemulsification versus small incision cataract surgery in patients with uveitis

AIM

To compare the safety and efficacy of phacoemulsification and small incision cataract surgery (SICS) in patients with uveitic cataract.

METHODS

In a prospective, randomized multi-centric study, consecutive patients with uveitic cataract were randomized to receive phacoemulsification or manual SICS by either of two surgeons well versed with both the techniques. A minimum inflammation free period of 3mo (defined as less than 5 cells per high power field in anterior chamber) was a pre-requisite for eligibility for surgery. Superior scleral tunnel incisions were used for both techniques. Improvement in visual acuity post-operatively was the primary outcome measure and the rate of post-operative complications and surgical time were secondary outcome measures, respectively. Means of groups were compared using t-tests. One way analysis of variance (ANOVA) was used when there were more than two groups. Chi-square tests were used for proportions. Kaplan Meyer survival analysis was done and means for survival time was estimated at 95% confidence interval (CI). A P value of <0.05 was considered statistically significant.

RESULTS

One hundred and twenty-six of 139 patients (90.6%) completed the 6-month follow-up. Seven patients were lost in follow up and another six excluded due to either follow-up less than six months (n=1) or inability implant an intraocular lens (IOL) because of insufficient capsular support following posterior capsule rupture (n=5). There was significant improvement in vision after both the procedures (paired t-test; P<0.001). On first postoperative day, uncorrected distance visual acuity (UDVA) was 20/63 or better in 31 (47%) patients in Phaco group and 26 (43.3%) patients in SICS group (P=0.384). The mean surgically induced astigmatism (SIA) was 0.86±0.34 dioptres (D) in the phacoemulsification group and 1.16±0.28 D in SICS group. The difference between the groups was significant (t-test, P=0.002). At 6mo, corrected distance visual acuity (CDVA) was 20/60 or better in 60 (90.9%) patients in Phaco group and 53 (88.3%) in the manual SICS group (P=0.478). The mean surgical time was significantly shorter in the manual SICS group (10.8±2.9 versus 13.2±2.6min) (P<0.001). Oral prednisolone, 1 mg/kg body weight was given 7d prior to surgery, continued post-operatively and tapered according to the inflammatory response over 4-6wk in patients with previously documented macular edema, recurrent uveitis, chronic anterior uveitis and intermediate uveitis. Rate of complications like macular edema (Chi-square, P=0.459), persistent uveitis (Chi-square, P=0.289) and posterior capsule opacification (Chi-square, P=0.474) were comparable between both the groups.

CONCLUSION

Manual SICS and phacoemulsification do not differ significantly in complication rates and final CDVA outcomes. However, manual SICS is significantly faster. It may be the preferred technique in settings where surgical volume is high and access to phacoemulsification is limited, such as in eye camps. It may also be the appropriate technique for uveitic cataract under such circumstances.

Follow-Up Study of Over Three Years of Patients with Uveitis after Cataract Phacoemulsification: Outcomes and Complications

PURPOSE

To evaluate the rate and onset of intraoperative and postoperative complications post-phacoemulsification.

METHODS

One hundred sixty-two eyes of 145 patients with uveitis who underwent phacoemulsification between 2006 and 2009 were identified through surgical record review. Fifty-nine eyes of 46 patients met the inclusion criteria. Hazard ratio (HR) and Kaplan-Meier survival probability were calculated for each class of uveitis.

RESULTS

Macular edema (ME) resulted to be associated to chronic postoperative inflammation (r = 0.6; p = 0.00) and mostly related to patients who presented more than one postoperative relapse/year (r = 0.2; p = 0.02). Fuchs uveitis resulted to be a risk factor for posterior capsule opacification (PCO) (HR 3.36 IC95%1.0-10.5; p = 0.03). Hypotony and elevated intraocular pressure (IOP) were detected in the anterior uveitis group (0.02 EY).

CONCLUSION

The HR to develop ME was significantly related to chronic anterior uveitis. PCO and elevated IOP are most frequent in Fuchs uveitis. The postoperative visual acuity result was good among all the uveitis groups.

Perioperative pharmacological management in patients with glaucoma

REVIEẂS AIM: When a phacoemulsification, a filtration surgery or a combined surgery are necessary, questions about the convenience of continuing certain antiglaucomatous drugs could appear. The aim of this review article is to unify criteria that will guide daily clinical practice and including the developing algorithms of action in the preoperative and postoperative periods of filtration surgery and/or cataract surgery.

