Cataract surgery in uveitis

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.

Pattern of Uveitis at a Tertiary Eye Hospital in Eastern Province of Saudi Arabia and Comparison with Local Literature

PURPOSE

To explore the patterns of uveitis in a main ophthalmic referral center in the Eastern province of Saudi Arabia.

METHODS

A retrospective chart review of uveitis cases was conducted in a tertiary eye hospital for five years. In addition, a comprehensive review of Saudi publications about uveitis patterns in the literature.

RESULTS

Out of 222 patients included, 54.4% were females, with a mean age of 38.5 years. Uveitis was bilateral in 55.7%, non-granulomatous in 55.9%, and infectious in 11.3%. Most of the cases were anterior uveitis (51.1%), followed by panuveitis (26%), intermediate uveitis (12.8%), and posterior uveitis (10%). Apart from idiopathic cases (43.7%), the most common diagnoses were Vogt-Koyanagi-Harada disease (11.3%) and Behcet's disease (7.7%) in adults. Juvenile idiopathic arthritis (7.2%) was commonest among children. Posterior synechiae was the leading complication (32.0%), followed by cataracts (22.8%).

CONCLUSIONS

VKH and Behçet disease were the primary non-idiopathic etiologies in Saudi Arabia.

Recurrence of Ocular Toxoplasmosis after Vitrectomy: Case Report and Review

PURPOSE

The purpose of this study is to report one case of ocular toxoplasmosis (OT) recurrence after vitrectomy and review the scientific basis about it.

CASE REPORT

A 58-year-old male patient with previous OT, properly treated, underwent vitrectomy due to macular hole. During follow-up, patient evolved with recurrence of the OT. After 1 year, patient presents visual acuity of 20/200 and extensive macular scar.

CONCLUSION

There is no consensus on using perioperative antiparasitic therapy aiming recurrence prophylaxis. Studies with better statistical design are necessary to evaluate the recurrence risk after ocular surgeries and the possible recommendation of prophylaxis, especially in countries where the strains are more virulent and the recurrence more common.

Manual small-incision cataract surgery under topical anesthesia for post-uveitis complicated cataract

Purpose

Cataract development is a common sequelae associated with uveitis. Despite phacoemulsification being the popular method of cataract surgery today, manual small-incision cataract surgery (MSICS) may still be a safe and effective alternative because of several inherent benefits. There is not much literature and studies on the efficacy and safety of MSICS under topical anesthesia in complicated cataract in patients with uveitis. We aimed to study the safety and visual outcome of MSICS under topical anesthesia for post uveitis complicated cataract.

Methods

This was a retrospective observational study. The electronic medical records of adult patients who underwent MSICS under topical anesthesia for post uveitis cataract were reviewed. The records were reviewed and analyzed for preoperative clinical characteristics and visual acuity, intraoperative complications and postoperative visual acuity, and complications.

Results

A total of 71 eyes of 59 patients were taken for final analysis. The average age of patients was 59.9 years. There was improvement in the best corrected visual acuity by 0.7 logMAR (P value &lt;0.0001). Average follow-up period was 9.8 months. The mean gain in visual acuity in eyes that received preoperative steroids was 0.6 logMAR compared to the eyes that did not receive steroids (0.71 logMAR). The difference was not statistically significant (P = 0.407). Complications seen during long-term follow-up were recurrence (15.5%), cystoid macular edema (7%), Epiretinal membrane (8.5%), and posterior capsular opacification (5.5%).

Conclusion

With proper technique and precautions, MSICS can be safely and comfortably performed under topical anesthesia even in complicated cataracts with excellent visual and safety outcomes.

Assessment of Anterior Uveitis Through Anterior-Segment Optical Coherence Tomography and Artificial Intelligence-Based Image Analyses

Purpose

The purpose of this study was to develop an automated artificial intelligence (AI) based method to quantify inflammation in the anterior chamber (AC) using anterior-segment optical coherence tomography (AS-OCT) and to explore the correlation between AI assisted AS-OCT based inflammation analyses and clinical grading of anterior uveitis by Standardization of Uveitis Nomenclature (SUN).

