Cataract surgery in uveitis: a multicentre database study

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.

Posterior segment parameters after uveitic cataract surgery: A prospective study with 1-year results

PURPOSE

To evaluate the changes in posterior segment after uncomplicated cataract surgery in uveitic patients.

METHODS

Retinal nerve fiber layer thickness (RNFLT), ganglion cell layer thickness (GCLT), central macular thickness (CMT), and choroidal thickness (CT) of 38 eyes of 28 patients were measured pre- and postoperatively on day 1, week 1, and month 1, 3, 6, 9, and 12.

RESULTS

The RNFLT increased after surgery. Although the measurements taken were higher than the baseline CMT at all postoperative times, no significant difference was detected between the paired comparisons. The GCLT was found to be higher than the baseline value in all quadrants at the 12th month. A decrease in CT was observed at 5 measured points on the 1st day compared to the baseline.

CONCLUSION

During the 1-year follow-up, the effect of cataract surgery on the retina and choroid in uveitic eyes was most evident at the postoperative month 1.

Prognostic factors of cataract surgery in patients with uveitis

PURPOSE

To evaluate the long-term visual outcomes of patients with uveitis undergoing cataract surgery and to identify possible factors influencing the visual prognosis and the development of postoperative complications.

METHODS

Retrospective study of all patients with uveitis who underwent cataract surgery between January 2015 and February 2020 in our tertiary referral center.

RESULTS

A total of 78 eyes from 78 patients were included in the study. The best-corrected visual acuity (BCVA) improved in 86% of patients, and a BCVA of 0.5 or better was achieved in 57 (73%) patients. A significant correlation was shown between the preoperative and postoperative BCVA (Spearman r = 0.521, p < 0.01). Final BCVA differed between diverse anatomical uveitis entities (p = 0.047), and anterior uveitis demonstrated the best outcomes. Chronic uveitis resulted in a worse final BCVA than acute recurrent uveitis (p = 0.001). The presence of CME any time before the surgery and intermediate uveitis were associated with worse visual prognosis, while systemic therapy for uveitis before surgery and iris manipulation during surgery were not related to visual outcomes. Postoperative development of cystoid macular edema (CME) was closely associated with preexisting CME (p < 0.001) and intermediate uveitis (p = 0.01).

CONCLUSIONS

Visual results of cataract surgery in patients with uveitis were beneficial, but limited visual outcomes were more frequently observed in patients with chronic uveitis and intermediate uveitis with a history of CME. In consequence, prevention, or adequate treatment of CME, especially in patients with intermediate uveitis, might result in better visual results of their cataract surgery.

Cataract Surgery in Patients With Uveitis Treated With Systemic Therapy in the Multicenter Uveitis Steroid Treatment (MUST) Trial and Follow-up Study: Risk Factors and Outcomes

PURPOSE

To evaluate the rate of, risk factors for, and outcomes of cataract surgery in patients with intermediate, posterior, and panuveitides treated with systemic corticosteroids and immunosuppression.

DESIGN

Cohort study of participants from a randomized clinical trial.

METHODS

A multicenter clinical trial with extended follow-up comprised the study setting. From the cohort of participants assigned to systemic therapy in the Multicenter Uveitis Steroid Treatment (MUST) Trial and Follow-up Study, 125 phakic eyes of 74 patients with intermediate, posterior, or panuveitides treated with systemic therapy were included. The main outcome measures were cataract surgery and visual acuity after cataract surgery.

RESULTS

The cumulative incidence of cataract surgery was 43% at 7 years of follow-up, and the risk did not plateau. Risk factors for cataract surgery included age >50 years (hazard ratio [HR] 2.86, 95% CI 1.52, 5.42; P = .001), topical corticosteroid use (time-updated HR 3.13, 95% CI 1.42, 6.94; P = .005), glaucoma medication use (HR 2.75, 95% CI 1.38, 5.47; P = .004), and possibly history of anterior chamber inflammation (HR 1.90, 95% CI 0.95, 3.84; P = .07). Median gain in acuity and median best corrected visual acuity 1 year after cataract surgery were 4.8 lines and 20/25, respectively, among 42 eyes undergoing cataract surgery with 1-year follow-up data.

CONCLUSIONS

Among patients with intermediate, posterior, and panuveitides, treated with oral corticosteroids and immunosuppression, there is a substantial long-term risk of cataract surgery. Visual acuity outcomes after cataract surgery are generally good.