PROPOSED PROTOCOLS

In the preoperative period of cataract surgery, the use of non-steroidal anti-inflammatory drugs is at the discretion of the surgeon, with the monodose presentation being recommended. The suspension of prostaglandines a fewdays before the surgery should be considered. Preservative-free drugs ensure a better recovery of the ocular surface (OS) after cataract surgery. Once all modifying factors of the intraocular pressure (IOP) have been removed, baseline IOP should be evaluated again, choosing preservative-free antiglaucomatous drugs when needed. The use of preservative-free ocular antihypertensive drugs and steroids in the preoperative period of glaucoma surgery reduces the risk of surgical failure. The interruption of prostaglandines is recommended. In the postoperative period of glaucoma surgery, steroids are the anti-inflammatory treatment of choice, the preservative-free ones being preferred. When reintroducing antiglaucomatous treatment, preservatives should be avoided to prevent scarring. The appropriate perioperative management of patients with glaucoma is essential to obtain a correct control of IOP, improve the situation of the OS, prevent complications and improve the result of the filtration surgery and cataract surgery.

CONCLUSIONS

this protocol aims to unify the different lines of action in order to decrease the incidence of adverse events and maximize the surgical outcome.

Short-term outcomes of coaxial microincision cataract surgery for uveitis-associated cataract without postoperative systemic steroid therapy

PURPOSE

To study the necessity of prophylactic systemic steroid therapy after coaxial microincision cataract surgery (MICS) conducted in aged patients during remission of uveitis.

PROCEDURES

A total of 17 consecutive patients who underwent MICS were enrolled in this retrospective study. The median age was 73 years. MICS via a 2.2-mm incision was performed. None of the patients received systemic steroid administration after surgery. The visual acuity, intraocular pressure (IOP) and inflammation scores were recorded.

RESULTS

The mean logMAR visual acuity was significantly improved from 0.56 ± 0.58 to 0.10 ± 0.30, and the mean inflammation score was reduced from 0.20 to 0.14. Postoperative complications were recurrence of ocular inflammation in 1 eye and elevation of IOP more than 21 mm Hg in 1 eye, which were resolved by topical steroids and topical antiglaucoma medication.

CONCLUSIONS

Prophylactic systemic steroid therapy after MICS may not be necessary in aged uveitis patients without posterior complications before cataract surgery.

Intraoperative dexamethasone implant in uveitis patients with cataract undergoing phacoemulsification

PURPOSE

To study the role of intraoperative intravitreal dexamethasone implant in patients of uveitis with cataract undergoing phacoemulsification.

METHODS

This prospective study included 20 patients with uveitis and cataract who underwent phacoemulsification with intraocular lens implantation. Ten patients (10 eyes) received an intravitreal dexamethasone implant intraoperatively (implant group), and 10 patients (10 eyes) received oral steroids (steroid group). Outcome measures were best-corrected visual acuity (BCVA), intraocular pressure (IOP), and central macular thickness (CMT).

RESULTS

The logMar BCVA improved from 0.93 ± 0.49 to 0.23 ± 0.23 and from 1.29 ± 0.47 to 0.22 ± 0.16 in the implant and steroid groups, respectively. Postoperative IOP and CMT showed no statistically significant differences between the two groups. None of the patients in either group had significant IOP rise requiring any surgical intervention.

CONCLUSIONS

A single intraoperative intravitreal dexamethasone implant during phacoemulsification in patients of uveitis with cataract seems to be an effective alternative for postoperative oral steroids.

Favourable outcome after cataract surgery with IOL implantation in uveitis associated with juvenile idiopathic arthritis

PURPOSE

Management of uveitic cataract in patients with juvenile idiopathic arthritis (JIA) is challenging, and intraocular lens (IOL) implantation is controversial. This study investigated the outcome after minimally invasive surgery with IOL implantation.

METHODS

Retrospective analysis after phacoemulsification with in-the-bag IOL implantation was performed in 16 patients (17 operations) with ANA-positive JIA-associated chronic uveitis. In these patients, 25 G capsulectomy and anterior vitrectomy was performed and they received an intravitreal triamcinolone (TA) injection.