Methods

A prospective double blinded study of AS-OCT images of 32 eyes of 19 patients acquired by Tomey CASIA-II. OCT images were analyzed with proprietary AI-based software. Anatomic boundaries of the AC were segmented automatically by the AI software and Spearman's rank correlation between parameters related to AC cellular inflammation were calculated.

Results

No significant (p = 0.6602) differences were found between the analyzed AC areas between samples of the different SUN grading, suggesting accurate and unbiased border detection/AC segmentation. Segmented AC areas were processed by the AI software and particles within the borders of AC were automatically counted by the software. Statistical analysis found significant (p < 0.001) correlation between clinical SUN grading and AI software detected particle count (Spearman ρ = 0.7077) and particle density (Spearman ρ = 0.7035). Significant (p < 0.001) correlation (Pearson's r = 0.9948) between manually and AI detected particles was found. No significant (p = 0.8080) difference was found between the sizes of the AI detected particles for all studies.

Conclusions

AI-based image analysis of AS-OCT slides show significant and independent correlation with clinical SUN assessment.

Translational Relevance

Automated AI-based AS-OCT image analysis suggests a noninvasive and quantitative assessment of AC inflammation with clear potential application in early detection and management of anterior uveitis.

Liposomal drug delivery system for anti-inflammatory treatment after cataract surgery: a phase I/II clinical trial

Liposomes as a drug delivery system may overcome the problems associated with non-compliance to eyedrops and inadequate control of inflammation after cataract surgery. We evaluated the safety and efficacy of a single subconjunctival injection of liposomal prednisolone phosphate (LPP) for the treatment of post-cataract surgery inflammation. This is a phase I/II, open-label non-comparative interventional trial of patients undergoing cataract surgery. All patients received a single injection of subconjunctival LPP intraoperatively. The primary outcome measure was the proportion of eyes with an anterior chamber cell count of 0 at postoperative month 1. Ocular and non-ocular adverse events, including elevated intraocular pressure, rebound iritis and pseudophakic macular edema were monitored. Five patients were enrolled in this study. The mean age was 66.6 ± 6.2 and 4 (80%) were male. The proportion of patients with AC cell grading of 0 was 0%, 80%, 80%, and 100% at day 1, week 1, month 1, and month 2 after cataract surgery, respectively. Mean laser flare photometry readings were significantly elevated at week 1 after cataract surgery (48.8 ± 18.9, p = 0.03) compared with baseline, decreasing to 25.8 ± 9.2 (p = 0.04) at month 1 and returned to baseline by month 2 (10.9 ± 5.1, p = 1.0). No ocular or non-ocular adverse events were observed. Liposomal prednisolone phosphate, administered as a single subconjunctival injection intraoperatively, can be a safe and effective treatment for post-cataract surgery inflammation. The delivery of steroids with a liposomal drug delivery system could potentially replace eyedrops as anti-inflammatory therapy following cataract surgery.

LONG-TERM INCIDENCE AND RISK FACTORS OF OCULAR HYPERTENSION FOLLOWING DEXAMETHASONE-IMPLANT INJECTIONS: THE SAFODEX-2 STUDY

PURPOSE

To analyze the incidence, risk factors, and time to onset of ocular hypertension (OHT) after intravitreal injections (IVI) of dexamethasone implant and to evaluate the long-term cumulative probability of intraocular pressure elevation.

METHODS

Eyes of patients having received at least one dexamethasone implant IVI between October 2010 and February 2015 were included in the present study. Ocular hypertension was defined as intraocular pressure > 25 mmHg and/or an increase of 10 mmHg over the follow-up period compared with baseline intraocular pressure.

RESULTS

Four hundred ninety-four eyes were studied in 410 patients. For a total of 1,371 IVI, the incidence of OHT was 32.6% in the study eyes with a mean follow-up period of 30 months (3-62.5) and a median follow-up of 29 months. Pressure-lowering treatment was introduced for 36.9% of eyes. Topical treatment alone was sufficient to manage OHT in 97%. Young age, male sex, uveitis and retinal vein occlusion, and glaucoma treated with a double- or triple-combination topical pressure-lowering medication were found to be risk factors for OHT. The incidence of OHT did not change with an increase in the number of IVI, and there was no cumulative effect, defining by an increase of the incidence of OHT in patients after repeated IVI (P = 0.248).