Pharmacological management of intra-operative miosis during cataract surgery

Cataract surgery requires a well-dilated and stable pupil for a good outcome. Unexpected pupillary constriction during surgery increases the risk of complication. This problem is more pronounced in children. There are now pharmacological interventions that help tackle this unforeseen happening. Our review discusses the simple and quick options available to a cataract surgeon when faced with this dilemma. As cataract surgical techniques continue to improvise and get faster, an adequate pupil size is of paramount importance. Various topical and intra-cameral drugs are used in combination to achieve mydriasis. Despite good pre-operative dilation, the pupil can be quite unpredictable during surgery. Intra-operative miosis limits the field of surgery and increases the risk of complications. For example, if the pupil size decreases from 7 mm to 6 mm, this 1 mm change in pupil diameter will lead to a decrease of 10.2 mm2 in the area of surgical field. Making a good capsulorhexis with a small pupil can be a challenge, even for an experienced surgeon. Repeated touching of the iris increases the risk of fibrinous complications. Removal of cataract and the cortical matter becomes increasingly difficult. Intra-ocular lens implantation in the bag also requires adequate dilation. When dealing with challenging cases like lens subluxation, pseudo-exfoliation, and zonular dehiscence, a small pupil further increases the risk and adversely affects the surgical outcome. Hence, achieving and maintaining adequate mydriasis throughout surgery is essential. This review highlights the risk factors for small pupils during surgery and current management strategies.

Long term complications and vision loss in HLA-B27 uveitis

OBJECTIVES

To evaluate the long term complications and vision loss in HLA-B27 uveitis.

METHODS

Retrospective review of subjects with HLA-B27 uveitis in a public tertiary centre between January 2008 and 2020.

RESULTS

562 HLA-B27-positive subjects (834 eyes) had mean follow-up of 9.8 years (8173.2 eye-years). Median visual acuity at ten years was 0.1 logMAR (IQR 0.0-0.1). Complications occurred in 404 eyes (48.4%): posterior synechiae (39.7%), cataract (22.1%), elevated intraocular pressure (15.5%), cystoid macular oedema (6.0%). Permanent moderate vision loss ( ≤ 0.4 logMAR) due to uveitis occurred in 14 eyes (1.7%) and severe vision loss (≤ 1.0 logMAR) in 7 eyes (0.8%). Complications were more common with older age (OR 1.017 p = 0.016), chronic inflammation (OR 5.272 p < 0.001) and intermediate uveitis (OR 5.982 p < 0.001).

CONCLUSIONS

Complications are frequent in HLA-B27 uveitis, especially in older subjects, chronic inflammation and intermediate uveitis. Despite this, the majority of subjects maintain good visual prognosis.

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.

Risk Factors Associated with Unexpected Refractive Outcomes in Uveitic Cataract Surgery

OBJECTIVE

Assess refractive outcomes following uveitic cataract surgery and identify factors associated with deviations from the target refractive goal.

METHODS

A multicenter retrospective chart review was performed for 216 subjects with uveitis undergoing cataract surgery. Prediction error was calculated and tested for association with demographic and clinical characteristics using single variable and multiple regression analysis.

RESULTS

39.8% of eyes deviated from the intended refractive target by at least 0.5 diopters (D). The mean prediction error was 0.56 ± 0.67 D. Younger age (p = 0.042), preoperative inflammatory corneal findings (keratic precipitates and/or band keratopathy) (p = 0.0004), and poorer postoperative visual acuity (p = 0.0054) were associated with a deviation from the intended refractive target by at least 1 D.

CONCLUSIONS

A higher percentage of eyes undergoing uveitic cataract surgery deviated from the intended refractive target when compared to reported refractive outcomes in normal subjects. Younger age, preoperative inflammatory corneal sequelae, and poorer postoperative visual acuity were associated with this outcome.

Non-biologic, steroid-sparing therapies for non-infectious intermediate, posterior, and panuveitis in adults

BACKGROUND

Non-infectious intermediate, posterior, and panuveitis (NIIPPU) represent a heterogenous collection of autoimmune and inflammatory disorders isolated to or concentrated in the posterior structures of the eye. Because NIIPPU is typically a chronic condition, people with NIIPPU frequently require treatment with steroid-sparing immunosuppressive therapy. Methotrexate, mycophenolate, cyclosporine, azathioprine, and tacrolimus are non-biologic, disease-modifying antirheumatic drugs (DMARDs) which have been used to treat people with NIIPPU.