RESULTS

  Mean age at uveitis onset was 5 ± 2 years, and surgery was performed at a mean age of 11 ± 2.2 years. Preoperatively, uveitis was inactive in all patients, and visual acuity was logMAR 0.8 ± 0.44; additional uveitis complications were present in all patients, and 15 patients were receiving systemic immunosuppression/biologicals. After surgery (mean follow-up 26.5 ± 11.7 months), presence of cystoid macular oedema, papilloedema, ocular hypertension/glaucoma and hypotony did not increase compared with baseline. There was no significant worsening of AC inflammation (by cell numbers and laser flare values). IOL deposits persisted in four patients, and synechiae developed in eight. The visual acuity was improved (≥2 lines) in all patients (mean logMAR 0.3 ± 0.24). Retrolental membrane formation was not noted. Secondary capsular opacification was observed in seven patients, requiring Nd:YAG capsulotomy in five of them.

CONCLUSIONS

Phacoemulsification and in-the-bag IOL implantation may improve visual outcome in JIA-associated uveitis with minimally invasive surgical technique and intravitreal TA injection. Well-controlled uveitis with appropriate use of topical steroids and systemic immunosuppression or biologicals appears as a perioperative requirement.

Cataract surgery in uveitis

Cataract surgery in uveitic eyes is often challenging and can result in intraoperative and postoperative complications. Most uveitic patients enjoy good vision despite potentially sight-threatening complications, including cataract development. In those patients who develop cataracts, successful surgery stems from educated patient selection, careful surgical technique, and aggressive preoperative and postoperative control of inflammation. With improved understanding of the disease processes, pre- and perioperative control of inflammation, modern surgical techniques, availability of biocompatible intraocular lens material and design, surgical experience in performing complicated cataract surgeries, and efficient management of postoperative complications have led to much better outcome. Preoperative factors include proper patient selection and counseling and preoperative control of inflammation. Meticulous and careful cataract surgery in uveitic cataract is essential in optimizing the postoperative outcome. Management of postoperative complications, especially inflammation and glaucoma, earlier rather than later, has also contributed to improved outcomes. This manuscript is review of the existing literature and highlights the management pearls in tackling complicated cataract based on medline search of literature and experience of the authors.

Clinical Course before and after Cataract and Glaucoma Surgery under Systemic Infliximab Therapy in Patients with Behçet's Disease

Purpose

Patients with Behçet's disease often need intraocular surgeries for the treatment of secondary cataract or glaucoma. This study aims to report the clinical course before and after the intraocular surgeries of 5 patients who were systematically treated with infliximab.

Methods

Retrospective case series.

Results

Seven eyes of 5 male patients with Behçet's disease, who underwent intraocular surgery while under systemic infliximab therapy at Yokohama City University Hospital from 2007 to 2009, were included in the study. The mean age at surgery was 44.2 years. Phacoemulsification was performed on 4 eyes, and trabeculectomy was done on the remaining 3 eyes. The mean duration since the onset of the ocular symptoms was 107 months. Control of the ocular attacks with the use of other systemic medications was difficult for all patients; however, the use of infliximab enabled adequate control of the attacks. The visual acuity status during the preoperative stage did not worsen during the postoperative period. No infectious complication was observed in all cases.

Conclusions

Our results suggest that infliximab treatment does not complicate any subsequent intraocular surgery. Patients with Behçet's disease in need of intraocular surgery can benefit from control of attacks with infliximab treatment.

Comparison of orbital floor triamcinolone acetonide and oral prednisolone for cataract surgery management in patients with non-infectious uveitis

PURPOSE

To compare orbital floor triamcinolone acetonide and oral prednisolone in cataract surgery in patients with chronic non-infectious uveitis with regard to visual outcome, postoperative inflammation and macular edema.

METHODS

Monocentric prospective randomized clinical trial with 40 eyes included. Patients underwent phacoemulsification with intraocular acrylic foldable lens (IOL) implantation. Patients were randomized either to intraoperative orbital floor triamcinolone acetonide (TA) (1 ml = 40 mg) (group 1, n = 20), or to 4-week postoperative oral prednisolone (group 2, n = 20). Laser flare photometry (LFM), cells in the anterior chamber (AC), best-corrected visual acuity (BCVA), IOL cell deposits, cystoid macular edema (CME) by means of fluorescein angiography, and central foveal thickness (OCT), posterior capsule opacification (PCO), and intraocular pressure (IOP) were analysed during a 6-months period.

