The management of cataracts in uveitis patients can be complex and anything but routine. The cornerstones of successful management of uveitic cataracts include aggressive and meticulous control and management of pre- and post-operative inflammation and knowing when and where to put the intraocular lens.
Lecturer: Dr. Ramana Moorthy, Associate Clinical Professor of Ophthalmology,
Indiana University School of Medicine, USA
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Dr. Ramana Moorthy: Let me start here. Welcome everybody. Thank you for attending. I will… I will hope that you gain some insights about cataracts extraction in patients with you uveitis. Last year we did some lectures and talked about the nature of diagnosis. And at least he hit a little bit of management issues regarding the uveitis patients. Cataracts are a relatively common complication of patients who have uveitis. And when I say uveitis I mean I’m talking mainly about chronic uveitic conditions here. Umm, acute uveitic conditions such as HLA-B27-associated hypopyon iritis, etcetera, there are those kinds of things can cause cataracts of course. Their management may be similar. But this most of this lecture refers to the more difficult patients who have chronic uveitis chronic anterior chamber inflammation along with intermediate or posterior or panuveitis who have cataracts that obscure visualization of the posterior segment and interfere with the patient’s vision.
As with other… excuse me I’ve given away the answer here.
So… the first question that I have and the answer is already given it’s actually goin to be… I think I’ve given away the answer the first question that we have is in which of the following conditions is placement of an intraocular lens often contraindicated at the time of cataract surgery. And I’ll talk a little bit more about this. Is it in patients who have Behcet’s disease, patients who have recurrent HLA-B27-associated iritis or uveitis, juvenile rheumatoid or idiopathic arthritis associated uveitis or toxoplasmosis?
We’ll take a quick poll here and I already showed you the answer that I was thinking of but let’s see what you guys think. Right. Should we. So. So most people thought that yes JIA-associated uveitis and certainly there are forms of Behcet’s disease and severe recurrent HLA-B27 where we would be very concerned about putting intraocular lenses in patients as wel. Here with children, I think there is a relative contraindication in some cases and we’ll get to that and we’ll talk about some of the details of this in a moment.
I’m going to go to the next slide here. The complications of uveitis are myriad but cataracts and glaucoma and perhaps cystoid macular edema are the most common causes. Cataracts are much more common in chronic and recurrent inflammatory disease of the eye. And usually it’s the combination of both the presence of chronic intraocular inflammation as well as the exacerbation of cataracts from the use of concomitant corticosteroids that result in cataract progression in many of these patients. But if you were to ask me which is more predominant I would say in most chronic uveitic cases it’s the inadequate control of inflammation that really causes the development of cataracts. And when we see cataracts in uveitic patients morphologically most of these tend to be posterior subcapsular cataracts – the same kind of cataract you may see with corticosteroid use. In addition you obviously will have age related nuclear sclerotic changes changes and also climate and a solar exposure related cortical changes that may be present as well. And we talk about surgical management when the cataract is visually significant or precludes the view of the posterior segment which is required for monitoring the disease status. OK? Those are the two potential indications for surgery.
In children the risk factors for cataract surgery and uveitis are very similar.
But again if you look at the number of uveitis flares per year this is based on some, a recent study that from this year from the British group looking at the European group looking at the multi-center kind of approach to cataract surgery in uveitic… in patients… children with you uveitis. In these cases the presence of cystoid macular edema and number uveitis flares per year, the presence of posterior synechiae when the patient presents with disease and the use of local corticosteroid injections all are significant factors and interestingly look where it says treatment with systemic and topical corticosteroids were not necessarily significant risk factors. Keep in mind that this study is a tertiary center based study where we’re probably seeing a lot of people are the uveitis trained and so they’ve been managing the corticosteroids systemic and topical appropriately in order to try to reduce their contribution to development of cataract. But more important than all… then everything is that controlling the inflammation, even using higher dose of systemic steroids is of importance in preventing ocular complications like Cataracs so we can’t lose sight of the fact that even though corticosteroids may contribute to cataract worsening the most important thing that we have to do for our patients with chronic uveitis is to get the inflammation under as good control as possible for as long as possible to assure that they will maintain long term good visual outcome.
There are some contraindications for cataract surgery in uveitis patients. If there’s anything that I want to take away from this talk, it is that: (a) if you have active anterior chamber inflammation in the patient and you’re thinking about cataract surgery you should put that thought out of your mind because cataract surgery in uveitis patients with very few exceptions is not routine. It’s not something where you can do phaco, you know, and not worry about them and send them out and not have to see them for a month after their first post-op after day visit. They need to be monitored carefully because these patients will develop – even those who are well-controlled – will develop post-operative inflammation in excess of what you’re used to seeing… seeing in the in the typical patient. And these patients will need more aggressive pre and post-operative intervention. The other contraindication in addition to active anterior segment inflammation for cataract extraction in uveitis patients is presence of active surface infection.
Somebody who has a corneal ulcer, bacterial keratitis, if somebody has active Herpetic disease in the cornea obviously those are contraindications. And if they have concurrent ocular pathoology that is likely to prevent functional improvement even if it was successful cataract surgery. That will be a relative contraindication in those cases surgery should be done only if it’s necessar to allow visualization of the fundus to help improve the treatment process.