CONCLUSION

This study confirmed that OHT is of moderate incidence, transient, controlled by topical treatment and provides data on the long-term cumulative probability of intraocular pressure elevation in a large cohort of eyes treated with dexamethasone implant IVI. Repeat injections of dexamethasone implant neither increase nor decrease the risk of OHT.

Surgical Outcomes of Contrast Sensitivity and Visual Acuity in Uveitis-Associated Cataract

Purpose

To evaluate the pre- and post-operative outcomes of phacoemulsification in patients with uveitis-associated cataract in remission, such as conventional visual acuity (VA), photopic and mesopic contrast visual acuity (CVA), and flares in the anterior chamber objectively assessed as intraocular inflammation.

Patients and Methods

This prospective study included 26 eyes of 19 patients with uveitis and 45 eyes of 26 controls who underwent cataract surgery at the Kyushu University Hospital and Kyushu Medical Center in Fukuoka, Japan, from October 2016 to December 2018. Conventional VA and flare values in the anterior chamber were evaluated preoperatively and 1 and 3 months postoperatively. Photopic and mesopic CVAs were assessed preoperatively and 3 months postoperatively.

Results

The best-corrected VA (BCVA) was improved significantly from baseline to 1 and 3 months postoperatively in both groups (P < 0.01 in both groups). The mean preoperative 100% and 10% CVAs under the photopic condition were significantly lower in the uveitis group than in the control group (P < 0.05 for both CVA), whereas the mean preoperative 100% CVA under the mesopic condition was comparable between the two groups. Although the mean preoperative 100% and 10% CVAs improved significantly from baseline under both photopic and mesopic conditions in both groups (P < 0.01 in both groups), the postoperative contrast sensitivities under both photopic and mesopic conditions remained lower in the uveitis group than in the control group (P < 0.01 for both conditions). The postoperative complications included recurrence of active inflammation in five eyes and cystoid macular edema in one eye and were managed by topical steroid therapy alone.

Conclusion

Cataract surgery for uveitis-associated cataracts during remission is well tolerated. However, the present results suggest that amelioration of hemeralopia and/or nyctalopia is not as good as expected after cataract surgery in patients with uveitis.

Corectopia grading: A novel classification system

Objectives: To present and validate the novel grading system for objective classification of corectopia.Subjects and Methods: We evaluated 28 eyes of 28 patients with or without corectopia and validated the grading and classification system for corectopia according to three major criteria: (i) direction, (ii) extent, and (iii) alteration of mydriasis. Intraclass correlation coefficient (ICC) and inter-rater agreement between 7 inexperienced and 1 experienced ophthalmologist against a golden standard (GS) were calculated.Results: The ICC for the 7 inexperienced ophthalmologists regarding the grading of direction and centration of the pupil was 0.83 (95% confidence interval (CI), 0.74 to 0.90; p < .001) and 0.57 (95% CI, 0.43 to 0.72; p < .001), respectively. The inter-rater agreement was the same or almost the same in cases of pupil decentration between the inexperienced, experienced ophthalmologists and the GS (k = 0.82; 95% CI, 0.64-1.00; p < .001). In assessing the direction of pupil displacement, the inter-rater agreement was almost perfect between the inexperienced (k = 0.93; 95% CI, 0.84-1.00; p < .001) and experienced (k = 0.92; 95% CI: 0.82-1.02; p < .001) ophthalmologists and the GS.Conclusion: The first detailed clinical classification is proposed for objective corectopia grading particularly relevant in documenting and assessing progressive disease. It was confirmed to be acceptable for clinical use by inexperienced and experienced ophthalmologists alike.

[Results of surgical treatment of complicated uveal cataract]

PURPOSE

A retrospective analysis of the results of surgical treatment of complicated uveal cataracts of different origin.

