Phacoemulsification Versus Manual Small Incision Cataract Surgery in Patients With Fuchs Heterochromic Iridocyclitis

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1 ORIGINAL CLINICAL STUDY Phacoemulsification Versus Manual Small Incision Cataract Surgery in Patients With Fuchs Heterochromic Iridocyclitis Rahul Bhargava, MS,* Prachi Kumar, MD, Shiv Kumar Sharma, MS, and Yogesh Arora, MS* Purpose: To compare the safety and efficacy of phacoemulsification and manual small incision cataract surgery (SICS) to treat cataract in patients with Fuchs heterochromic iridocyclitis (FHI). Design: A randomized, double-masked, prospective, multicenter study. Methods: Consecutive patients with cataract after FHI were randomly assigned to have phacoemulsification or manual SICS by 1 of 2 surgeons experienced in both techniques. Complications (intraoperatively and postoperatively), operative time, visual acuities, endothelial cell counts, and surgically induced astigmatism were compared. Results: At 6 months, 65 (92.8%) patients in the phacoemulsification group and 70 (92.1%) in the manual SICS group had a corrected distance visual acuity of 20/63 or better (P = 0.974). Surgical time was significantly shorter in the SICS group (11.2 ± 2.4 minutes) than in the phacoemulsification group (14.2 ± 3.1 minutes) (P < 0.001). The mean surgically induced astigmatism was 0.8 ± 0.2 diopters (D) in the phacoemulsification group and 1.16 ± 0.2 D in the SICS group (P <0.001). Endothelial cell counts at 1 week and at 6 months did not differ significantly in the phacoemulsification and SICS groups (t test; P = and P = 0.032, respectively). Intraoperatively, 2 (3%) eyes randomized to receive phacoemulsification and 4 (5.3%) eyes randomized to receive SICS had posterior capsular rent (P =0.465). Conclusions: Both techniques achieved good visual outcomes with low rates of complications. Manual SICS may be a viable alternative for cataract management in patients with FHI in settings with limited access to phacoemulsification. Key Words: phacoemulsification, Fuchs heterochromic iridocyclitis, small incision cataract surgery (Asia Pac J Ophthalmol 2016;5: ) Fuchs heterochromic iridocyclitis (FHI) is a chronic intraocular inflammatory disease of unknown cause. What triggers inflammation in FHI is still not known; the rubella virus, Toxoplasma gondii, and cytomegalovirus have all been implicated as possible causes. 1 Fuchs heterochromic iridocyclitis is often complicated by the formation of cataract in about 15% to 75% of cases. 2 The aim of cataract surgery in patients with uveitis is to visually rehabilitate the patients and better visualize the fundus to manage posterior segment pathology. 3 Having said this, the most important step in the management of complicated cataracts is adequate preoperative control of inflammation; most authors consider the absence of cells in the anterior chamber (AC) to be synonymous with inflammatory control, as mild cellular reaction in the vitreous may persist even in inactive stages of FHI. 4 From the Departments of *Ophthalmology and Pathology, School of Medical Sciences and Research, Sharda University, Greater Noida; and Department of Ophthalmology, Rotary Eye Hospital, Maranda, Palampur, India. Received for publication June 29, 2015; accepted December 23, The authors have no funding or conflicts of interest to declare. Reprints: Rahul Bhargava, MS, B2/004, Ananda Apartments, Sector-48, Noida , India. brahul_2371@yahoo.co.in. Copyright 2016 by Asia Pacific Academy of Ophthalmology ISSN: DOI: /APO The clinical course, management, and visual outcomes in patients with uveitis may vary according to the type and course of uveitis, along with the technique of cataract surgery. In FHI, conventional extracapsular cataract extraction (ECCE) is associated with complications like bleeding from fragile vessels, posterior capsular rent with vitreous loss, secondary glaucoma, and retinal detachment. However, with modern small incision surgical techniques, introduction of acrylic intraocular lenses (IOLs), and more comprehensive management of complications, there has been a great improvement in visual outcomes in patients with FHI. 5,6 Phacoemulsification is now the preferred surgical modality of treating cataract in patients with uveitis, but manual small incision cataract surgery (SICS) may be an