So if a patient has decreased visual acuity that is explained by the cataract alone they have inability to examine the posterior segment in potentially progressive postior disease they have in some cases if the uveitis is caused by the lens. In other words there is a traumatic rupture of the anterior capsule. And we’re seeing a phaco-antigenic uveitis… in those cases obviously we’re going to need to do cataract surgery. You don’t have to wait for the inflammation necessarily to be quiet. You also may need to consider the age of the patient. In a pediatric patient especially a patient who is under the age of 10, we may have more urgent amblyogenic about having a cataract so the patient has a cataract who is four years old and significant visually and is really interfering their vision.
You don’t want to leave that for several months because that will induce fairly dense amblyopia but that also has to be tempered with the idea that good control of inflammation is necessary for adequate and good surgical outcomes following cataract surgery. So we like to in many cases in pediatric patients try to defer cataract surgery if at all possible into middle or later childhood until the eye is more mature. Until the uveitis has a really good chance to be well-controlled before we consider elective cataract surgery. There are many factors that complicate cataract surgery in uveitis patients and here a couple of pictures. I apologize for the little bit of a horizontal parallax distortion in the images but I think you get the idea.
The presence of posterior synechiae… obviously you don’t have a nice round beautiful 8 or 10 millimeter pupil to be working with and doing cataract surgery in these cases. Sometimes the pupilary dilation is extremely poor as you see in the lower right. You may see epilenticular membranes as you see in the lower right. You may see calcific band keratopathy the as you see in the lower right. The cataract may be white and mature as you see in the lower… lower right. And the lens may be hyper mature as you see in the lower right. So this patient has a very dense white cataract. You can see that there was a peripheral iridotomy that was performed previously for iris bombe that they had in the lower right.
The upper right picture. You see this patient actually has three areas of posterior synechiae… moderate dilation of the pupil, these synechiae will need to be broken at the time of surgery. Notice the patient has an iris nodule here so they may not have good, complete control of their inflammation. Band keratopathy mentioned friable iris vessels as you see in the picture on the lower right you can see this. These are… vascular anomalies within the fibrous membrane that is secluding and occluding the pupillary plane here. And then you see a calcitic band keratopathy the in the upper upper right the anterior chamber maybe shallow and you can’t see it but the lower right picture is a shallow enter chamber and the lower right also the patient who has various profound hypotonia already. Pressure is four. So.. and prior glaucoma or vitrectomy surgery, they may have weak zonules or zonular dialysis because of chronic intermediate uveitis where the… those inflammatory cells on the zonules that have caused some gradual weakening of the zonules.
This is a typical patient with a dense white cataract you can actually see ectropian uvea you see as the pupil is tended to be dilated and they have 360 degrees of posterior synechiae and probably a very thin pupilary membrane is also present. Occluding or secluding the pupillary plane. In this case this this patient will require fairly complicated cataract surgery assuming that their anterior chamber inflammation is completely quiescent on therapy. Here’s another close up of those friable Iris vessels.
You also need to assess in these patients what does the back of their eye look like? Pre-operatively, we need to make sure that the lens opacity is the main cause of their reduced vision. If the patient has severe cystoid macular edema as you see in the pictures below or they have severe glaucomatous cupping as you see in the lower right where you have significant loss of the nerve fiber layer substance and a very thin nerve rim. These things are going to interfere with visual outcomes and you need to have a good idea of telling the patient what to expect if cataract surgery is indeed planned, or you may decide that cataract surgery will not be appropriate because of these other underlying problems. The presence of active cystoic macular edema like this to me would be a relative contraindication to proceeding with cataract surgery because I know after cataract surgery this cystoid macular edema will become more severe and very recalcitrant to treatment and will result in severe vision loss.
Here’s our next question, I won’t give away the answer here.
So in a patient with a history of scleritis and vision loss, the clinical appearance shown, what measurement would be most important prior to considering cataract extraction?
Corneal pachymetry? Retinoscopic refraction? Dilated fundus examination? Or intraocular pressure check?
And this is kind of a tough question because it’s kind of like, “think what I’m thinking”. I’ll give you a few seconds to answer.
So this is a patient with scleritis.
All right so you know the answer is here.
So yes I think all of these, this is this kind of a tricky question but none of you got this right, this is interesting. So the all of these are very very important. But I think if you were to ask, well, let’s say that I should have said, well, you know the fundus examination is normal. The intraocular pressure is normal, corneal pachymetry is, you know, reveals some odd or it reveals normal doesn’t show any abnormalities but the topography may reveal irregular astigmatism. So a retinoscopic refraction, if the patient has reduced vision as a result of this, retinoscopic refraction actually is the is the is the thing that we’re thinking about because the retinoscopic refraction will result in… the… for you finding out that that patient who has irregular cylinder actually refracts to 20/16 or 20/15.
So think about that in patients who have scleritis because as the scleritis goes away as you see here and there is, you know thinning of the sclera you will see also some changes in the axis of the astigmatism that may have a profound impact on the patient’s refractive error and may not require surgery. Now in a patient with scleritis, you can still do an inactive scleritis, a clear Corneel approach to cataract surgery and many patients with inactive well controlled scleritis will do extremely well with cataract surgery. So I apologize for the rather obtuse question here. All of those answers are necessarily not incorrect, so none of you are incorrect in your thoughts. But in this case we were thinking about the possibility that retinoscopic refraction may tell you, you know immediate So don’t overlook the simplest things that we can do for our patients. So consider a PAM or laser inferometry to determine predict visual outcome if you can’t necessarily get a good view of the posterior pole. Obtain an OCT sometimes, an OCT will show you much more information in the macula about CME than you can glean from a binaocular indirect ophthalmoscopy examination or a slit lamp examination. And you need to counsel the patient about managing their expectation, the possibility of a limited prognosis.