MATERIAL AND METHODS

The study analyzed the results of surgical treatment of uveal cataract in 30 patients (34 eyes) who were divided into three groups by uveitis etiology. The first group included 11 patients with spondyloarthritis associated with the HLA-B27 antigen; the second group included 10 patients with juvenile chronic arthritis and spondyloarthritis, negative for HLA-B27 antigen; the third group consisted of 9 patients with other systemic autoimmune diseases and uveitis of unknown etiology, also negative for the HLA-B27 antigen. The average age of the patients was 35.8±2.6; 30.8±3.8 and 34.0±2.3 years, respectively. Four patients (6 eyes) with juvenile chronic arthritis and severe ribbon-like corneal degeneration underwent standard intracapsular cataract cryoextraction with subsequent spectacle correction of aphakia. In other cases, ultrasound phacoemulsification with implantation of an intraocular lens (IOL) was used as a surgical aid.

RESULTS

Regardless of the surgery technique and the cause of uveal cataract, a statistically significant decrease in the number of exacerbations per year (p<0.0001) and an increase in best corrected visual acuity (BCVA) were noted after its removal. In the long-term follow-up (2-24 months), 9 patients experienced persistent decompensation of the IOP level, which required various types of antiglaucoma surgery.

CONCLUSION

Surgical treatment of uveal cataracts of various etiologies with adequate pre- and postoperative therapy provides an improvement in visual acuity and a reduction in the frequency of inflammation recurrence. Considering the high likelihood of IOP decompensation in the long-term postoperative period, IOP control should be given attention in such cases.

Phacoemulsification in patients with uveitis: long-term outcomes

BACKGROUND

To assess the long-term outcomes of phacoemulsification and intraocular lens (IOL) implantation in eyes with uveitis.

METHODS

One hundred and five eyes of 81 patients, who underwent phacoemulsification and IOL implantation between January 2009 and July 2016, were included in this study. The demographic data, preoperative clinical findings, postoperative outcomes, and intraoperative and postoperative complications were recorded. All collected data and risk factors with regard to visual prognosis were analyzed with the help of the Statistical Package for the Social Sciences version 20.0 software program (IBM Corp., Armonk, NY, USA).

RESULTS

During follow-up (mean: 35.2 ± 22.2 months), corrected distance visual acuity (CDVA) improved in 87.7% of all eyes and reached a level of 0.3 LogMAR or greater in 61.3% of eyes. Postoperative complications included posterior capsule opacification (50.9%), posterior synechiae (21.7%), cystoid macular edema (16%), epiretinal membrane (13.2%), glaucoma (11.3%), increased intraocular pressure (8.5%), and severe inflammation (6.6%). Uveitis recurred in 55.7% of all eyes. The risk for the development of cystoid macular edema was found to be associated with recurrence in the early postoperative period. Low visual acuity risk was 11.1-fold higher with macular scarring (p = 0.001) and 14-fold higher with optic atrophy (p < 0.001), respectively.

CONCLUSIONS

With appropriate management during the pre- and postoperative periods, phacoemulsification and IOL implantation surgery can be safe and effective in eyes with uveitis. However, great caution must be taken to prevent complications both before and after the surgery.

Risk factors for ocular complications in adult patients with uveitis

PURPOSE

To report risk factors for ocular complications in adults with uveitis.

METHODS

Retrospective cohort study of 653 patients with uveitis (869 eyes) followed up for at least 1 month attended between May 1989 and December 2012.

RESULTS

After a median follow-up of 16 months (interquartile range = 3-59), 43.5% of patients developed one or more complications, including cataract formation (25%), iris alterations (20%), and macular edema (16%) as the most frequent. Older age, intermediate uveitis, chronic course, and uveitis activity >3 months were significantly more frequent among patients with complications. In the multivariate analysis, age ⩾65 years (hazard ratio = 2.76, 95% confidence interval = 1.72-4.4), chronic course (hazard ratio = 1.78, 95% confidence interval = 1.23-259), and uveitis activity >3 months (hazard ratio = 1.94, 95% confidence interval = 1.33-2.84) were predictors of complications.

CONCLUSION

In the present series of patients with uveitis, advanced age, chronic uveitis, and inflammatory activity >12 weeks were risk factors for complications.