alternative in settings with high surgical volume or regions with limited access to phacoemulsification. It requires minimal instrumentation and can be performed in rural and semirural settings as well. 7,8 However, the safety and efficacy of SICS in FHI has not been established. An extensive review of the literature did not reveal any published randomized controlled trials comparing phacoemulsification and manual SICS for FHI (MEDLINE search). A prospective, randomized clinical trial was done at 3 referral eye centers in the subcontinent to compare risks and postoperative outcomes of the 2 techniques in patients with FHI. MATERIALS AND METHODS This study was performed between May 2012 and February 2015 at the Laser Eye Clinic, Noida; Rotary Eye Hospital, Palampur; and School of Medical Sciences and Research, Sharda University, Greater Noida, India. During this period, 206 patients were diagnosed with FHI; the diagnosis of FHI was based on the criteria proposed by Kimura et al. 9 The institutional review boards and the local ethics committee approved the trial. Written informed consent was obtained from all patients based on Helsinki protocol. Inclusion and Exclusion Criteria Patients with visually significant cataract (reduction of best corrected visual acuity of 2 or more Snellen lines) after FHI and that impairing adequate visualization of the posterior segment participated in the study. A minimum inflammation-free period (defined as 5 or less than 5 cells per high power field in AC) of 3 months was a prerequisite for eligibility for surgery. 10 However, cases with mild cellular reaction in the vitreous were included, as cells in vitreous may persist even in inactive stages and cannot be completely eliminated. Exclusion criteria were less than 6 months of follow-up, posterior synechia, traumatic and subluxated cataracts, and diabetes mellitus. Outcome Measures The primary outcome measure was the improvement in visual acuity (VA) postoperatively. The secondary outcome measures were assessment of postoperative intraocular inflammation and the rate of postoperative complications. Surgical time was recorded from initial side-port entry to hydration of paracentesis Asia-Pacific Journal of Ophthalmology Volume 5, Number 5, September/October 2016

2 Asia-Pacific Journal of Ophthalmology Volume 5, Number 5, September/October 2016 Phacoemulsification vs SICS in FHI Preoperative Evaluation The preoperative protocol included routine investigations such as total and differential leucocyte counts, erythrocyte sedimentation rate and blood sugar levels, Mantoux test, chest x-ray, and x-rays of the cervical spine and sacroiliac joints. Special investigations were done as needed and included rheumatoid factor, angiotensin converting enzyme essay, antinuclear factor, human leucocyte antigen typing, and enzyme-linked immunosorbent assay for TORCH infections (toxoplasmosis, other agents, rubella, cytomegalovirus, herpes), human immunodeficiency virus, and tuberculosis. B-scan ultrasonography was performed in cases where funduscopy was not possible due to dense cataract. Gonioscopy was done in all patients with Sussman 4 mirror handheld gonioscope (Ocular Instruments, USA). Intraocular pressure (IOP) was measured with applanation tonometry. Endothelial cell counts (ECCs; cells/mm 2 ), variation in size of endothelial cells (CV), and cell coefficient of variation and central corneal thickness measurements were done by EM-3000 specular microscope (Tomey, Japan). Preoperatively, topical antibiotic eye drops were prescribed to all patients. Oral prednisolone, 1 mg/kg body weight, was given 7 days before surgery and tapered off postoperatively in patients with persistent vitreous haze, posterior keratic precipitates, and previously documented macular edema. Sample Size and Randomization To estimate sample size to compare mean difference in logmar VA between the 2 groups, a pilot study was done on 20 subjects. The mean decrease in logmar VA in the SICS group was 0.78 to 0.28 (0.5 logmar units). The mean decrease in logmar VA in the phacoemulsification group was 0.80 to 0.21 (0.59 logmar units). The common standard deviation was Assuming 1:1 randomization, α was set at 0.05 and power 80%. The sample size in each group was estimated to be 63. To account for 20% loss in follow-up, the idea was to randomly assign 