You need to discuss why we’re doing the surgery. You know one of the expected outcome and the prolonged follow up and the increased need for medications in the perioperative period and the likelihood that additional procedures such as post-operative injections, imaging, lasers etc. may be necessary more than their grandpa joe who got cataract surgery and got 20:20 the first post-operative day and never had to take any drops. These are, You know these patients we have to manage their expectations and I think that’s very very important. The threshold for cataract surgery in uveitis patients is very different I think than the routine cataract surgery patients. If We have 20:25 vision of glare that’s rarely an indication for surgery in a patient with severe uveitis, because the risks are greater so when the, like any surgery when we weigh out and balance the risks versus benefits we have to make sure the benefits outweigh the risks before we can be an advocate for suggesting surgery for a patient of any type.
So we often required periocular and steroids, immunosuppressive therapy and that incurs additional risk in trying to pressure issues immune suppression increasing the risk of post-operative infections etc. those kinds of things need to think about. What are the general principles. What do you need to do beforehand, so this is the second point that I want you to take away, the first point is cataract surgery in uveitis patient is almost never routine. OK. The second point is that when you’re treating patients with chronic uveitis, you need to make sure that the eye is quiet. That means no inflammation. But that doesn’t mean off of all medications, whatever it takes to control the inflammation you need to keep them controlled with no cells, no cells in my opinion in the anterior chamber. OK. And baseline flare. And if you can keep them quiet that way for three months without a flare then you have at least some likelihood that you do have and have reasonably good control of inflammation pre and post-op, because this control of the inflammation pre-operatively and post-operatively is going to have everything to do with your surgical outcome. OK. It’s not how good and fast you’re doing phaco, all of you guys I’m sure are fantastic phacoemulsification surgeons or Cataract surgeons but it’s more than that. It’s about the medical management of these patients before and after surgery. So in the up, in the upper right hand picture here, you see a patient who has sarcoid anterior uveitis and you can see both koeppe nodules and also these busacca nodules.
And you see posterior synechiae in nearly 350 degrees of the of the iris. And in this patient they’re not well-controlled, they’re not ready for cataract surgery, in fact their lens looks reasonably clear, probably young patient here. So this patient will require very very good control of inflammation, all the nodules to essentially be gone and you shouldn’t see any anterior chamber cells etc. when you’re looking at these patients and they need to be that way for at least three months. And I would kind of say you know three to six months. So you need to optimize that uveitis status prior to surgery. Treat the cystoid macular edema because that’s going to get worse after surgery and treat the anterior segment inflammation, because if you don’t, you’re going to have you’re going to have a worse post-operative result. So quiet eye for at least three months and the patient should have an examination, perhaps even the day before cataract surgery or very shortly before cataract surgery, make sure the eye is quite, OK. And if you have good control of inflammation you’re talking about based on recent data in JIA patients for example, they’re likely to be in 20 40 or better if they are well-controlled inflammation is 71 percent compared to those who are not well controlled. You know they are only 22 percent were better than 20:40 after cataract surgery. So these good visual outcome is is proportional to good control of inflammation. So prior to cataract surgery many of us will have increase in perioperative oral and topical corticosteroids. Now there are some controversy, if the patient has not taken oral corticosteroids prior and they had been controlled just with topical agents,
I often will just defer to using frequent topical agents and I will use prednisolone 1 percent drops or durezol, if durezol is available, very frequently durezol every two hours or prednisolone every hour starting one week before cataract surgery and then gradually tapering the topical drops based on the post-operative inflammation. And these patients should be monitored Weekly this first four to six weeks after surgery. In addition in patients who have had, who are on systemic immunomodulatory therapeutic agents and low doses of oral corticosteroids or if they required oral steroids in the past I would start them on 40 milligrams of oral Prednisone and I’m not trying to be dogmatic, but generally it’s between 0.5 to one milligram per kilogram per day. So about 40 milligrams of prednisone starting one week before surgery, continuing the week after surgery at the same dose and then gradually tapering weekly to every two weeks based on their inflammation of the oral prednisone as well. So back down to their baseline level of prednisone, that is my pre operative imposed operative management in a nutshell. So that’s the second thing that I want you to take away from this talk. Appropriate preoperative management, quiet eye for three months before you consider surgery. Don’t even think about surgery if the eye is not quiet. So there is an interesting study recently that looked at whether or not and it was a randomized controlled trial so I think that this is good data and it makes sense.
So people who had, people who were treated who had chronic uveitis, who were getting a cataract surgery and they had about 50 patients in each group that were randomized, 1 for oral plus topical, one for topical alone. And they had very similar outcomes in this study. Again this is a two setter uveitis specialist driven kind of approach. And so in these cases,please keep in mind that you know again we’re not talking about general ophthalmologist doing these studies. So these are ideal circumstances, so these patients are already well controlled and these patients have good pre and post-operative control, are on appropriate therapy for chronic uveitis management. So intraoperatively there are many considerations and I am a retina surgeon so I am going to admit that when I do cataract surgery it’s usually a parsplana lensectomy approach and there are some cases of pediatric uveitis or chronic uveitis where parsplana lensectomy is the right approach. So my approach is very different than the anterior segment surgeon obviously. But for the anterior segment surgeon who’s doing an anterior approach for cataract removal, you need to once, since the eye is quiet, you can then do a clear corneal wound that’s preferred especially in patients with scleritis, obviously you don’t want to do a scleral tunnel in a patient, who’s had previous scleritis. So clear corneal wounds, temporal approach is fine whatever you like, depending again if there is scleral keratitis or corneal thinning in certain areas, you want to try to avoid that. You want to go in and remove pupillary membranes,you need to do synechiolysis and then stretch the pupil. Often we use iris retractors or malyugin ring depending on how easy each of those is to get in. We get them do a capsularhexis that’s rather broad and wide.