Optimising graft survival in endothelial keratoplasty for endothelial failure secondary to cytomegalovirus endotheliitis

BACKGROUND

There is limited information regarding Descemet stripping automated endothelial keratoplasty (DSAEK) for endothelial failure secondary to cytomegalovirus (CMV) endotheliitis. Treatment is difficult with high recurrence rates. We describe a case when systemic valganciclovir therapy is directed by aqueous CMV-DNA levels, leading to good graft survival.

FINDINGS

A 59-year-old male with bilateral CMV endotheliitis despite antiviral therapy developed endothelial failure and underwent DSAEK. Prior to surgery, aqueous polymerase chain reaction (PCR) for CMV was repeatedly performed, where CMV-positive episodes were treated with systemic valganciclovir. Monthly aqueous analysis was performed until CMV-DNA was undetectable before DSAEK was performed. Post-operative prophylactic systemic valganciclovir treatment was instituted and switched to topical valganciclovir treatment when aqueous samples were negative for CMV.

CONCLUSION

Targeted aqueous sampling for CMV-DNA perioperatively guides antiviral therapy and ensures adequacy of treatment, minimising the duration of systemic valganciclovir therapy to reduce adverse effects of long-term treatment.

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.

Evaluation of the etiology of persistent iritis after cataract surgery

Background

The purpose of this study was to evaluate patients with persistent iritis after cataract surgery to determine its incidence and risk factors. Adjusting the management of patients at risk could allow for a more predictable post-operative course and outcome. A retrospective chart review was performed of patients who had post-operative iritis longer than 1 month after cataract surgery during a 2-year period at Storm Eye Institute at the Medical University of South Carolina (MUSC) in Charleston, South Carolina. Patient demographics and various pre-operative, intra-operative, and post-operative factors were analyzed for trends.

Results

Thirty-nine patients (49 eyes) met the inclusion criteria, and this group was compared to a control cohort of 40 patients (66 eyes) who did not have persistent iritis after cataract surgery. The overall incidence of post-operative iritis was 1.75%. In all patients with post-operative iritis lasting greater than 1 month, African American race and pupil expansion device use were statistically significant factors. After excluding patients with a history of ocular inflammation or known inflammatory or autoimmune diagnosis (1.20% incidence), there were still a significantly higher proportion of African Americans compared to the control group. When patients with post-operative iritis of less than 6 months in duration were additionally excluded, the incidence was 0.32%, and history of diabetes was statistically significant in addition to race.

Conclusions

Risk factors for persistent iritis after cataract surgery include being diabetic, of African American racial background, and pupil expansion device use. These patients can be better informed of the higher risk of prolonged inflammation in their post-operative course, and peri-operative management can be tailored accordingly.

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.

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.

Long-term effect of cataract phacoemulsification on the inflammation control and clinical outcome in uveitis patients

IMPORTANCE

Cataract is one of the most common complications associated with uveitis, and is the leading cause of vision loss in these patients.

BACKGROUND

The study aimed to evaluate the effect of phacoemulsification on the long-term clinical outcome and inflammation control in uveitis patients.

DESIGN

Longitudinal study.

PARTICIPANTS

Of 1907 eyes with uveitis, 309 eyes underwent phacoemulsification were compared to a control group of 300 phakic eyes with uveitis.

METHOD

The risk of vision loss and macular oedema in pseudophakic eyes were compared to the phakic group. The rates of corticosteroids administration and uveitis relapse were also measured in pseudophakic eyes and compared to preoperative period.

MAIN OUTCOME MEASURES

Change in uveitis activity post phacoemulsification by measuring rate of uveitis relapse and use of topical and systemic steroids. Also, to measure the risk of vision loss and macular oedema post surgery.

RESULTS

Over a median follow-up time of 6.7 years or 2249 eye-years (EY), pseudophakic eyes had a greater risk of vision loss (hazard ratio [HR] 2.4, CI 1.4 to 4.0; P < 0.001) and macular oedema (HR 2.2, CI 1.4 to 3.4, P < 0.001) compared to the phakic uveitis group. Over 5 years post-surgery, the annual rate of uveitis relapses was less than the same period pre surgery (-1.2, 95% CI -2.0 to -0.2, P = 0.012) with no significant change in the annual rate of using topical and systemic prednisolone >7.5 mg/day.