OBJECTIVES

To compare the effectiveness and safety of selected DMARDs (methotrexate, mycophenolate mofetil, tacrolimus, cyclosporine, and azathioprine) in the treatment of NIIPPU in adults.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register), MEDLINE, Embase, the Latin American and Caribbean Health Sciences database, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform, most recently on 16 April 2021.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) comparing selected DMARDs (methotrexate, mycophenolate, tacrolimus, cyclosporine, and azathioprine) with placebo, standard of care (topical steroids, with or without oral steroids), or with each other.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included 11 RCTs with a total of 601 participants in this review. DMARDs versus control Two studies compared an experimental DMARD (cyclosporine A or enteric-coated mycophenolate [EC-MPS]) plus oral steroid with steroid monotherapy. We did not pool these results into a meta-analysis because the dose of cyclosporine used was much higher than that used in current clinical practice. The evidence is very uncertain about whether EC-MPS plus low-dose oral steroid results in a higher proportion of participants achieving control of inflammation over steroid monotherapy (risk ratio [RR] 2.81, 95% confidence interval [CI] 1.10 to 7.17; 1 study, 41 participants; very low-certainty evidence). The change in best-corrected visual acuity (BCVA) was reported separately for right and left eyes. The evidence for improvement (lower logarithm of the minimum angle of resolution (logMAR) indicates better vision) between the groups is very uncertain (mean difference [MD] -0.03 and -0.10, 95% CI -0.96 to 0.90 and -0.27 to 0.07 for right and left, respectively; 1 study, 82 eyes; very low-certainty evidence). No data were available for the following outcomes: proportion of participants achieving a 2-line improvement in visual acuity, with confirmed macular edema, or achieving steroid-sparing control. The evidence for the proportion of participants requiring cessation of medication in the DMARD versus control group is very uncertain (RR 2.61, 95% CI 0.11 to 60.51; 1 study, 41 participants; very low-certainty evidence). Methotrexate versus mycophenolate We were able to combine two studies into a meta-analysis comparing methotrexate versus mycophenolate mofetil. Methotrexate probably results in a slight increase in the proportion of participants achieving control of inflammation, including steroid-sparing control, compared to mycophenolate at six months (RR 1.23, 95% CI 1.01 to 1.50; 2 studies, 261 participants; moderate-certainty evidence). Change in BCVA was reported per eye and the treatments likely result in little to no difference in change in vision (MD 0.01 logMAR higher [worse] for methotrexate versus mycophenolate; 2 studies, 490 eyes; moderate-certainty evidence). No data were available for the proportion of participants achieving a 2-line improvement in visual acuity. The evidence is very uncertain regarding the proportion of participants with confirmed macular edema between methotrexate versus mycophenolate (RR 0.49, 95% CI 0.19 to 1.30; 2 studies, 35 eyes; very low-certainty). Methotrexate versus mycophenolate may result in little to no difference in the proportion of participants requiring cessation of medication (RR 0.99, 95% CI 0.43 to 2.27; 2 studies, 296 participants; low-certainty evidence). Steroids with or without azathioprine versus cyclosporine A Four studies compared steroids with or without azathioprine (oral steroids, intravenous [IV] steroids, or azathioprine) to cyclosporine A. We excluded two studies from the meta-analysis because the participants were treated with 8 mg to 15 mg/kg/day of cyclosporine A, a significantly higher dose than is utilized today because of concerns for nephrotoxicity. The remaining two studies were conducted in all Vogt-Koyanagi-Harada disease (VKH) populations and compared cyclosporine A to azathioprine or IV pulse-dose steroids. The evidence is very uncertain for whether the steroids with or without azathioprine or cyclosporine A influenced the proportion of participants achieving control of inflammation (RR 0.84, 95% CI 0.70 to 1.02; 2 studies, 112 participants; very low-certainty evidence), achieving steroid-sparing control (RR 0.64, 95% CI 0.33 to 1.25; 1 study, 21 participants; very low-certainty evidence), or requiring cessation of medication (RR 0.85, 95% 0.21 to 3.45; 2 studies, 91 participants; very low-certainty evidence). The evidence is uncertain for improvement in BCVA (MD 0.04 logMAR lower [better] with the steroids with or without azathioprine versus cyclosporine A; 2 studies, 91 eyes; very low-certainty evidence). There were no data available (with current cyclosporine A dosing) for the proportion of participants achieving a 2-line improvement in visual acuity or with confirmed macular edema. Studies not included in synthesis We were unable to include three studies in any of the comparisons (in addition to the aforementioned studies excluded based on historic doses of cyclosporine A). One was a dose-response study comparing cyclosporine A to cyclosporine G, a formulation which was never licensed and is not clinically available. We excluded another study from meta-analysis because it compared cyclosporine A and tacrolimus, considered to be of the same class (calcineurin inhibitors). We were unable to combine the third study, which examined tacrolimus monotherapy versus tacrolimus plus oral steroid, with any group.

AUTHORS' CONCLUSIONS

There is a paucity of data regarding which DMARD is most effective or safe in NIIPPU. Studies in general were small, heterogenous in terms of their design and outcome measures, and often did not compare different classes of DMARD with each other. Methotrexate is probably slightly more efficacious than mycophenolate in achieving control of inflammation, including steroid-sparing control (moderate-certainty evidence), although there was insufficient evidence to prefer one medication over the other in the VKH subgroup (very low-certainty evidence). Methotrexate may result in little to no difference in safety outcomes compared to mycophenolate.