And make sure that we do a complete cortical cleanup and if you’re going to put an intraocular lens implant in the eye, it must be intraocular lens implant placed in the bag. And generally I use acrylic or PMMA lenses, I will not use silicone lenses and I in fact as a retina specialist, I really don’t like silicone lenses for obvious reasons, if I have complex or retinal detachments I don’t want to have it even in the routine cases. Silicone lenses are wonderful lenses but they are not really suited for for the retinal surgeon and potential complications of retinal surgery, but acrylic and PMMA only. And generally I prefer rather than the single piece acrylic, I like the three piece acrylic. But you know that is my own preference, as a retina specialist I see more complications and problems with the acrylic single piece of foldable lenses. But again as long as they are in the bag and you get appropriate contraction of the capsular bag, those acrylic lenses won’t go anywhere. But early in the post-operative period, I have seen many acrylic lenses that were thought to be in the bag that were not, one haptic was actually tucked in, the knee of the haptic was rubbing against the iris. There are lots of little things that can happen with that. Whereas with a three piece acrylic lens, typically you’ll have prolene haptics and you’re able to adjust those haptics fairly easily and have good seating of this and with a single piece PMMA lens it’s going to be relatively easy to get back in the bag as well,but you need a larger incision and I like PMA lenses as well.
Intravitreal triamcinolone can be given trans parsplana or even through the anterior segment. If you want to at the end of the procedure generally this is very helpful for the management of the inflammation post-operatively and cystoid macular edema. So again posterior synechiae may be present and pupillary dilatation, epilenticular membranes as you mentioned. The white cataract and hyper mature lens is often found as well. How do we decide intra operatively or pre-operatively whether the patient to get an intraocular lens, that is another difficult question. Then I’ll come to towards the end of this talk a little bit more here. If the patient has band keratopathy that needs to be addressed obviously so you can have good visualization, So the band keratopathy procedure should be done first and let the patient heal first from that. Doing band keratopathy removal with the chelation with the EDTA scrubs, that potentially could be problematic. If you’re going to do cataract surgery the same time I wouldn’t advise it. I think the band kaeratopathy should be taken care of first and then the cataract after that, after the cornea is sealed.
The synechiolysis we’ll talk about in a moment, peripheral iridectomy or iridotomy may be required to gain access to the pupil and excising epilenticular membrane will require a fine utrata or intraocular 25 gauge forceps, pupil stretching with Iris hooks or malyugin ring may be useful, and off course trypan blue staining the capsule is useful in these dense cataracts. So clear corneal surgery is nice especially in scleritis patients, you can avoid contact with the sclera and leave the conjunctiva alone if you’re going to consider future glaucoma procedures. Couple of things surgically, these are things that my colleague Deborah Goldstein has put together, it’s a really nice little drawings of how we approach patients who have who need cataract surgery in uveitis and when and when we see somebody who has 360 degrees of posterior synechiae, I’ll get at the synechiae from the anterior chamber. Now if you’ve ever just entered the anterior chamber in hopes that then using a a small Iris hook or perhaps using a synskey hooke and to try to hook the edge of the iris and try to stretch the iris, you often will find a pupillary membrane and that membrane needs to be removed first and is very hard difficult to pick up that pupillary membrane or remove the membrane. One of them, the other thing is that the posterior synechiae are not just at the margin, this chronic inflammation is affected the whole iris, so often this synechiae will have broad adehesions not only at the pupillary margin but there may be adhesions that are, go on to the mid and far peripheral iris as well. So generally one good way to do is to make a small peripheral iridotomy superiorly that will come in handy later. And this is a superior approach and then using any iridodialysis spatula, go underneath the iris and then very gently sweep the synechiae off the surface of the lens capsule.
This is a very very effective and once you do that this will actually allow you to see the pupillary membrane, you can make a rent in the pupillary membrane from the posterior, anterior chamber or it can go back in anteriorly with utratas or other forceps and peel that lenticular membrane off. Once that’s done then you’re ready to stretch the pupil and you can use iris hookes. I really like irishookes as a retina guy, I don’t use malyugin ring very often, the iris hookes are nice. Three small self-sealing clear corneal incisions and their self-retaining may provide a nice surgical square pupil with a broad area of exposure. So you can use the capsular dye to create a capsulotomy, especially in a white cataract. There’s a malyugin ring being placed in a patient who had synechiae, this is the initial photos in the upper left and you can see we are doing this surgery intraoperatively. Sometimes you can see a significant zonular disruption or dialysis. In these cases,you need to think whether or not is it safe to continue surgery. So look at the picture,look at the picture here in the lower right and you can see here, this patient has tremendous zonular disruption even with appropriate,you know she’s using a specific capsular hooks here and holding the capsular bag in place whiles she is doing the capsularhexis. This can be very problematic obviously once the phaco is done and the lens has been taken care of. How do you then manage the intraocular lens placement, you’re going to have to use either some sort of capsular support system and or probably get this intraocular lens in the bag and then try to center it and the centration may be very difficult because that might require you suture the lens into the sulcus.