CONCLUSIONS AND RELEVANCE

There was no significant increase in uveitis relapse rate post-phacoemulsification with the use of current prophylactic inflammation control measures.

Outcomes and Complications of Scleral-Fixated Intraocular Lens Combined with Ahmed Tube Surgery

Background

To evaluate the outcome and complications of transscleral suture-fixated posterior chamber intraocular lens (PCIOL) implantation combined with Ahmed glaucoma valve (AGV) surgery in Asian eyes.

Design

This was a retrospective study that included 22 eyes from 22 participants. The surgeries were performed at Singapore's National University Hospital. Participants underwent an Ahmed tube surgery, together with transscleral suture-fixated posterior chamber intraocular lens.

Main Outcome Measures

Complete success was defined as 6 ≤ intraocular pressure (IOP) ≤ 21 mmHg without medications at the last follow-up visit, with no reoperation required and no progression to no perception of light (NPL).

Results

At the last follow-up, there was a significant reduction in mean IOP (22.4 ± 6.5 mmHg versus 13.9 ± 3.9 mmHg; p < 0.001) and mean number of intraocular pressure-lowering medications (2.45 ± 1.30 versus 0.05 ± 0.21; p < 0.001). There was no significant change in visual acuity [1.43 ± 1.21 (LogMAR) versus 1.09 ± 1.31 (p = 0.204)]. Sixteen eyes (72.7%) achieved complete success. The 3 commonest complications were bullous keratopathy, choroidal detachment, and displacement of intraocular lens.

Conclusion and Relevance

This technique showed good success for intraocular pressure control and vision preservation. Postoperative complications were relatively common although most were self-limiting. Patients at increased risk of trabeculectomy failure may be suitable for this procedure.

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.

Management of cataract in uveitis patients

PURPOSE OF REVIEW

This review is timely because the outcomes of surgical invention in uveitic eyes with cataract can be optimized with adherence to strict anti-inflammatory principles.

RECENT FINDINGS

All eyes should be free of any cell/ flare for a minimum of 3 months preoperatively. Another helpful maneuver is to place dexamethasone in the infusion fluid or triamcinolone intracamerally at the end of surgery. Recent reports about the choice of intraocular lens material or lens design are germane to the best surgical outcome. Integrating these findings will promote better visual outcomes and allow advancement in research to further refine these surgical interventions in high-risk uveitic eyes.

SUMMARY

Control of inflammation has been shown to greatly improve postoperative outcomes in patients with uveitis. Despite better outcomes, more scientific research needs to be done regarding lens placement and materials and further research needs to adhere to the standardized reporting of uveitis nomenclature. Future studies should improve postoperative outcomes in eyes with uveitis so that they approach those of eyes undergoing routine cataract procedures.

The Influence of Phacoemulsification on Intraocular Pressure Control and Trabeculectomy Survival in Uveitic Glaucoma

OBJECTIVES

To evaluate the influence of phacoemulsification on intraocular pressure (IOP) control and survival of mitomycin C (MMC)-enhanced trabeculectomy in uveitic glaucoma (UG).

MATERIALS AND METHODS

Retrospective case-control study included 54 eyes from 40 patients with UG who underwent MMC-enhanced trabeculectomy as an initial procedure to treat glaucoma at King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia between 2002 and 2014. Eyes were divided into 2 groups: the first group included eyes that later underwent cataract surgery in the form of phacoemulsification, and the second group included eyes that did not have cataract surgery. The main outcome measures were changes in the IOP, the number of antiglaucoma medications, IOP control, and trabeculectomy survival.

RESULTS

There were no differences in the overall trabeculectomy survival of eyes that underwent cataract surgery and those that did not (P=0.681, log-rank) nor the final IOP [15.54 mm Hg (±6.3) in the study group and 13.34 mm Hg (±5.6) in the control group, P=0.247]. However, more antiglaucoma medications were needed to control the IOP after cataract surgery at the last follow-up [1.59 medications (±1.4) in the study group and 0.50 medications (±0.7) in the control group; P=0.009].

CONCLUSIONS

UG eyes that underwent phacoemulsification following MMC-enhanced trabeculectomy required more medications to control the IOP than those that did not undergo cataract surgery and therefore less IOP control. Such changes in IOP control did not affect the overall trabeculectomy survival rate.