Risk factors associated with post-operative uveitis after cataract surgery: a retrospective case-control study

BACKGROUND/AIM

Post-operative uveitis is the most common complication after cataract surgery in the UK. The study aims to evaluate the risk of post-operative uveitis in cataract surgery patients of different ethnicity in the presence and absence of co-morbidities as well as operative complications using multivariate analysis.

METHODS

A retrospective case-control study of patients undergoing phacoemulsification cataract surgery between January 2018 to December 2019 at two hospital sites. Differences in demographic and clinical characteristics were compared between two groups defined by the development of post-operative uveitis. Statistically significant factors in univariate analysis were further analysed using multivariate analysis to account for confounders.

RESULTS

One thousand and five hundred eighty seven eyes had undergone phacoemulsification cataract operations with 104 (6.6%) developing post-operative uveitis. Compared to eyes of White/Mixed/Other ethnicity, Asian and Afro-Caribbean eyes were associated with a twofold (OR 2.02, 95% CI 1.16-3.52, P = 0.013) and fivefold (OR 5.15, 95% CI 2.85-9.29, P < 0.001) risk of post-operative uveitis, respectively. Complicated surgery involving eyes with small pupil/iris hooks/Malyugin ring (OR 2.70, 95% CI 1.16-6.30, P = 0.022) and posterior capsular rupture (OR 6.00, 95% CI 2.55-14.12, P < 0.001) were associated with an increased risk of post-operative uveitis.

CONCLUSIONS

The factors significantly associated with a post-operative uveitis outcome were patients of Asian and Afro-Caribbean ethnicity, small intra-operative pupil size, use of iris hooks or Malyugin ring and PCR. The post-operative management plan should be tailored in these group of patients with a view of early assessment and prompt management of symptoms.

Challenges of Pediatric Cataract Surgery in a Case of Seasonal Hyperacute Panuveitis (SHAPU)

A four-year-old female child diagnosed as a case of severe Seasonal Hyperacute Panuveitis (SHAPU) underwent lens-sparing core vitrectomy in her left eye with intravitreal antibiotic and steroid. Patient responded well to treatment and intraocular inflammation subsided. However, three months later, she developed vision impairing dense cataract which also made posterior segment assessment difficult. Lens aspiration with primary posterior capsulotomy and anterior vitrectomy with intraocular lens (IOL) implantation was performed. However, four weeks later, the patient developed occlusio pupillae with iris bombe. She did not respond to medical management so synechiolysis with surgical iridectomy was performed after which a normal depth anterior chamber was attained. Synechia and iris bombe were also relieved, and vision was regained.

Risk of Cataract in Intermediate Uveitis

PURPOSE

To determine the incidence of and predictive factors for cataract in intermediate uveitis.

DESIGN

Retrospective cohort study.

METHODS

Patients were identified from the Systemic Immunosuppressive Therapy for Eye Diseases Cohort Study, in which medical records were reviewed to determine demographic and clinical data of every eye/patient at every visit at 5 participating US tertiary care uveitis centers. The primary outcome was development of vision-compromising cataract as defined by a decrease in visual acuity to 20/40 or less, or requiring cataract surgery. Survival analysis assessed visually defined cataract to avoid bias due to timing of surgery vis-à-vis inflammatory status.

RESULTS

Among 2,190 eyes of 1,302 patients with intermediate uveitis, the cumulative incidence of cataract formation was 7.6% by 1 year (95% confidence interval [CI] = 6.2%-9.1%), increasing to 36.6% by 10 years (95% CI = 31.2%-41.6%). Increased cataract risk was observed in eyes with concurrent anterior uveitis causing posterior synechiae (hazard ratio = 2.68, 95% CI = 2.00-3.59, P < .001), and in eyes with epiretinal membrane formation (hazard ratio = 1.54, 95% CI = 1.15-2.07, P = .004). Higher dose corticosteroid therapy was associated with significantly higher incidence of cataract, especially time-updated use of topical corticosteroids ≥2 times/d or ≥4 periocular corticosteroid injections. Low-dose corticosteroid medications (oral prednisone 7.5 mg daily or less, or topical corticosteroid drops <2 times/d) were not associated with increased cataract risk.

CONCLUSIONS

Our study found that the incidence of clinically important cataract in intermediate uveitis is moderate. The risk is higher with markers of severity and with higher doses of corticosteroid medications, the latter being potentially modifiable.

Shorter Axial Length Is a Risk Factor for Proliferative Vitreoretinopathy Grade C in Eyes Unmodified by Surgical Invasion

PURPOSE

To investigate the risk factors for the development of proliferative vitreoretinopathy grade C (PVR-C), independent of prior surgical invasion.