RESULTS

Mean BCVA postoperatively improved (p < 0.01) from logMAR 0.74 and 0.86 to 0.23 and 0.35 in groups 1 and 2 respectively.The number of AC cells, LFM and IOL cell deposits did not differ. Macular edema stayed unchanged in most cases in both groups, and mean foveal thickness (OCT) initially increased postoperatively, but after 6 months it nearly returned to baseline thickness. Differences between the groups were not significant. Up to 12% in group 1 and 28% of group 2 developed IOP elevation over 21 mmHg.

CONCLUSIONS

A single intraoperative orbital floor injection of triamcinolone acetonide is as effective on postoperative inflammation, macular edema, and visual outcome as a 4-week course of postoperative oral prednisolone in cataract surgery with IOL implantation in uveitis patients.

Cataract surgery in the setting of uveitis

PURPOSE OF REVIEW

To describe recent evidence from the literature concerning optimal treatment of cataract in patients with concomitant uveitis.

RECENT FINDINGS

Optimal treatment of cataract in the setting of uveitis requires optimal management of uveitis, including appropriate diagnostic workup and scrupulous attention to preoperative preparation, intraoperative technique, and postoperative management. Recent literature suggests high rates of recurrence of certain forms of uveitis (such as ocular toxoplasmosis) after surgery, suggesting that perioperative prophylaxis may be warranted. Placement of intraocular lenses in the setting of certain forms of uveitis, such as juvenile idiopathic arthritis-associated uveitis, remains controversial. Although excellent outcomes can be achieved with many types of intraocular lenses, several recent studies have suggested that the incidence of postoperative complications may be lower in patients receiving acrylic intraocular lenses compared with other materials. Recent long-term outcome studies in cohorts of uveitis patients undergoing cataract surgery suggest very good outcomes in the majority of patients.

SUMMARY

Provided the unique challenges of cataract surgery in the setting of uveitis are recognized and appropriately addressed, excellent visual outcomes can be achieved in most patients.

Comparison between intravitreal and orbital floor triamcinolone acetonide after phacoemulsification in patients with endogenous uveitis

PURPOSE

To compare the effect of intravitreal and orbital floor triamcinolone acetonide (TA) on macular edema, visual outcome, and course of postoperative inflammation after cataract surgery in uveitis patients.

DESIGN

Prospective, randomized clinical trial.

METHODS

Monocenter study (40 patients) with chronic endogenous uveitis who underwent phacoemulsification with intraocular lens implantation with either 4 mg intravitreal TA (n = 20) or 40 mg orbital floor TA (n = 20). The primary outcome was influence on cystoid macular edema (CME). Secondary outcome measures were best-corrected visual acuity (BCVA), anterior chamber cell grade, laser flare photometry, giant cell deposition, posterior capsule opacification (PCO), and intraocular pressure.

RESULTS

Mean central foveal thickness decreased in the intravitreal TA group and increased in the orbital floor TA group (P < .001 at one and three months). CME improved in 50% of patients after intravitreal TA, whereas it was unchanged after orbital floor TA (difference between the groups at three months, P = .049). Mean BCVA (logarithm of the minimal angle of resolution) improved postoperatively (P < .001) from 0.76 and 0.74 to 0.22 and 0.23 in the intravitreal TA and orbital floor TA group, respectively. Anterior chamber cell count at one month was lower in the intravitreal TA than in the orbital floor TA group (P = .02). Laser flare photometry values and giant cell numbers were slightly higher after orbital floor TA than after intravitreal TA. The groups did not differ with respect to PCO rate and ocular hypertension.

CONCLUSIONS

The CME improvement and anti-inflammatory effect after intravitreal TA was better than after orbital floor TA injection in cataract surgery in uveitis patients.

Cataract surgery in pediatric uveitis

Uveitis in children is associated with several sight-threatening ocular complications, including the formation of cataracts. The surgical management of uveitic cataracts in children is both challenging and controversial and, unlike in adult uveitic cataracts, surgery has historically been associated with poor visual outcomes. Juvenile idiopathic arthritis-associated uveitis in particular poses unique therapeutic challenges and the issue of correction of aphakia in these patients remains a contentious one. The growing use of immunotherapies and, where needed, targeted biologic agents in childhood uveitis increases our potential to implant lenses and predict outcomes. The authors review the available evidence base for the treatment of these children.