144 patients to either of the 2 surgical techniques. Bias and Confounding The allocation codes were generated by disc operating system based computer software in the Department of Community Ophthalmology at our institute. The allocation was concealed in sequentially numbered blue envelopes that were opened by health care staff not involved in patient care 10 minutes before surgery. Patients were not informed of the type of procedure assigned. There were 2 independent investigators (A.K. and A.A.), an ophthalmologist (not a study surgeon), and an optometrist who assessed vision, respectively. They were masked to the identity of the operating surgeons and the type of procedure. Surgical Technique All surgeries were performed by 2 surgeons who received fellowship training from the same institute and were well versed in both procedures. Peribulbar anesthesia was delivered. Asepsis was achieved as per the standard norms for an intraocular procedure. This included ciprofloxacin (0.3%) eye drops 6 to 8 times, 24 hours before the procedure; instillation of 5% povidone-iodine solution in the cul-de-sac before surgery; and ensuring patency of the nasolacrimal duct. In the preoperative holding area, periocular skin was cleansed with 10% povidone-iodine solution. On the operating table, periocular cleansing was repeated and a drop of 5% povidone-iodine solution instilled on the ocular surface. Manual SICS was done as per the technique described previously. 11 The type of viscoelastic used (2% hydroxypropyl methyl cellulose) and the IOL implanted (foldable acrylic) did not differ between the 2 techniques. Phacoemulsification was performed with superior scleral tunnel incision using peribulbar anesthesia. Two side-port corneal incisions were created 180 degrees apart with a 20G microincision vitrectomy knife. Anterior chamber entry was fashioned with a 2.8-mm keratome. Anterior chamber was maintained with 2% hydroxypropyl methylcellulose. Trypan blue assisted continuous curvilinear capsulorrhexis was done as described previously. Cortical cleavage hydrodissection was done just below the anterior capsule rim and the nucleus rotated in the bag. Phacoemulsification was performed with an Infinity vision system (Alcon, Inc) using the phaco-chop method. Cortical material was removed by bimanual irrigation/aspiration. A foldable acrylic IOL was implanted in the capsular bag using a cartridge. Paracentesis was hydrated. At the end of surgery, a subconjunctival injection of 20 mg gentamicin and 4 mg dexamethasone was given to all patients. Postoperative Care Patients were followed up on the first, third, and seventh postoperative days, then weekly for 2 weeks, monthly for 2 months, and every 3 months thereafter. The postoperative regimen included topical moxifloxacin every 4 hours for 7 days and topical betamethasone 0.1%, every 2 hours, tapered over 6 to 8 weeks depending on response. At each follow-up day, VA, AC reaction, and vitreous haze were evaluated. Goldmann applanation tonometry was done on the first postoperative day, and if normal, repeated at monthly intervals for 3 months. Detailed fundus examination was done at 1 week, 1 month, and repeated at 3-month intervals. Statistics Statistical analysis was performed on an intent-to-treat basis using SPSS software for Windows (version 22, IBM Corp). Independent t tests were performed to ensure group similarities at baseline; the assumptions of performing t tests were met. χ 2 tests were used for proportions. One-way analysis of variance was used when there were more than 2 groups. RESULTS A total of 140 patients were enrolled in the study. Sixty-five (46.4%) were randomized to the phacoemulsification group and 75 (53.6%) to the SICS group. In the phacoemulsification group, the type of cataract was posterior subcapsular in 73 (97.3%) cases and pearly white in 2 (2.7%) eyes. In the SICS group, cataract was posterior subcapsular in 59 (90.8%) cases and pearly white in 7 (9.2%) eyes. In-the-bag implantation was achieved in all but 1 eye in the phacoemulsification group and 70 eyes in the SICS group. One hundred thirty-four patients (95.7%) completed 6 months of follow-up. Six patients were lost to follow-up. All dropouts were included for analysis based on the last observation carried forward method. The mean age (P = 0.375), sex (P = 0.261), and follow-up (P = 