METHODS

Patients who underwent surgery for rhegmatogenous retinal detachment were prospectively registered with the Japan-Retinal Detachment Registry, organized by the Japanese Retina and Vitreous Society, between February 2016 and March 2017. Data obtained from general ophthalmic examinations performed before and at 1, 3, and 6 months after surgery were analyzed.

RESULTS

We included 2013 eyes of 2013 patients (men, 1326 (65.9%); mean age, 55.2 ± 15.2 years) from amongst 3446 registered patients. Preoperative PVR-C was observed in 3.6% of patients. Propensity score matching revealed that a shorter axial length (AL) was a risk factor for preoperative PVR-C (OR (Odds Ratio), 0.81; 95% CI (Confidence Interval), 0.69 to 0.96; p = 0.015), which was a risk factor for surgical failure (OR, 4.22; 95% CI, 1.12 to 15.93; p = 0.034); the association was particularly significant for eyes with an AL < 25.0 mm (p = 0.016), while it was insignificant for eyes with an AL ≥ 25.0 mm.

CONCLUSIONS

A shorter AL was related to the development of PVR-C before surgical invasion. Our results will help elucidate the fundamental pathogenesis of PVR and caution clinicians to meticulously examine eyes with a shorter AL to detect retinal detachment before PVR development.

Cataract Surgery with or without Intraocular Lens Implantation in Pediatric Uveitis: A Systematic Review with Meta-Analyses

Purpose

To systematically review the results of comparative studies of modern cataract surgery in pediatric uveitis with or without intraocular lens (IOL) implantation and to perform comparative meta-analyses to compare visual acuity outcomes and complication rates.

Methods

On 12 November 2020, we systematically searched the Cochrane Central, PubMed/MEDLINE, EMBASE, ClinicalTrials.gov, and all affiliated databases of the Web of Science. Two authors independently reviewed studies and extracted data. Studies were reviewed qualitatively in text and quantitatively with meta-analyses. Outcome measures were preoperative and postoperative best-corrected visual acuity (BCVA), inflammation control, and rates of postoperative complications.

Results

Ten studies of 288 eyes were eligible for review of which the majority were eyes with juvenile idiopathic arthritis-associated uveitis. Summary estimates revealed that the BCVA was better in pseudophakic eyes vs. aphakic eyes (1-year postoperative: −0.23 logMAR, 95% CI: −0.43 to −0.03 logMAR, P=0.027; 5-year postoperative: −0.35 logMAR, 95% CI: −0.51 to −0.18 logMAR, P=0.000036). Pseudophakic eyes had more visual axis opacification (OR 6.76, 95% CI: 2.73 to 16.8, P=0.000036) and less hypotony (OR 0.19, 95% CI: 0.04 to 0.95, P=0.044).

Conclusions

In modern era cataract surgery on eyes with pediatric uveitis with IOL implantation leads to satisfactory and superior visual outcomes and no differences in complication rates apart from an increased prevalence of visual axis opacification and a decreased prevalence of hypotony when compared to aphakia. However, limitations of the retrospective design and the presence of selection bias necessitate a careful interpretation.

Intraoperative intravitreal triamcinolone acetonide injection for prevention of postoperative inflammation and complications after phacoemulsification in patients with uveitic cataract

Background

We aimed to evaluate the efficacy and safety of phacoemulsification with intravitreal 3 mg triamcinolone acetonide injection in preventing postoperative inflammation and complications in patients with non-infectious anterior uveitis and panuveitis complicated cataract.

Method

In this retrospective cohort study, 140 uveitic cataract patients who received phacoemulsification and intraocular lens implantation in Shanxi Eye hospital from January 2018 to January 2020 were reviewed. The IVTA group (51 eyes of 41 patients) received intravitreal injection of 3 mg triamcinolone acetonide (TA) at the end of surgery, and the control group (51 eyes of 41 patients) without injection matched by propensity score matching were enrolled. Outcome measures were best corrected visual acuity (BCVA), anterior chamber inflammation, intraocular pressure, corneal endothelial cell density, central macular thickness and complications within 3 months follow-up.

Results

The degree of postoperative anterior chamber inflammation in the IVTA group was lighter than that in the control group (P < 0.05). The postoperative logMAR BCVA of anterior uveitis was better and improved more quickly in the IVTA group(P < 0.05). Postoperative time of using corticosteroids was shorter in the IVTA group as compared to the control group (P < 0.05). The central macular thickness at postoperative month 1 was statistically significantly lower in the IVTA group (P < 0.05). There were no statistically significant differences between the two groups in postoperative corneal endothelial cell density and intraocular pressure (P > 0.05). Two of 51 eyes (3.9%) in the IVTA group and 8 of 51 eyes (15.7%) in the control group had recurrence of uveitis; 6 of 45 eyes (13.3%) in the control group developed cystoid macular edema but none in the IVTA group; 11 of 51 eyes (21.6%) in the IVTA group and 22 of 51 eyes (43.1%) in the control group developed posterior synechiae postoperatively.