Uveal and capsular biocompatibility of two foldable acrylic intraocular lenses in patients with endogenous uveitis--a prospective randomized study

BACKGROUND

To compare a hydrophobic and a hydrophilic acrylic single-piece intraocular lens (IOL) in uveitis patients with respect to biocompatibility and visual outcome.

METHODS

Prospective, randomized study in patients with noninfectious uveitis after phacoemulsification and implantation of either a hydrophobic AcrySof (group 1, n = 30) or a hydrophilic Akreos adapt (group 2, n = 30), sharp-edged acrylic IOL. The primary outcome was uveal biocompatibility, detected by giant-cell deposition, anterior chamber cell count and laserflare photometry over a 6-month follow-up period. Secondary outcome measures were capsular biocompatibility, as detected by posterior capsule opacification (PCO), lens epithelial cell outgrowth and Nd:YAG capsulotomies, and visual outcome.

RESULTS

The groups did not differ with respect to anatomic type of uveitis, immunosuppressive treatment, associated systemic disease, and intraoperative manipulation. The number of giant cells on the anterior IOL surface was higher in group 1 than in group 2 (p = 0.03). The number of anterior chamber cells, laser flare photometry levels, and uveitis reactivations after surgery did not differ between the groups. After 6 months, the number of patients with PCO development (p = 1.0) and Nd:YAG capsulotomies (p = 0.21), lens epithelial cell outgrowth, visual outcome and uveitis complications were comparable in both groups.

CONCLUSIONS

Both of the acrylic IOLs used had good uveal and capsular biocompatibility, leading to significant improvement in BCVA in patients with noninfectious uveitis. No obvious differences were detected at 6 months with respect to uveal and capsular biocompatibility and visual outcome.

Combined lensectomy, vitrectomy, and primary intraocular lens implantation in patients with traumatic eye injury

PURPOSE

To analyse the postoperative anatomic and functional outcomes in addition to complications after combined lensectomy, vitrectomy, and primary intraocular lens (IOL) implantation in patients with traumatic eye injury.

METHODS

Retrospective review of patients with traumatic cataract and posterior segment injury who underwent combined lensectomy, vitrectomy, and primary IOL implantation with a minimum follow up (FU) of 3 months.

RESULTS

Thirteen consecutive patients (all male) with a mean age of 42.8 years (range 17-82 years) underwent combined lensectomy, vitrectomy, and primary IOL implantation from February 2000 to January 2006. Postoperative FU ranged from 3 to 54 months (mean 17.6 months). Best corrected visual acuity (BCVA) at presentation ranged from 20/30 to hand movement and was worse than 20/200 in eight patients (61%). Four patients (31%) had blunt trauma with no globe rupture. Of the nine patients (69%) with a penetrating eye injury (PEI), eight had an intraocular foreign body (IOFB) with one retinal detachment at presentation. Four patients had primary closure at the time of the vitrectomy. All eight IOFBs were removed. Seven patients had additional scleral buckling and four intravitreal gas injection. BCVA at last FU ranged from 20/20 to 20/300 and was 20/40 or better in eight eyes (62%). All patients had an attached retina at last FU. One eye had further surgery for epiretinal membrane proliferation and ptosis.

CONCLUSIONS

These results suggest that combined vitrectomy, lensectomy and primary intraocular implantation can offer good visual rehabilitation in patients with traumatic cataract and posterior segment injury.

Intraoperative use of intravitreal triamcinolone in uveitic eyes having cataract surgery: pilot study

PURPOSE

To report the outcomes of cataract extraction with intraoperative intravitreal triamcinolone (IVTA) in eyes with a history of posterior uveitis.

SETTING

Moorfields Eye Hospital Uveitis Service, London, United Kingdom.

METHODS

Nineteen eyes of 17 patients with posterior uveitis thought to require systemic corticosteroid prophylaxis for cataract surgery were included. The use of systemic corticosteroids at the time of surgery would have been problematic in 7 of the patients, who had a history of systemic hypertension. Three of the 7 patients were also diabetic. All patients were not happy about using oral corticosteroids.

RESULTS

Median visual acuity 1 day after surgery was 20/40 (range 20/20 to counting fingers). At final follow-up (mean 25.2 months; range 7 to 41 months), 17 eyes (89.5%) eyes achieved visual acuity of 20/40 or better; 2 eyes failed to achieve a final visual acuity of 20/40 or better, 1 as a result of optic atrophy and the other as a result of macular edema. No patient lost acuity and no eye developed macular edema within 4 months of surgery. Intraocular pressure elevation occurred after surgery in 3 eyes; all were controlled by topical medication that was discontinued after 3 months. One patient developed severe intraocular inflammation after surgery that resolved with intensive topical corticosteroid therapy within 1 week.