0.162) were comparable in both groups. Table 1 shows the baseline characteristics of the patients. Surgical Time, Intraoperative Procedures, and Complications Intraoperatively, 2 (3%) eyes randomized to receive phacoemulsification and 4 (5.3%) eyes randomized to receive SICS had posterior capsular rent. One (1.3%) eye in the phacoemulsification group was converted to manual SICS and the IOL placed in sulcus. However, sulcus fixation of IOLs was successfully accomplished in 4 eyes in the SICS group. Intraoperative hyphema was seen in 3 (4%) eyes in the SICS group but did not obscure visualization during surgery. The mean surgical time was significantly shorter in the SICS group (11.2 ± 2.4 minutes) than in the phacoemulsification group (14.2 ± 3.1 minutes) (P < 0.001) Asia Pacific Academy of Ophthalmology 331

3 Bhargava et al Asia-Pacific Journal of Ophthalmology Volume 5, Number 5, September/October 2016 TABLE 1. Mean Patient Characteristics Parameter Phacoemulsification Group SICS Group Age 35.5 ± ± * Sex, n Male Female Preoperative BCVA 1.1 ± ± * (logmar) Follow-up, mo 10.3 ± ± * Surgical time, min 13.8 ± ± 1.9 <0.001* Preoperative ECC 2983 ± ± * SIA 0.80 ± ± 0.2 <0.001* *t test. χ 2 test. BCVA indicates best corrected visual acuity. Intraocular Inflammation Ten (15.4%) eyes in the phacoemulsification group and 12 (16%) eyes in the SICS group had mild to moderate AC reaction on the first postoperative day. At the end of the first postoperative month, 7 eyes in the phacoemulsification group and 5 eyes in the SICS group had 2+ AC cells. Topical steroids were continued for 8 weeks and resulted in resolution of inflammation. However, 3 (4.6%) eyes in the phacoemulsification group and 4 (5.3%) eyes in the SICS group had recurrent episodes of uveitis. Out of these, 2 eyes in both groups developed posterior capsule opacification (PCO) subsequently. The eyes with recurrent uveitis had persistent vitreous haze at final follow-up examination. Visual Acuity and Astigmatism There was significant improvement in vision after both the procedures (paired t test; P < 0.001). On the first postoperative day, uncorrected distance visual acuity was 20/63 or better in 36 (55.4%) patients in the phacoemulsification group and 41 (54.6%) patients in the manual SICS group. The difference was not statistically significant (P = 0.323). Corrected distance visual acuity (CDVA) did not differ significantly (Fig. 1) between the groups at 6 months; 65 (92.8%) patients in the phacoemulsification group and 70 (92.1%) in the manual SICS group had a CDVA of 20/63 or better (P =0.974). The cause of final CDVA worse than 20/120 in the phacoemulsification group was persistent uveitis in 4 cases, age-related macular degeneration in 1 case, and macular edema in 2 cases. In the SICS group, final CDVAworse than 20/120 was due to persistent uveitis in 3 cases and macular edema in 1 case. Twenty-four (34.3%) patients in the phacoemulsification group and 25 (32.9%) patients in the SICS group received systemic corticosteroids. In the SICS group, final vision was significantly better (0.246 ± 0.2 logmar units) than in patients who did not use (0.265 ± 0.18) preoperative corticosteroids (t test; P = 0.012). In the phacoemulsification group, final vision was significantly better (0.24 ± 0.12) than in patients who did not use (0.26 ± 0.14) preoperative corticosteroids (t test; P =0.001). Surgically induced astigmatism (SIA) was calculated using the rectangular coordinate method. The mean SIA was 0.8 ± 0.2 diopters (D) in the phacoemulsification group and 1.16 ± 0.2 D in the SICS group. The difference between the groups was significant (t test; P < 0.001). P FIGURE 1. Line diagram comparing preoperative, day 1, and final best corrected visual acuity. Endothelial Cell Count Endothelial cell count at the first week and at 6 months did not differ significantly in the phacoemulsification and SICS groups (t test; P = and P = 0.032, respectively). Figure 2 and Table 2 show mean ECC and endothelial cell loss over time. Complications There were postoperative complications in both groups (Table 3). On the first postoperative day, there were more cases of corneal edema (12, 17.1%) in the phacoemulsification group than in the SICS group (8, 11.4%) (P = 0.046). The mean endothelial cell loss in these patients was 26.8% at 1 week and 31.4% at 6 months