Conclusions

Intraoperative Intravitreal injection of 3 mg TA is an effective and safe adjunctive therapy for preventing postoperative inflammation and complications to promote early recovery for anterior uveitis or panuveitis complicated cataract patients following phacoemulsification.

Trial registration

This retrospective cohort study was in accordance with the tenets of the Helsinki Declaration and was approved by the Shanxi Eye Hospital Ethics Committee. Written informed consent was obtained from all participants for their clinical records to be used in this study.

A Systematic Switch From Originator Infliximab to Biosimilar Infliximab in Patients With Non-Infectious Uveitis

PURPOSE

To investigate the efficacy of biosimilar infliximab compared to that of the originator infliximab for the treatment of chronic non-infectious uveitis.

DESIGN

Before-and-after study.

METHODS

All patients in the Central Norway Health Region between 2007 and 2018 were included. They were switched from originator to biosimilar infliximab therapy from 2014 to 2017. The primary outcome was quiescence of uveitis before and after the switch. All patients were seen every 1-3 months. Visits were binned into 3-month long periods for each patient takingboth medications. Poisson regression analysis was used to estimate the incidence rate ratio (IRR) of quiescence between the 2 treatments.

RESULTS

Twenty-nine patients were treated with infliximab. Twenty-three of those patients were switched from originator to biosimilar infliximab. The majority were white (87%), female (92%), and had chronic anterior uveitis (65%). For patients taking the originator and biosimilar drugs, the median treatment duration was38 months (range: 8-131 months) and 15 months (range: 5-55 months), respectively. Concomitant immunosuppressive medications and topical and oral steroids were used similarly during treatment with both originator and biosimilar infliximab. The IRR for quiescence was 0.91 (95% confidence intervals [CI]: 0.7-1.1; P = 0.38), which indicated no statistically significant differences in achieving quiescence after the switch. Also, there were no differences in the incidence rate of flare events with the switch (IRR: 1.04; 95% CI: 0.36-2.98; P = 0.95). IRR adjusted for intraocular surgery was 0.90 (95% CI: 0.7-1.1; P = 0.37).

CONCLUSIONS

No evidence of differences in effectiveness were found in comparing biosimilar to originator infliximab in patients with chronic non-infectious uveitis.

Cataract Surgery Outcomes in Human Immunodeficiency Virus Positive Patients at a Tertiary Care Academic Medical Center in the United States

Purpose: To compare cataract surgery complications and visual outcomes in patients with and without human immunodeficiency virus (HIV).Methods: A retrospective cohort study was conducted on eyes undergoing phacoemulsification cataract surgery at an academic eye center from 1/1/2014 to 8/31/18. Outcomes included best corrected distance visual acuity (CDVA), intraoperative complications, cystoid macular edema (CME), and persistent anterior uveitis (PAU). Binary outcomes were analyzed using logistic regressions with generalized estimating equations. Visual outcomes were analyzed using a linear mixed model.Results: 9756 eyes from 5988 patients were included in the analysis. Of these, 66 eyes from 39 patients were HIV positive (HIV+). HIV+ patients were significantly younger at the time of surgery than HIV negative patients (p < .0001). Among HIV+ patients with available lab data, the mean CD4 count was 697.3 (SD = 335.7), and 48.7% of subjects had an undetectable viral load. Five eyes from three HIV+ patients had a history of cytomegalovirus retinitis (CMVR). Positive HIV status was not associated with increased risk of intraoperative complications. Post-operative CDVA was better in the HIV negative group compared to the HIV+ group but not significantly different (about 20/24 vs. 20/28, p = .0829). Eyes from HIV+ patients were at increased risk of developing PAU after surgery (adjusted OR = 6.04, 95% CI: 2.42-15.1, p = .0001), as well as CME (adjusted OR = 3.25, 95% CI: 1.02-10.4, p = .0470).Conclusions: Eyes from HIV+ patients were at greater risk of developing PAU and clinically significant CME; however, HIV+ patients had similar CDVA after cataract surgery compared to HIV negative patients.

Paediatric cataract in the uveitis setting

BACKGROUND/AIMS

Cataract formation is common in uveitis and is visually more threatening in the paediatric cohort due to the risk of amblyopia. In addition, paediatric uveitis can often be difficult to manage. We report our experience with IOL placement in cataract surgery in the setting of paediatric uveitis.

