Cataract Surgery in Patients with Uveitis

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1 Cataract Surgery in Patients with Uveitis Chris Kalogeropoulos MD, PhD, FEBO Professor of Ophthalmology Faculty of Medicine, University of Ioannina President of Hellenic Society for the Study of Ocular Inflammations and Infections (HSSOII) Basic Cataract Course 32 st International Congress of HSIOIRS, 2018 Athens, Hilton

2 Financial Disclosure ABBVIE ALCON ALLERGAN BAYER BAUSCH & LOMB MAXYN NOVARTIS THEA VALEANT ZWITTER Conflict of interest: None to declare

3 Uveitic Cataract Surgery Most common type of uveitic cataract: Subcapsular cataract Posterior plaque Sarcoidosis TBC

4 Acute edematous (soft) cataract in patient with bilateral uveitis treated with per os CSs Postoperatively

5 Background Cataract: the most common cause of visual acuity decrease in patient with chronic or recurrent uveitis Incidence In uveitis: Cataract 50% (up to 75% in chronic anterior uveitis) Complicated cataract : challenge - timing, status of inflammation and ocular complications due to uveitis - Meticulous preparation of surgical steps with regard to the clinical estimation to avoid surprises during surgery - Postoperative suppression of inflammation Failure of inflammation control hypotony phthisis bulbi )

6 General considerations of uveitic cataract surgery Small surgical incision - New IOLs (foldable/ use of injector, preloaded) - Recent innovations in uveitis treatment (espec. in noninfectious) appropriate time of surgery Time for surgery: absent or minimum inflammation Dense cataracts and prominent inflammation of posterior segment Difficult or impossible the evaluation of posterior segment

7 Uveitic Cataract Evaluation of possibilities for a favorable vision restoration Medical history Α και Β-mode echography Ultrasound Biomicroscopy (UBM) OCT (anterior and posterior segment) Electrophysiology

8 Surgical technique of choice You have to expect the unexpected ; how to diminish or even eliminate this concept Answer Topography of ocular complications due to uveitis: Preoperative evaluation of difficulties and surgical techniques selection (eventually general anesthesia) Surgeons prefer phaco instead of ECCE in uveitic cataract patients with the exception of peculiar cases Phaco (with or without IOL) Earlier improvement of visual acuity Postoperative inflammation ICCE / lensectomy + vitrectomy in specific cases

9 Intraoperative tips Pupil dilation Posterior synechiae lysis Attention during anterior capsulorrhexis Attention during iris manipulations (chronic inflammation tendency for hemorrhage) 82% of cases

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12 Selection of intraocular lenses Type of uveitis Expected surgical injury and expected postoperative reaction Αcrylic PCIOL(hydrophylic or hydrophobic), PMMA (HSM) in children Minimal surgical manipulations Children with RA and severe complications of uveitis : avoid IOL implantation

13 After phaco + IOL (Acrysof) Sarcoidosis: subcapsular cataract + posterior synechiae

14 Woman 56 years old Panuveitis: Mantoux (-), SACE (sarcoidosis) Postoperatively

15 Postoperative Complications Cystoid Macular Edema (CME) PCO IOP increase Uveitis recurrence (early after surgery) The main early postop inflammation was inflammatory membrane of the pupil responding to corticosteroids eye drops and mydriatics treatment

16 Comments (I) Phaco + PCIOL vs ECCE + PCIOL : Intraoperative hemorrhage(fhic) CME incidence ERM incidence Posterior synechiae and pupil With phaco abnormalities incidence Uveitis recurrences But: visual acuity results comparable concerning the 2 techniques Total functional status of the eye: better after phaco

17 Comments (II) Infectious uveitis has been usually treated at the time of cataract surgery Attention: In Hx (+) of herpetic origin uveitis intense prophylaxis with antiherpetic drugs (i.e.: i.v. Acyclovir or Ganciclovir perioperatively, extended administration of Acyclovir postoperatively (HSV, HZV) or Valganciclovir (CMV) - In case of lens lesions (quick evolution of inflammatory cataract along with lysis of capsule) urgent operation under antimicrobial treatment may be needed Aspergillus endophthalmitis: administration of amphotericin Β (i.v., IC and IVTR)

18 Conclusive remarks The improvement of cataract surgery outcome in uveitis and ocular inflammations in general is due mainly to: 1. Better inflammation control pre and postoperatively 2. Immunomodulators vs steroids steroid induced cataracts 3. Patients selection and appropriate time for surgery 4. Microsurgery evolution ( equipments-technology, instruments and techniques) 5. Improvement of IOLs material 6. More effective anti-inflammatory management of postoperative complications