Cataract surgery with ciliary sulcus fixation of intraocular lenses in patients with uveitis

A Cross-Sectional Online Survey Identifies Subspecialty Differences in the Management of Pediatric Cataracts Associated with Uveitis

Introduction

To determine if differences exist between pediatric ophthalmologists and uveitis ophthalmologists in the treatment of pediatric uveitic cataracts and placement of intraocular lenses.

Methods

Uveitis ophthalmologists and pediatric ophthalmologists were surveyed via an online poll regarding their therapeutic management of pediatric uveitic cataract and intraocular lens (IOL) placement.

Results

Sixty-two responses from uveitis ophthalmologists and 47 responses from pediatric ophthalmologists were recorded. According to 79% of all responses, uveitis was not a contraindication for primary IOL implantation in patients with controlled intraocular inflammation. Pediatric ophthalmologists were more likely to respond that the presence of chronic juvenile idiopathic arthritis-associated iridocyclitis, pars planitis, or recurrent acute anterior uveitis is a contraindication for primary IOL implantation in pediatric cases with full control of intraocular inflammation. There was no consensus within either specialty with regard to the preferred IOL material for lens implantation. Uveitis ophthalmologists were more likely to report the use of intravenous and intravitreal steroids for perioperative treatment. In cataract surgery for a child with recurrent acute anterior uveitis, a higher percentage of uveitis ophthalmologists (71%) than pediatric ophthalmologists (50%) responded that the posterior capsule should be primarily opened. A higher percentage of uveitis ophthalmologists also stated that anterior vitrectomy should be performed at the time of cataract surgery in all three uveitis types.

Conclusions

Pediatric ophthalmologists and uveitis ophthalmologists have similar approaches to the management of pediatric uveitic cataract removal and IOL insertion, but several differences remain between these subspecialties. Continued collaboration between the subspecialties would be helpful to better develop consistent criteria to improve patient care.

Electronic supplementary material

The online version of this article (10.1007/s40123-020-00245-x) contains supplementary material, which is available to authorized users.

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.

Ultrasound biomicroscopy in chronic pseudophakic ocular inflammation associated with misplaced intraocular lens haptics

PURPOSE

To evaluate the usefulness of ultrasound biomicroscopy in confirming intraocular lens haptic-induced ocular irritation and in the management of these patients.

DESIGN

A retrospective review of patient data.

METHODS

Twenty pseudophakic patients who underwent ultrasound biomicroscopy examination between May 2009 and February 2011 to confirm the clinical suspicion of misplacement of intraocular lens haptics were reviewed. Ophthalmic findings at the time of presentation and at each follow-up visit, and management of each patient, were recorded.

RESULTS

Intraocular lens haptic misplacement was confirmed by ultrasound biomicroscopy in all suspected cases. In 75% of the eyes 1 haptic was embedded in the iris; it extended into the ciliary body process in 35% and into the pars plana in 10%. Focal iris thinning/atrophy was detected by ultrasound biomicroscopy in 15% of cases and focal angle closure in 25%. Intraocular lens exchange was performed in 40% of patients. The remaining 60% were kept under observation, with the addition of topical steroids and/or cycloplegics in eyes that demonstrated anterior chamber inflammation and intraocular pressure-lowering medications in eyes with persistent elevated intraocular pressure or glaucoma.

CONCLUSIONS

Ultrasound biomicroscopy appears to be a valuable tool in confirming the presence of haptic-induced ocular irritation and in assisting the management of these patients.

Intraoperative intravitreal injection of triamcinolone acetonide for cataract extraction in patients with uveitis

PURPOSE

To evaluate the efficacy of intravitreal triamcinolone injection in controlling postoperative inflammation after cataract extraction in patients with uveitis.

METHODS

This retrospective study included 30 eyes with uveitis that had phacoemulsification or extracapsular cataract extraction with intraocular lens implantation. Intravitreal triamcinolone acetonide (4 mg) was injected at the end of surgery. No systemic steroids were given after surgery.

RESULTS

Visual acuity improvement of 2 lines or more occurred in 26 eyes (86.7%). Six eyes (20%) had a best-corrected visual acuity of 6/60 or better before surgery, which increased to 22 eyes (73.3%) after surgery. Five eyes (16.7%) had a visual acuity of 6/12 or better after surgery. Intravitreal triamcinolone injection controlled the postoperative inflammation in all eyes for at least 3 months following surgery.

CONCLUSION

Intravitreal triamcinolone injection was effective in controlling postoperative inflammation after cataract extraction in patients with uveitis sparing the use of systemic steroids.