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.

Long-term results of cataract surgery in patients with anterior uveitis

PURPOSE

This study was aimed to assess the long-term results of phacoemulsification and posterior chamber intraocular lens implantation in patients with anterior uveitis.

METHODS

Patients with complicated cataract secondary to anterior uveitis who underwent phacoemulsification and posterior chamber intraocular lens implantation were included in this study. Long-term results and all complications were evaluated throughout the postoperative 4 years.

RESULTS

A total of 55 eyes of 48 patients were identified in this study. Cases with anterior uveitis were categorised into four aetiologic groups. Of the 55 eyes, 22 (19 patients) had idiopathic anterior uveitis, 10 (9 patients) had viral anterior uveitis, 10 (9 patients) had Fuchs' anterior uveitis and 13 (11 patients) had anterior uveitis associated with collagen vascular diseases. Preoperative macular oedema was more frequent (63.6%) in the idiopathic group than in the other groups (p < 0.001). The success rates of the best corrected visual acuity of 20/40 or better ranged from 80.0 to 100.0% in the groups. While postoperative increased intraocular pressure rate was statistically significantly higher in the Fuchs' group (p = 0.047), there was no statistically significant difference in other complication rates between the groups.

CONCLUSIONS

The long-term outcomes of phacoemulsification with intraocular lens implantation in patients with uveitic cataract were satisfactory with excellent visual acuity and relatively low complication rates.

Outcomes of cataract surgery with/without vitrectomy in patients with pars planitis and immunosuppressive therapy

BACKGROUND

The purpose of this study was to evaluate the characteristics and outcomes of cataract surgery with/without vitrectomy in patients with pars planitis who received immunosuppressive therapy.

METHODS

This was a retrospective case series, single-center study. Twenty-two patients with pars planitis who received immunosuppressive therapy were included, with a median age at presentation of 9.5 years, having had cataract surgery. The following data was collected: age at presentation and at cataract surgery, time of follow-up, best-corrected visual acuity (BCVA) before the surgery and at 1 week, 1 and 6 months after the procedure, immunosuppressive therapy, complications and causes for failed visual improvement. The variables associated with an improvement in visual acuity were evaluated.

RESULTS

All patients had phacoemulsification with intraocular lens implantation. The most common immunosuppressive therapy used for the patients was methotrexate in nine patients (40.9%). The BCVA improved from a median of 20/400 to 20/100 after 6 months of follow-up (p = 0.0005); 14 patients (63.6%) improved two lines of vision or more. No significant risk factors were found for the association with improvement in visual acuity after the surgery. No improvement in visual acuity was attributed to posterior segment manifestations or amblyopia; the most common complication was posterior capsule opacification in 11 eyes (50%). The median follow-up after the surgery was 32 months.

CONCLUSION

Phacoemulsification was the procedure for all the patients. Visual acuity improved in patients with pars planitis treated with immunosuppressive drugs who underwent cataract surgery, except for the patients with posterior segment complications or amblyopia.

Complications of Uveitis: The Northern California Epidemiology of Uveitis Study

PURPOSE

To describe the uveitis complications in a large, community-based cohort.

METHODS

Retrospective, community-based, cross-sectional cohort study analyzing complications and associations with complications.

RESULTS

A total of 844 cases of uveitis were found; 342 were new-onset, and 462 were prior-onset. In total, 29.5% of patients were affected by one or more complications associated with age, gender, course, and anatomic location of uveitis. Visual loss was experienced by 19.1% of patients and was associated with age, course of disease, and anatomic location of uveitis. Of the patients who developed glaucoma or elevated intraocular pressure over 30 mmHg, 3.9% (n = 33) were related solely to uveitis; 5.2% (n = 44) had an unclear or combined mechanism; and 1.8% (n = 15) were related solely to steroid response. Cystoid macular edema was associated with course of disease and anatomic location of uveitis.

CONCLUSIONS

Complications affect a significant portion of uveitis patients, and are often associated with demographic and clinical factors.

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.