Again any manipulation of uveal tissues, the more you do manipulation of the uveal tissues the more you’re going to see post-operative inflammation and post-operative problems. So on the one in the lower right here in this case, it might have been even better just to do parsplana lensectomy and leave the patient aphakic. But I can see why she’s you know encouraged and wanting to do this because there is no synechiae, there’s not really a lot of structural damage to the iris. So in this case she is out to do, and this patient did very well, had anterior segment surgery, had a capsular tension ring placed along with it and I think this was sutured ultimately into the sulcus at least one suture holding it in the sulcus and the patient did very well. Tension rings can be utilized but remember that these go in the bag. I have retrieved a few tension rings and from the retina in the past, so you got to know exactly where the capsulatomy is and make sure that you have the ring inside the bag. It does no good if you can’t see how the ring is being placed and you don’t get into the equator of the capsular bag. so the trypanblue can also be utilized as well to expose the anterior capsule and make it nicer to see the anterior capsule. We already talked about the intraocular lens, so in the bag location of the intraocular lens is the preferred one. Sulcus intraocular lenses you know can be used.
There is probably some greater risk of developing iris shaping and rubbing if the inappropriate lens is used, you cannot use a gummy bear or a single piece acrylic lens in the sulcus, it even says that in the package, this is not for sulcus placement. So you have to use a three piece acrylic if you’re going to do that or a PMMA lens. And I would suggest that if you, if there’s vitreous loss etc. and things aren’t going well and you can’t put it in the in the bag, either not put a lens at all or do a thorough vitrectomy and then put a PC IOL, you may have to suture the PC IOL into the sulcus if it’s insufficient capsular support. Again this can carry with it a much greater risk of intraocular hemorrhage because these are inflamed eyes, greater risk of post-operative inflammation. All of this that we have kind of way out and unfortunately intraoperatively we’re kind of you know stuck making decisions on the go. But remember pre and post-operative inflammatory control is going to determine outcome. We definitely want to avoid anterior chamber intraocular lens placement because that’s going to cause chronic irits and that’s exactly what we’re trying to prevent,the flare up after cataract surgery. Typically, because we’re using frequent topical corticosteroid drops, there is usually a need for wound closure so there’s going to be inhibition of wound healing. So you should put a stitch to make sure that the wound is closed even if it looks watertight, I’d be cautious. The patient is at a greater risk for wound leak and eventually infection. Don’t give in to peer pressure.
This is kind of a blurry cartoon from Larson but don’t give in to peer pressure, of saying well I’m just going to do phaco and I’m going to put you know use whatever lens I want to use. You have to be, you have to kind of do this in a measured way when you approach cataract surgery in uveitis patient because not everybody needs to get an IOL. I have many patients who’re aphakic, who had very severe inflammation who underwent cataract surgery, who are doing extremely well with 20:20 vision with appropriate aphakic contact lens correction. It’s not ideal. Yes I agree. But there many children with, young children with uveitis over the years that I’ve done vitrectomy, lensectomy on, that are inflammation free. Many of them off of medications doing well. So patients who have extensive posterior synechiae and particularly patients who have significant flare or hypotony or have a history of noncompliance before these three months of control and they’ve not been well controlled. These are the cases where I’m going to think long and hard about using an intraocular lens implant. And you know if they fail in intraocular lens in their fellow eye, meaning that they have a cocooned lens or the lens required explantation because of persistent inflammation, in those cases leave the other eye apkakic. That is my approach. Now, being in the 21st century you may say wow thats crazy, you people aphakic, but you know I have.
I would much rather have an aphakic patient wearing a contact lens with 20:20 vision than I would have a pseudo phakic patient with a cocoon lens and hand motions vision where I had to go in and remove the lens and they’re at risk then for developing other complications from the lens removal such as retinal detachment, intraocular hemorrhage and all kinds of other nonsense. So the risk of intraocular lens placement you know in uveitis patient, what are the things that we will what what will happen? let’s put we put in the entire lens and all heck breaks loose and all the inflammation goes awry what’s going to happen. Well, dense intraocular lens precipitates are going to develop, cycltic membranes will develop in the ciliary body and around the zonules and the IOL will become cocooned. It will actually be surrounded by white anterior and posterior capsular fibrosis and you will see ciliary body detachment and probably irreversible hypotony. And I have a few patients where this was, the uveitis patients had surgery and this happened. So this is not, this is not something to take lightly. This happens more frequently than we know but we’re seeing it less commonly now because we have much many more drugs,we have more aggressive uveitis specialists who are controlling the inflammation and getting the patient teed up for the cataract surgeon to have appropriately good outcomes with cataract surgery. So in JIA there’s some controversy as I mentioned in my first question. That’s the one case where you know if you’re going to leave a patient aphakic, you’re going to more likely do that. So people who are younger, who have extensive posterior synechiae, who have a lot of flare,the proteinaceous flare in the anterior chamber,I’m going to leave aphakic. The more flare you have the more likely you are to develop cocooning of the intraocular lens implant.