Cataract surgery in the setting of uveitis

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Pigment release and secondary glaucoma after implantation of single-piece acrylic intraocular lenses in the ciliary sulcus

PURPOSE

To report the association of sulcus-fixated, single-piece hydrophobic acrylic intraocular lenses (HAIOL) with pigment release and secondary glaucoma.

DESIGN

Interventional case series.

METHODS

HAIOL was implanted in the ciliary sulcus of 20 eyes that developed posterior capsule rupture during phacoemulsification. We analyzed postoperative best-corrected visual acuity, manifest refraction, frequency of intraocular lens malpositioning, and postoperative complications.

RESULTS

Postoperative best-corrected visual acuity was 20/40 or better in all eyes. The mean postoperative sphere was -0.5 +/- 0.7 diopters (range +1.25 to -2.00); the mean postoperative cylinder was -1.2 +/- 0.8 diopters (range 0 to -2.50). None of the HAIOLs was decentered or dislocated, and none required repositioning. Seven eyes (35%) developed pigment release; three eyes (15%) developed secondary glaucoma.

CONCLUSIONS

Implantation of single-piece HAIOLs in the ciliary sulcus is associated with pigment release and secondary glaucoma. Alternative methods of aphakic correction should be considered.

Long-term results of cataract extraction with intraocular lens implantation in patients with uveitis

OBJECTIVE

To investigate the long-term visual results after cataract extraction in patients with uveitis, and to demonstrate the long-term viability of intraocular lenses.

DESIGN

In all, 61 patients (72 eyes), with update clinical examination, were retrospectively evaluated. Comparison of preoperative, postoperative, and latest visual function including best-corrected Snellen visual acuity, progression of uveitis and its complications, need for postoperative medical or surgical interventions.

RESULTS

After a minimum follow-up of 5 years (mean 7 years 7 months), 82% of eyes maintained a visual improvement of two Snellen lines, 74% maintained 6/9 or better, and 14% had 6/18 or worse. The mode acuity was better than 6/6. The prevalence of macular oedema or scarring was 24%, of posterior capsule opacification 96%, and of glaucoma drainage, 15%.

CONCLUSIONS

We report the long-term follow-up of cataract extraction and intraocular lens (IOL) implantation performed by a single surgeon on patients with uveitis attending a regional tertiary referral uveitis clinic. Using stringent perioperative and postoperative control of inflammation, patients with uveitis usually maintain high visual acuity over long-term follow-up. The incidence of sight-threatening postoperative complications is low and no ongoing complication has been attributed to IOL implantation.

Bilateral dislocation of in-the-bag posterior chamber intraocular lenses in a patient with intermediate uveitis

We present a case of bilateral dislocation of in-the-bag intraocular lenses (IOLs) in a patient with intermediate uveitis. The IOLs dislocated into the vitreous cavity 24 and 41 months postoperatively. A complete pars plana vitrectomy with sutured posterior chamber IOL implantation was performed after each dislocation. The final visual acuity was 20/20(-) in each eye.

Phacoemulsification with intraocular lens implantation in patients with uveitis

PURPOSE

To investigate the safety and efficacy of phacoemulsification with intraocular lens implantation in eyes affected by uveitis.

METHODS

A retrospective case series is presented including casenote review and update patient examinations. Patient data were withdrawn from the Uveitis Clinic database. All uveitis patients undergoing phacoemulsification with intraocular lens implantation from August 1995 to November 2000 were included. A pre-operative preparation protocol was used. Operative and post-operative complications, degree of postoperative inflammation, best-corrected and final visual acuity were the main outcome measures.

RESULTS

Eighty-six eyes of 75 patients underwent surgery, which in 11 cases was combined with trabeculectomy. Mean follow-up was 24.1 months. Eight eyes (10%) had severe or fibrinous uveitis post-operatively. The mean delay between surgery and return to baseline treatment was 8.6 weeks. Posterior capsule opacification occurred in 42% of eyes and Nd-YAG capsulotomy was required in 21%. Cystoid macular oedema was seen in 2 eyes. Seventy-two per cent of eyes retain a visual acuity of 6/9 or better, and 87% of eyes retain a post-operative improvement of 2 or more lines of Snellen acuity.

CONCLUSIONS

With careful patient selection, appropriate pre-operative preparation, diligent surgery and close post-operative supervision, phacoemulsification with intraocular lens implantation is safe and effective in the great majority of eyes with uveitis.

Phacoemulsification cataract extraction and posterior chamber lens implantation in patients with uveitis

PURPOSE

This study reports outcomes of phacoemulsification cataract extraction and posterior chamber intraocular lens implantation within the capsular bag in patients with uveitis.