Analysis and Outcomes of Cataract Surgery in Patients with Acquired Immunodeficiency Syndrome

PURPOSE

To investigate the surgical outcomes, complications and postoperative progression in HIV patients undergoing cataract surgery in a teaching hospital.

METHODS

A retrospective cohort study of patients with HIV/AIDS who had cataract surgery from January 2000 until December 2011 at a tertiary referral multidisciplinary hospital in Singapore.

RESULTS

We identified 44 eyes from 29 patients. Preoperatively, 41.3% had no ophthalmic manifestations of HIV/AIDS, while 16 eyes had quiescent cytomegalovirus retinitis (CMVR). Postoperatively, 1 eye developed new CMVR, while 1 eye had reactivation of previous CMVR. Of eyes with new or previous CMVR, 1 eye developed rhegmatogenous retinal detachment (RD) postoperatively. Only 3 eyes had prolonged postoperative inflammation. There were no cases of endophthalmitis or cystoid macular edema. Postoperative improvement of at least two Snellen lines was achieved in 86.6% of eyes.

CONCLUSIONS

Cataract surgery in HIV patients is generally safe, regardless of CD4 count, but their general and ocular health should be optimized preoperatively.

Controversies in intraocular lens implantation in pediatric uveitis

Cataract is one of the most common and visually debilitating complications of pediatric uveitis. It develops as a consequence of chronic inflammation and steroid use and is seen most often in juvenile idiopathic arthritis (JIA)-associated uveitis. Cataract extraction with intraocular lens (IOL) insertion has been carried out with a measure of success in non-uveitic pediatric eyes, but in cases of uveitis, multiple factors affect the final outcome. Chronic inflammation and its sequelae such as band keratopathy, posterior synechiae, and cyclitic membranes make surgical intervention more challenging and outcome less certain. Postoperative complications like increased inflammation, glaucoma, posterior capsular opacification, retrolental membranes, and hypotony may compromise the visual outcome. Early refractive correction is imperative in pediatric eyes to prevent amblyopia. The use of contact lenses and intraocular lenses in pediatric uveitic eyes were fraught with complications in the past. Surgical interventions such as vitreo-lensectomy followed by contact lens fitting and small incision cataract surgery followed by different types of intraocular lenses have been utilized, and many reports have been published, albeit in small patient groups. This review analyzes and discusses the existing literature on intraocular lens implantation in cases of pediatric uveitic cataract surgery.

Trabeculectomy With Mitomycin C or Ahmed Valve Implantation in Eyes With Uveitic Glaucoma

PURPOSE

To report and compare the results of trabeculectomy with mitomycin C (MMC) and Ahmed valve implantation in the management of uveitic glaucoma.

PATIENTS AND METHODS

The records of 41 eyes of 29 patients who underwent trabeculectomy with MMC or Ahmed valve implantation for uveitic glaucoma were retrospectively reviewed. Seventeen eyes underwent trabeculectomy with MMC, and 24 eyes underwent Ahmed valve implantation. Outcomes included postoperative intraocular pressure (IOP), percent reduction from preoperative IOP, postoperative number of medications, time to failure, and complications.

RESULTS

Mean follow-up was 21.2 months in the trabeculectomy group and 23.8 months in the valve group (P=0.06). Mean IOP was reduced from 29.2 to 18.4 mm Hg in the trabeculectomy group (31.3%), compared with a reduction from 33.4 to 15.5 mm Hg in the Ahmed valve group (42.7%, P=0.53). Postoperatively, 1.76 medications were used in the trabeculectomy group, compared with 1.83 medications in the Ahmed valve group (P=0.89). Cumulative success at 1 year was 66.7% in the trabeculectomy group, compared with 100% in the Ahmed valve group (P=0.02). Mean time to failure was 8.36 months with trabeculectomy, and 21.8 months with Ahmed valve (P=0.02). Complications in both groups were typically rare and self-limited, with recurrent inflammation being most common.

CONCLUSIONS

Although both trabeculectomy with MMC and Ahmed valve implantation are reasonable surgical options in the management of uncontrolled uveitic glaucoma, Ahmed valve implantation was associated with higher cumulative success rate at 1 year and a longer mean time to failure.

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.

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.