METHODS

This non-comparative, retrospective interventional case series examined our cases of paediatric cataract occurring in patients with uveitis from 2003 to 2016. Parameters examined included visual acuity (VA), underlying diagnosis, immunosuppression status, intra-operative complications and requirement for further surgery.

RESULTS

In total, 10 eyes of seven patients were identified. The mean age at diagnosis of uveitis was 7.7 years (range 5.2-14 years) with onset of cataract at a mean of 29.3 months later (range 0-66 months). Three cases were bilateral and four cases were unilateral. Final visual outcomes were excellent with 80% showing improvement in VA achieving greater than 6/9.5 (p < 0.05). These patients had significant co-morbidities with concurrent glaucoma, band keratopathy and cystoid macular oedema. Uveitis was quiet for a minimum of 6 months in all cases prior to surgery with augmentation of immunosuppression pre-operatively as well as intra-operative local or intra-venous steroids. Tight post-operative care was necessary as 80% developed further flare-up of uveitis requiring increased immunosuppression and surgical interventions to manage their uveitis.

CONCLUSION

Paediatric uveitis patients who develop cataract can have good visual outcomes with IOL insertion at the time of surgery when there is aggressive control of uveitis in the pre, peri and post-operative period.

Kataraktoperationen bei Uveitis

Die Katarakt stellt bis heute eine maßgebliche Ursache für Visusverlust bei Patienten mit einer Entzündung der Uvea dar. Mehrere Studien der letzten Jahre zeigten hier zwar, dass eine Kataraktoperation eine Verbesserung des Visus erzielen kann, die Prognose jedoch im Vergleich zu einer normalen Patientengruppe stark reduziert ist.

Visual outcome and prognostic factors in cataract surgery in ocular tuberculosis

Purpose:

To analyze the outcome of cataract surgery in patients with ocular tuberculosis (OTB).

Methods:

Medical records of patients with OTB who underwent cataract surgery between 2005 and 2018 were retrospectively reviewed. The primary outcome measure was corrected distant visual acuity (CDVA), and a good outcome was defined as CDVA 20/40 or better.

Results:

There were 35 patients (41 eyes), of whom 13 (37.1%) were males and 22 (62.9%) were females. The mean age was 41.6 ± 13.8 (range 18–65) years. Anterior uveitis was present in 24 (58.5%) eyes, intermediate uveitis in 5 (12.2%) eyes, posterior uveitis in 6 (14.6%) eyes, and panuveitis in 6 (14.6%) eyes. Posterior sub-capsular cataract (51.2%) was the most common type of cataract. Total cataract was present in 9 (22%) eyes. The two most common ocular comorbidities were small pupil (85.4%) and glaucoma (17.1%). Phacoemulsification was performed in 36 (87.8%) eyes and ECCE was performed in 5 (12.2%) eyes. Intraoperatively the pupil was mechanically dilated in 36 (87.8%) eyes. Overall 26 (63.4%) and 23 (56.1%) eyes achieved CDVA 20/40 or better at 1- and 6-month follow-up visit, respectively. The mean preoperative LogMAR CDVA significantly improved from 1.28 ± 0.57 to 0.38 ± 0.36 at 1-month (P < 0.0001). One eye had fibrinous anterior chamber reaction and 24 (58.5%) eyes had 1 or more episodes of reactivation of uveitis in the follow-up period. The three commonest complications were glaucoma (26.8%), posterior capsule opacification (19.5%), and epiretinal membrane (17.1%). Postoperative posterior segment complications like epiretinal membrane formation, vitreous inflammation and cystoid macular edema affected final visual acuity (P < 0.002).

Conclusion:

The visual outcome after cataract surgery in OTB was satisfactory as significant number of patients achieved a good final visual acuity.

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).

Differentiation of Underlying Pathologies of Macular Edema Using Spectral Domain Optical Coherence Tomography (SD-OCT)

Purpose: To describe the morphological characteristics of macular edema (ME) of different origins using spectral domain optical coherence tomography (SD-OCT). Methods: This article summarizes and highlights key morphologic findings, based on published articles, describing the characteristic presentations of ME of different origins using SD-OCT. The following pathologies were included: uveitic macular edema, pseudophakic cystoid macular edema (PCME), diabetic macular edema (DME), macular edema secondary to central or branch retinal vein occlusion (CRVO/BRVO), microcystic macular edema (MME), ME associated with epiretinal membrane (ERM), and retinitis pigmentosa (RP). Conclusions: Macular edema of different origins show characteristic patterns that are often indicative of the underlying cause and pathology. Thus, trained algorithms may in the future be able to automatically differentiate underlying causes and support clinical diagnosis. Knowledge of different appearances support the clinical diagnosis and can lead to improved and more targeted treatment of ME.