METHODS

We retrospectively reviewed the charts of 32 patients (39 eyes) with uveitis who underwent phacoemulsification cataract extraction and posterior chamber intraocular lens implantation by two surgeons at The Cleveland Clinic Foundation from January 1990 to June 1998. Patients with less than 3 months of follow-up were excluded.

RESULTS

Diagnoses of uveitis included idiopathic (15 eyes), sarcoidosis (10 eyes), pars planitis (four eyes), CMV retinitis (two eyes), Fuchs heterochromic iridocyclitis (two eyes), syphilis (two eyes), and one eye each of tuberculosis, Crohn's disease, HLA-B27 associated, and acute retinal necrosis. Average follow-up was 20 months (range, 3 to 63 months). Best-corrected visual acuity improved in 37 eyes (95%). Average improvement was 4 +/- 3 Snellen acuity lines (range, 1 to 10 lines). Thirty-four eyes (87%) attained final visual acuity better than or equal to 20/40. Visual loss occurred in one eye (3%) with CMV retinitis. No improvement in visual acuity was seen in one eye (3%) that developed a retinal pigment epithelial detachment. Posterior capsule opacification occurred in 24 eyes (62%), 12 of which required Nd:YAG capsulotomy (31%). Other postoperative complications included recurrence of uveitis (41%), cystoid macular edema (33%), epiretinal membrane formation (15%), and posterior synechiae (8%).

CONCLUSIONS

Phacoemulsification cataract extraction with posterior chamber intraocular lens implantation is safe in patients with uveitis. The incidences of recurrence of uveitis, cystoid macular edema, epiretinal membrane, and posterior synechiae were lower than those reported previously for extracapsular cataract extraction.

Cataract surgery in children with uveitis

PURPOSE

To report the technique and postoperative results of cataract surgery in children with uveitis.

METHOD

Between 1988 and 1998, nine children (age range: 2.5-11 years) who developed secondary uveitic cataract and underwent cataract extraction were studied retrospectively. Seven children had juvenile rheumatoid arthritis and two had chronic anterior uveitis of unknown etiology. The surgical technique was lensectomy and wide anterior vitrectomy with limbal approach, lysis of anterior synechiae and in some cases, peripheral iridectomy. Postoperative aphakia was corrected with soft contact lenses in all patients. Follow-up ranged from 6 months to 6 years.

RESULTS

Postoperatively, visual acuity in all patients improved and final visual acuity ranged from 20/70 to 20/25. Significant intraoperative complications did not occcur in any patient. One boy with juvenile rheumatoid arthritis developed cystoid macular edema 1 month postoperatively, which was successfully managed. He also developed hypertonia 1 year later, which was also successfully managed. Seven of the nine children had fewer and milder relapses of uveitis after surgery.

CONCLUSION

Cataract surgery, using the lensectomy-vitrectomy technique in children with uveitis, is a safe technique with a relatively small percentage of postoperative complications and good functional results.

Long-term posterior and anterior segment complications of immune recovery uveitis associated with cytomegalovirus retinitis

PURPOSE

To identify and describe long-term posterior and anterior segment complications of immune recovery uveitis in patients with inactive cytomegalovirus retinitis who are undergoing highly active antiretroviral therapy-mediated recovery of immune function.

METHODS

A prospective cohort study at a university medical center. Twenty-nine eyes of 21 patients with immune recovery uveitis and inactive cytomegalovirus retinitis were followed for 14.5 to 116 weeks (median, 43 weeks) after diagnosis of immune recovery uveitis.

RESULTS

Nine eyes of nine patients developed visually important complications involving the posterior segment, anterior segment, or a combination of both. Posterior segment complications included severe proliferative vitreoretinopathy in three eyes and spontaneous vitreous hemorrhage from avulsion of a blood vessel secondary to contraction of the inflamed vitreous in one eye. Proliferative vitreoretinopathy recurred in all cases after surgery, severely compromising the visual outcome. Anterior segment complications included posterior subcapsular cataracts with vision decrease in five eyes and persistent anterior chamber inflammation after cataract extraction, resulting in posterior synechiae and large visually important lens deposits in three eyes.

CONCLUSION

Persistent inflammation in immune recovery uveitis may lead to vision-threatening complications, such as proliferative vitreoretinopathy, posterior subcapsular cataracts, and severe postoperative inflammation. Immune recovery uveitis is a chronic inflammatory syndrome that may result in complications months to years after the onset of inflammation.