You will have early post-operative fibrin formation in the anterior chamber and you’ll likely have cystoid macular edema in those patients in my experience. So and you know patients who have high hypotony etc. are those those people are not going to do well with an intraocular lens implant. So people who are older, well-controlled inflammation, good compliance and who don’t have a lot of synechiae, don’t have a lot of flare, and a significant cataract. Those people are going to do well. So here are some inflammatory deposits on the intraocular lens implant, dense and you can, you can YAG these off but they’ll come right back if the inflammation is not well controlled. So the YAG laser can be used to actually brush these off, it’s kind of fun to do but it’s just you know you can’t keep doing it. And here’s a patient that got epilenticular membranes, a lot of synechiae following cataract surgery, he’s still seeing OK. But look that, he has synechiae almost all way around the eye even all this area is synechiaed to the posterior capsule, anterior capsule I mean. And so you see these fibrinous membranes, so this patient had a lot of fibrin post-operatively, immediately postoperatively that left the fibrous membranes on the surface of the lens. Herre’s a cocooned intraocular lens implant.
And many of us have seen patients like these, these patients have a very poor visual prognosis, will require explantation of the intraocular lens, if they’re not hypotonous,we might be able to open up that capsule posteriorly and they might need a vitrectomy, they are at greater risks with the vitrectomy for developing retinal detachment as well because many of these patients will have detached ciliary body and an altered anatomy of their are parsplana parsplacata area where a retina surgeon might put his instruments. So post-operatively control inflammation aggressively. Sometimes I have used internal cameral TPA. I’ve done that a few times over the last several years where somebody develops severe fibrin in the anterior chamber. TPA works very beautifully,usually you seen it, will see it in the first one or two days post-operatively. Remember you have to make sure this fibrin is not from endophthalmitis obviously right. So this is a sterile fiber and you’ll see it it’ll be a very congealed and eye will look rather than fine. There’s just a lot of fiber in the first couple of days. There’s no hypopian usually in this case. And we give intracameral TPA, give him about 12.5mg to 25mg in tenth of cc and that usually breaks that up immediately, within 12 hours it’s gone. Pretty remarkable and it can be very very helpful in cases where there’s a lot of you know this f fibrinous inflammation. This happens more commonly in patients who have a lot of preexisting flare. It may happen more commonly in children.
And then of course cystoid macular edema, we need to use the topical nonsteroidals and aggressive use of intra vitreal periocular and or oral corticosteroids as well may be helpful in these cases. So again the important things to consider are good preoperative and postoperative control, set reasonable expectations, anticipate intra-operative techniques and equipment, control inflammation for at least three months before surgery. Intra-operatively you know, consider the PI, suture the corneal wound and manage the pupil membranes, zonules appropriately and then place the intraocular lens in the bag if at all possible and then these patients need to be followed post-operatively much more frequently because you know you can have these kinds of complications you see on the right where the intraocular lens is actually been displaced. It’s scarred, its pushing against the iris, there’s no you know you can see the edge of the haptic here. This is a disastrous outcome following a cataract surgery. You know in these patients you even monitor the fundus and aggressive control of inflammation is necessary. Which of the following pre-operative parameters is the most important predictor of post-operative outcomes after cataract extraction in uveitis patients? So the presence of band keratopathy, the presence of glaucoma, the presence of anterior chamber cells or presence of posterior synechiae. Which of the falling pre-operative parameters is the most important predictor? See what you guys got and so the presence of anterior chamber cells is really the main predictor of, so the patient has active inflammation. You know that’s the situation where you’re going to not do cataract surgery because you want the eye quiet for six months beforehand. You know the encouraging thing is that under appropriate management in the MUST trial results most recently this last year looking at all the 479 enrolled eyes, 117 underwent primary cataract surgery in this controlled clinical trial. The patients overall did very well. And these were patients who were managed by uveitis specialists who were participating in the study.
This is a multi-center randomised trial, we found that that no matter which whether they were on the implant or whether they were receiving systemic immuno suppression, this MUST trial actually is looking at and continues to look at which treatment is better. Is it better to have patients with chronic uveitis on systemic immunomodulatory therapy or is it better to treat them with a fluocinolone implant. And the seven years results have shown us that probably is this the systemic medication group actually we’ll have a better visual prognosis with about seven letters of better visual outcome after seven years of treatment compared to the implant group. OK. But when you look at cataract surgery in these patients that no matter which group they were in whether the systemic therapy or the fluocinolone implant alone, these patients had good outcomes because these patients had good control of pre-operative and post-operative inflammation and their overall letter being 23 letters. So most of them had substantial visual improvement following cataract surgery. So overall with appropriate control, cataract surgery is a very good visual prognosis for patients with uveitis. You know and if you look at all of the multi-center kind of approach, uveitis accounts for a very small minority of patients who undergo cataract surgery, only about one to two percent of patients who have cataract surgery. And then the eyes in the uveitic group usually had worse pre-operative visual acuity according to this British study and were younger patients, shorter axial lengths that had a higher incidence of co-ocular pathology including glaucoma and small pupils. And they regard additional surgical procedures and had developed more intraocular complications and compared to the general cataract surgeon, these patients tended to have poorer post-operative visual acuity and all follow up to six months. So that’s important to keep in mind too.
So the outcomes of these patients although good and definitely can be very good with appropriate control overall, still are a little worse than the typical cataract surgery patient. I hope I haven’t bored you with all the information. I think I’ll stop at this point and maybe take a few questions. I think we ended right at 40 42 minutes or so. So I will see if I can get at the get back to the chat screen here and we’ll see we’ve got, I wanted to ask if there’s any questions and I’m I’m happy to answer them at this point. I appreciate your your your interest. So yes so any. So let me start at the top here. The first question from Dr. Meta was, what is the what is there.
So what if there are vitreous membranes associated with JIA, idiopathic arthritis,do you vitrectomy associated with cataract extraction risk of doing and going into ciliary shut down and that’s an excellent question.