CONCLUSIONS

Cataract extraction by phacoemulsification with concurrent IVTA appears a useful treatment option. Targeted delivery of corticosteroid is achieved without the risks of systemic corticosteroid prophylaxis. The incidence of postoperative macular edema was markedly reduced. Levels of visual acuity after cataract surgery, similar to those in eyes without uveitis, were achieved in eyes with posterior uveitis.

Intraoperative intraocular triamcinolone injection prophylaxis for post-cataract surgery fibrin formation in uveitis associated with juvenile idiopathic arthritis

PURPOSE

To assess the efficacy of a single intraoperative intraocular injection of triamcinolone acetonide during cataract surgery to prevent postoperative fibrin formation in patients with iridocyclitis associated with juvenile idiopathic arthritis.

SETTING

Department of Ophthalmology, St. Franziskus Hospital, Muenster, Germany.

METHODS

The charts of 22 patients (16 girls and 6 boys) with juvenile idiopathic arthritis and chronic iridocyclitis having lensectomy and anterior vitrectomy were retrospectively reviewed. In 12 patients (14 eyes), triamcinolone acetonide 4 mg was injected into the anterior chamber at the end of the surgery (triamcinolone group). Another 10 patients (13 eyes) received an intraoperative intravenous injection of methylprednisolone and postoperative oral prednisolone (systemic treatment group). No intraocular lenses were implanted. Postoperatively, prednisolone acetate 1% eyedrops were given. The main problems included intraocular inflammation, the need for additional systemic corticosteroids, and intraocular pressure (IOP) elevation.

RESULTS

The mean patient age was 10.6 years +/- 3.1 (SD) in the triamcinolone group and 7.4 +/- 2.7 years in the systemic treatment group. The mean follow-up was 9.9 +/- 3.6 months and 10.9 +/- 1.2 months, respectively. All patients were taking systemic immunosuppression before surgery, and the medication was continued postoperatively. Fibrin formation was not seen after surgery in the triamcinolone group but occurred in 5 patients in the systemic treatment group (P = .02). Additional systemic corticosteroids were not required in the triamcinolone group. All patients had visual acuity improvement. No increase in IOP was noted after the triamcinolone acetate injections.

CONCLUSIONS

Intraoperative intraocular injection of 4 mg of triamcinolone acetonide may be more effective than intraoperative intravenous methylprednisolone and additional postoperative short-term oral prednisolone in preventing postoperative fibrin formation after cataract surgery in patients with juvenile idiopathic arthritis and iridocyclitis.

Clinical Results of Phacoemulsification in Patients With Uveitis

BACKGROUND AND OBJECTIVE

To evaluate the results of phacoemulsification and posterior chamber intraocular lens (IOL) implantation in patients with uveitis.

PATIENTS AND METHODS

Review of records of 37 eyes of 31 patients with uveitis (14 men and 17 women; mean age, 49.8 years; age range, 26 to 71 years) who underwent phacoemulsification with IOL implantation. The data recorded were age, gender, IOL type, treatment modalities, final visual outcome, and complications.

RESULTS

Panuveitis, anterior uveitis, posterior uveitis, and intermediate uveitis were detected in 16 (51.6%), 9 (29.0%), 5 (16.1%), and 1 (3.3%) of the patients, respectively. At 6 months postoperatively, 32 (86.5%) eyes had achieved a best-corrected visual acuity of 20/40 or better, and 22 (59.5%) eyes had a visual acuity of 20/20. Five (13.5%) eyes showed limited improvement in postoperative visual acuity due to posterior segment problems. Postoperative recurrence of inflammation occurred in 12 eyes (32.4%) of 10 patients and was treated and controlled with medical therapy.

CONCLUSION

When inflammation in uveitic eyes is under complete control, phacoemulsification and implantation of a foldable acrylic IOL in the posterior chamber is safe, effective, and tolerated well. To minimize vision-limiting complications, these patients must be observed closely after surgery, and must be treated aggressively if the inflammation recurs.