Perioperative Management of Uveitic Cataracts

Uveitis patients represent a unique subset of the population undergoing cataract surgery and pose several challenges that require special consideration and strategy. Maintenance of disease quiescence for at least three months prior to surgery maximizes postoperative outcomes, though these patients remain at increased risk for pseudophakic cystoid macular edema, which can be refractory to the traditional steroid treatments. In this review, we detail the pillars of preoperative optimization, intraoperative considerations, and postoperative management of uveitic cataracts, with special attention on the evidence surrounding prevention and treatment of refractory postoperative cystoid macular edema.

[Pharmacological treatment strategies and surgical options for uveitis]

BACKGROUND

Modern treatment of uveitis aims at a complete control of inflammatory activity, preservation of visual function and the prevention of secondary organ damage as a consequence of the underlying inflammatory disease and its treatment.

OBJECTIVE

This article gives an update about the strategies of pharmacological and surgical options for uveitis.

MATERIAL AND METHODS

The outcomes reported here are based on a PubMed search using the terms <"uveitis" AND "therapy"> and <"uveitis" AND "surgery" OR "surgical treatment">. All prospective studies and case series with more than 20 cases as well as review articles from the last 5 years along with cited cross-references were evaluated.

RESULTS

Local and systemic corticosteroids form the foundation of treatment after exclusion of an infectious etiology. If uveitis activity is not controlled within 6 weeks or if the daily corticosteroid dosage is unacceptably high, a treatment escalation using immunomodulatory drugs is required. If a complete control of inflammatory activity is not achieved, in a third phase treatment is supplemented by antibody-based treatment or cytokines, so-called biologics, with the aim of complete long-term freedom from disease without local or systemic steroid treatment. This target is achieved in 65-80% and guarantees long-term functional stability and anatomical integrity. Early treatment escalation in cases of persisting or recurrent activity as a rule prevents new secondary organ damage. Surgical options are utilized for diagnostic purposes, the administration of intravitreal drugs and for treatment of secondary complications.

CONCLUSION

Just like the majority of immunological diseases, uveitis is a chronic disease requiring long-term and possibly lifelong treatment and remission (absence of inflammation without treatment) is achieved in only <20%. Surgical interventions can be performed with a good prognosis, if the optic nerve head and macula are not involved. They have a substantially lower complication rate when freedom from symptoms exists preoperatively for at least 3 months.

Cataract management in Ebola virus disease survivors: clinical and scientific implications

"The EVICT study was the first study to demonstrate a step-wise approach on how to safely screen EVD survivors for cataract surgery, providing evidence that vision restoration though surgical management was safe and feasible in this cohort of EVD survivors".

Safety and efficacy of dexamethasone implant along with phacoemulsification and intraocular lens implantation in children with juvenile idiopathic arthritis associated uveitis

PURPOSE

To assess the safety and efficacy of intraoperative intravitreal dexamethasone implant in patients of juvenile idiopathic arthritis (JIA)-associated uveitis undergoing phacoemulsification with posterior chamber intraocular lens (PCIOL) implantation.

METHODS

Retrospectively, data of patients with JIA-associated uveitis undergoing phacoemulsification with PCIOL implantation with intraoperative dexamethasone implant injection were analyzed. Patients with a minimum follow-up of 6 months were included. Primary outcome measures were ocular inflammation, intraocular pressure (IOP), best-corrected visual acuity (BCVA), and worsening of uveitis.

RESULTS

8 eyes of 6 patients were included. BCVA was significantly improved at 1, 3, and 6 months postoperatively 0.20 ± 0.09, P = 0.008; 0.18 ± 0.11, P = 0.008; and 0.24 ± 0.11, P = 0.01, respectively. No statistical difference noted in mean IOP at various follow-up visits. None developed worsening of uveitis or Cystoid macular edema.

CONCLUSION

Intraoperative intravitreal dexamethasone implant is a safe and effective in preventing and managing the postoperative inflammation in children with JIA-associated uveitic cataract.

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.

Cataract Surgery Complications in Uveitis Patients: A Review Article

Uveitis is a leading causes of blindness worldwide, and the development of cataracts is common due to both the presence of intraocular inflammation and the most commonly employed treatment with corticosteroids. The management of these cataracts can be very challenging and often requires additional procedures that can compromise surgical results. The underlying disease affects a relatively young population at higher risk of complications. Preoperative control of inflammation/quiescent disease for at least three months is generally accepted as the minimum amount of time prior to surgical intervention. Phacoemulsification with intraocular lens is the preferred method for surgery, with some studies showing improvement in visual acuity in over 90% of patients. The most common postoperative complications include macular edema, posterior capsule opacification, recurrent or persistent inflammation, glaucoma, epiretinal membrane and IOL deposits, or dislocation. Despite the potential complications, cataract surgery in uveitis patients is considered a safe and successful procedure.