So if the patient has significant vitreous opacities, Yes we often will combine vitrectomy with cataract surgery, so the remove and this can be done in a staged process or in the case of children since you’re putting the patient under general anesthesia usually to reduce anesthetic risk, this can be done together. So the same surgeon or perhaps a retina surgeon can come and do the vitrectomy portion of the procedure and this can be done after the cataract has been removed, prior to the placement of the the intraocular lens implant or you can do the vitrectomy first if there is reasonable visualization and then remove the cataract and do the anterior segment work. I think it depends on what we find. What is going on with the patients clinically, so removal of the, doing a parsplana vitrectomy in my opinion when we do cataract surgery can be very beneficial too for inflammatory control of patients, particularly in patients who have intermediate or panuveitis, this may be very helpful. So the next question was let me see if I could get them in order. There are a lot of questions here.
Who would you put on an IOL in a quiet posterior Toxoplasma infection eye or would you put an IOL in there? If you have somebody with posterior toxoplasma necrosis that’s inactive with premacutive scar, in those patients I generally will put them on some sort of septra prophylaxis prior to surgery if they’re not on it and then go ahead and proceed with routine cataract extraction. I would not expect that that patients would have any major problems. Why in juvenile idiopathic arthritis is intraocular lens implants contraindicated? They’re not always contraindicated but patients who have extensive posterior synechiae, chronic flare, a poorly controlled inflammation, poor compliance, those patients you should avoid intraocular lens placement. And intraocular lens, regardless of how you look at it is still a foreign body in the eye, if somebody has poorly controlled inflammation they’re going to do well they’re not going to do well after cataract surgery because that’s just going to make their inflammation worse so very aggressive, good control of pre and postoperative inflammation is the key and you have to have that before you do cataract surgery.
So acrylic over PMA which lens do I prefer? I think that both are good. Again I told you that single piece acrylic lenses, you have to make sure that when you put them that they are both haptics or in the bag, there is a tendency for the knee of the single single piece acrylic lens sometimes to bend and not to come out of the edge of the capsule or bag especially the inferior part.
If that happens that can rub against the iris and create chronic inflammation and it really creates a real problem post-operatively. So you’ve got to make sure that that the IOL is in the bag and if you’re using a larger capsularhexis using a three piece acrylic lens might be better or using a PMMA lens might be better because these are less likely to migrate. Intracameral dexamethasone, Intracameral triamcinolone and posterior segment triamcinolone can be very useful. I use triamcinolone. I typically won’t give intracameral dexamethasone.
If you do that, I don’t think that that would be of any great harm. Again remember these patients are at greater risk for infection so you need to be considerate of that especially if they are on immunosuppressants. Is there any concern with corneal wound healing in patients with scleritis?
I should suture in those patients? If you do put sutures in patients who have previous scleritis. I would avoid going through the sclera deep into the sclera and again generally in uveitis patients, a clear corneal wound is utilized in patients who have previous scleritis and if you can’t put a suture or if you think you’re going to have to get in to thin sclera and causes problems with that you can avoid the suture. But generally I would try to put a suture through clear corneal wound.
And do we do it routinely in uveitis patients?
We do. I just think that why take the risk of wound leaks, why take the risk of hypotony, why take the risk of endophthalmitis in those patients who are at risk anyway. Lasik in aphakic uveitis patients, indications, counter indications. Well Lasik for aphakia as far as I know is still you know because if we’re trying to correct plus 10 diopters etcetera it may not be very successful. We may have inadequate correction of that level of hyperopia induced type aphakic hyperopia. So I don’t know that there I know the answer to that question. I don’t know that there is any specific contraindication, but any time we do any kind of ocular procedure especially in JIA patients we have to be particularly careful of flareups. I have seen patients with who have no active inflammation who underwent calcific band removal who had flareups of inflammation of their anterior chamber. So this is very very important to remember that, take no surgery on a especially a JIA patient you know lightly, because these patients can have flares with with with minimal with minimal intervention.
So the next question is pre-operative predictor of visual outcome to uncontrolled uveitis. So the question for preoperative outcomes you know when we look at patients who have bad flare and uncontrolled inflammation they’re going to have bad post-operative outcomes. So pre-operative factors that really impact outcomes or good control of inflammation they should have any cells in the eye. OK. If they have a lot of flare you can still do surgery. They are otne cells and they’ve been quiet for three or more months you can still do surgery OK but those patients will have a greater likelihood of of fibrin development post-operatively, development of cocooning of the inbtraocular lens, development of chronic cystoid macular edema and persistence of flare and development of hypotony. Keep that in mind, if they have dense flare not much cell and they already have lower pressures and they have a dense cataract. Those patients are probably better off if they have a parsplana lensectomy vitrectomy approach rather than an intraocular lens.
So let me see, would you use intravitreal steroid implant before or at the time of surgery?
I would say that if the patient has active inflammation and you’re using an intravitreal flucinolone implant, put the implant in, get the inflammation control and then do cataract surgery. Remember that according to the flucinolone implant study that they registered causes the vast majority of phakic patients 90 percent will get a cataract within the first two years of the implantation and will need cataract surgery. So that’s a done deal but you want to have inflammation control for at least three months, no cells before you do cataract surgery. Do we need antibiotics for infectious uveitis Preoperatively? You know if you have an infectious uveitis patient that’s controlled and treated, I still am careful and cautious. I have patients on prophylactic antibiotic therapy if they have toxoplasmosis for example.