Outcomes of phacoemulsification and in-the-bag intraocular lens implantation in Fuchs' heterochromic iridocyclitis

PURPOSE

To evaluate the visual outcomes and complications of phacoemulsification (PE) and posterior chamber intraocular lens implantation, (PC IOL) in patients with Fuchs heterochromic iridocyclitis (FHIC).

SETTING

Private clinic and an academic hospital.

METHODS

In this noncomparative interventional case series, existing data for 41 eyes of 40 consecutive patients clinically diagnosed with FHIC and cataract were studied retrospectively. Scleral tunnel PE and in-the-bag IOL implantation were performed in all cases. Preoperative and postoperative visual acuities and intraoperative and postoperative complications were evaluated.

RESULTS

Twenty-four male and 16 female patients aged 12 years to 70 (SD) (mean 35 +/- 12 years) were operated on and followed for 17.8 +/- 8.7 months. Preoperatively, best corrected visual acuity (BCVA) was less than 20/40 in all patients, which improved to 20/40 or better after surgery. Twenty-two eyes (53.6%) achieved BCVA of 20/20. The major cause of postoperative visual acuity less than 20/20 was vitreous haze. There were no major intraoperative complications. Postoperatively, mild anterior chamber fibrin reaction occurred in 4 patients (9.7%), IOL deposits occurred in 11 eyes (26.8%), and decentration was observed in 1 eye. During follow-up, 6 eyes (14.6%) developed posterior capsule opacification requiring a neodymium:YAG (Nd:YAG) laser capsulotomy. There was 1 case of clinical cystoid macular edema that resolved with medication. There were no cases of posterior synechias, postoperative glaucoma, or retinal detachment.

CONCLUSION

Phacoemulsification with PC IOL implantation is a safe procedure with good visual outcomes in patients with FHIC and cataract.

Phacoemulsification with intraocular lens implantation in cases of pars planitis

PURPOSE

To analyze the results of phacoemulsification cataract surgery with implantation of posterior chamber intraocular lenses (IOLs) of different biomaterials in eyes with pars planitis.

SETTING

Medical and Vision Research Foundations, Sankara Nethralaya, Chennai, India.

METHODS

The records of 86 patients (100 eyes) with pars planitis who had phacoemulsification with IOL implantation between January 1997 and April 2003 were retrospectively analyzed. The eyes were divided into 3 groups depending on IOL biomaterial: poly(methyl methacrylate) (PMMA) (n=32), heparin-surface-modified PMMA (n=39), or acrylic (n=29). The postoperative visual outcome and complications in each group were analyzed.

RESULTS

Forty-seven patients were men and 39, women. The mean age was 38 years (range 10 to 65 years) and the mean follow-up, 19.67 months (range 3.00 to 54.53 months). At the final follow-up, 91 eyes (91%) had better visual acuity than preoperatively; 79 had an improvement of 2 or more Snellen lines, 12 had an improvement of 1 Snellen line, 4 had no change, and 5 had a decrease as a result of reactivation of the pars planitis and progression of cystoid macular edema (CME). Significant posterior capsule opacification occurred in 10 eyes (10%), CME in 50 eyes (50%), reactivation of pars planitis in 51 eyes (51%), IOL deposits in 29 eyes (29%), IOL decentration in 1 eye (1%), and anterior capsule fibrosis in 14 eyes (14%). The most frequent cause of poor visual recovery was CME, submacular fibrosis, and epiretinal membrane. There was no statistically significant difference in these complications between the 3 groups.

CONCLUSIONS

Phacoemulsification with IOL implantation in eyes with pars planitis was safe and led to good visual outcomes in most cases. The factors in surgical success were control of inflammation, meticulous surgery, in-the-bag IOL implantation, and vigilant postoperative care.

Uveitis: A Potentially Blinding Disease

Uveitis (intraocular inflammation) is a potentially blinding group of, probably autoimmune, conditions predominantly occurring in the working age group. Although the aetiology is unknown in most cases, many patients have an associated underlying systemic disease. Central vision loss, in the form of cystoid macular oedema, is the commonest type of visual impairment. Although historical incidence and prevalence data exists, little is known about the degree of vision loss experienced, and the social and financial consequences of having temporary or permanent visual impairment in this age group. The literature is also full of uncontrolled studies and case reports of different modalities of drug therapy for uveitis. This article attempts to raise the awareness of uveitis as an important sight-threatening group of conditions by highlighting the paucity of evidence-based data on epidemiological, quality of life, socioeconomic, and therapeutic aspects.