As I said I will use some prophylaxis with oral septra Bactrim as initially, sometimes I may give if they have had recent episodes of toxoplasmosis intravitreal clindamycin. If they had a previous history of syphilitic uveitis I may consider giving them an injection of intraocular ceftriaxone or some cephalosporin or even vankomicin and that might be not an unreasonable thing to do. But that’s not required that’s just a personal preference. As long as the inflammation is quiet and you taking care of the infectious component previously.
In patients with uncontrolled IOP preoperatively, can we combine trab with cataract surgery?
Yes. In a uveitic patient when that happens you can do that. Generally though I will tell you that trabs tend to fail. We’ll talk about this as the next lecture in a couple of weeks. But trabeculectomies fail in uveitis more often than not. So generally when we’re doing this we’re considering a tube shunt placement in the patient such as a molteno tube or Baerveldt implant or Ahmed implant and cataract surgery simultaneously. That is a big surgery, especially in uveitis patients, JIA uveitis patients and those patients will have much more inflammation and many more post-operative problems. They are more at risk for choroidal hemorrhage, they are more at risk for malignant aqueous misdirection and other complications that can occur in the face of combined surgery.
So keep that in mind. Cycloplegic should be continued in the pre and post-operative period, is very very important to use cycloplegics in these patients to prevent posterior synechiae formation.
However if the pupil is very large after surgery and didn’t have synechiae, if you leave them on atropine for a long time, you can end up with a with a pupil thats stuck to the capsule on the periphery and that’s not good, then you have a very widely dilated pupil. So you need to use a milder cycloplegics after the initial first week or two of using strong cycloplegic, so you need to modulate even the cycloplegic therapy. Would you do a goniosynechialysis? Yeah, obviously if there is angle closure and yes if I’m already manipulating the iris and removing synechiae, you can certainly add that at the time of surgery. It may or may not help you with intraocular pressure control. You know advice about steroid responders and increased IOP. Obviously, yeah when you’re going to increase their, use durezol every two hours and you already have a steroid responder, their pressure is going to become very high. Control the pressure the best that you can because tantamount to a good outcome is good intraocular inflammation control. So inflammation control takes precedence to some extent over intraocular pressure control, not to, we don’t want to get dangerous levels of intraocular pressure control problems. So if you end up in a situation where the inflammation is well-controlled, the IOP is very high and they’ve got a cataract, glaucoma control maybe in glaucoma surgery, maybe more importantly there are maximum medical therapy.You might want to do that first before tackling the cataract.
Do you prefer intravitreal or systemic? My personal preference is systemic therapy, the MUST trials have show in general that these two entities are or are equally good but in chronic bilateral inflammatory disease these patients require therapy for more than five to ten years. Implants last three years so in my humble opinion systemic immunomoistrate therapy is the better way to go. The quality of life outcomes and now the visual outcomes seem to be as good or better than the implant and the likelihood of needing surgery, cataract surgery, glaucoma surgery, those kind of things are less in the patients who have systemic immunomoistrate therapy compared to the implant groups. Heparin coated lenses have been shown, Heparin coated intraocular lenses in cataract surgery have been shown to be beneficial and reducing inflammation in the post-operative period, reducing fibrin formation. So there is some role but most uveitis specialists in this country are not typically using heparin coated lenses, they don’t go out of their way to do that. And so most are relying on good pre and post operative control of inflammation. Patients with intraocular pressure elevation prior to surgery, do I use acetazolamide? Certainly I rarely use mannitol improperly if the patient requires some kind of control of their interaction of pressure, I might use ….. and I have not done that in 25 years. So generally the topical agents and good control of interactor pressure prior to surgery is important. You don’t want to be facing a patient in surgery with the pressure of 50 and no inflammation because their problem is not their Cataract at that point. Their problem is glaucoma.
So you have to remember, you know cataract visual loss is reversible glaucoma visual loss is not. So that’s how you need to organize your thought processes and how you can manage these very complex patients. So I hope I’ve answered your questions. I really appreciate your attentiveness and I hope you have a fantastic weekend. And I look forward to seeing guys in in a couple of weeks. There’s somebody else had one last question. It’s about flare post cataract surgery alone. So flare alone. So when I say flare I’m not talking about a flare up of inflammation, flare is proteinaceous flare and there’s no cell. So patients who have proteinaceous flare preoperatively have a longstanding uveitis.
OK. And those patients in my opinion are the ones that are going to have more post-operative problems with their intraocular lens, more likely to cocoon, more likely to develop hypotony, more likely to develop cystoid macular edema, that’s what I mean. And you know so that’s that is an important sign of uveitis to be aware of and something that would be important for you to consider in your surgical approach. Well would you use intra cameral medication for pupil dilation? You can, if you think you’re going to be able to dilate the pupil, sometimes you can’t because there’s chronic synechiae. In the non-uveitis patient, you know I don’t, Dr. Al-Bakri, I don’t know if I got your question right. I’m sorry if I didn’t but if you have you know, just flare in non-uveitis patient again those patients may have a little bit more proteinaceous exudation, there has to be some good reason why they have that flare, but temporary flare that’s not going to have any kind of major effect on the post-operative outcomes in non-uveitis patients. So thank you very much for attention. I look forward to seeing you guys next, in two weeks. We’ll talk about glaucoma and a similar approach, it won’t be quite as long a lecture but we’ll certainly open it up for questions. Thank you. Thank you.
September 8, 2017