in the phacoemulsification group and 22.7% and 26.4% in the SICS group, respectively. Although there was no case of new onset postoperative glaucoma in either group, the eyes of 8 patients in the phacoemulsification group and 6 patients in the SICS group had medically controlled glaucoma before surgery. Elevated IOP was seen in 3 eyes in the phacoemulsification group and 5 eyes in the SICS group at a mean postoperative duration of 1.06 ± 0.4 months; 3 eyes in each group developed a sustained rise in IOP despite maximum topical therapy with 2 drugs. These patients were referred to the glaucoma clinic for further management. The incidence of late complications like persistent uveitis (χ 2 test; P = 0.591), macular edema (P = 0.671), and PCO (P = 0.678) did not differ significantly between both groups. Other complications included superior iridodialysis (1 clock hour) in 2 eyes in the SICS group, retained subincisional cortical lens matter in 3 eyes in the phacoemulsification group and 4 eyes in the SICS group, and pigment deposits on the IOL surface in 2 eyes FIGURE 2. Line diagram comparing ECC preoperatively, at day 1, and at 6 months in both groups Asia Pacific Academy of Ophthalmology

4 Asia-Pacific Journal of Ophthalmology Volume 5, Number 5, September/October 2016 Phacoemulsification vs SICS in FHI TABLE 2. Comparison of Endothelial Cell Loss Mean ECC, cells/mm 2 Mean Cell Loss, n (%) Group Preoperatively 1 wk 6 mo 1 wk 6 mo Phacoemulsification 2962 ± ± ± (19.7) 607 (20.5) SICS 2939 ± ± ± (18.4) 564 (19.2) in the SICS group. Persistent uveitis had a significant effect on final CDVA in both groups (t test; P = and 0.001, respectively). Secondary Procedures Nd:YAG laser capsulotomy was done in 10 (14.2%) eyes in the phacoemulsification group and 13 (17.1%) eyes in the SICS group after a quiet postoperative period of 3 months. Four (5.7%) patients in the phacoemulsification group and 3 (3.9%) patients in the SICS group were referred to the retina clinic for epiretinal membrane peeling. Glaucoma filtering surgery was done in 3 (4.6%) and 2 (2.7%) eyes in the phacoemulsification and SICS groups, respectively. One eye in the SICS group had Ahmed glaucoma valve implantation. DISCUSSION Cataract is a common complication of FHI. However, unlike age-related cataract, patients present at a relatively earlier age (<45 years). In the present study, the mean age at presentation was 34 ± 6.2 years. The treatment of cataract in patients with FHI has evolved from intracapsular cataract extraction and conventional ECCE to phacoemulsification and from implantation of AC IOLs to acrylic posterior chamber IOLs. Younger patient age and the posterior subcapsular location of most of these cataracts make phacoemulsification an easy procedure with fewer complications. Manual SICS is an effective and efficient technique for subcontinent countries having limited access to phacoemulsification. Moreover, surgical speed may be of paramount importance in regions with high surgical volume. In the present study, SICS proved to be a significantly faster technique (11.2 ± 2.4 minutes) as compared with phacoemulsification (14.2 ± 3.1 minutes) in patients with FHI. In a study comparing phacoemulsification and SICS in uveitis patients, Bhargava et al 12 found that mean surgical time was significantly less in the SICS group (10.8 ± 2.9 versus 13.2 ± 2.6 minutes, respectively). Intraocular lens implantation in an inflamed eye may cause concern because of exaggerated postoperative inflammation. However, FHI is not typically associated with severe uveitis in TABLE 3. Complications Complication Phacoemulsification Group, n (%) SICS Group, n(%) χ 2 (P) Corneal edema 12 (17.1) 8 (11.4) Persistent uveitis 3 (4.6) 4 (5.3) Macular edema 6 (8.6) 9 (12) PCO 13 (18.6) 16 (21) Glaucoma 3 (4.6) 5 (6.7) Iridodialysis 0 (0) 2 (2.7) Retained cortex 3 (4.2) 4 (5.2) the postoperative period. In the present study, a mild to moderate reaction was seen in 15.3% of eyes in the phacoemulsification group and 16% of eyes in the SICS group; the difference was not statistically significant (P = 0.456). Recurrent uveitis with persistent vitreous haze at final follow-up examination was seen in 4.6% of eyes in the phacoemulsification group and 5.3% of eyes in the SICS group, respectively. Due to lack of posterior synechia in FHI and the fact that peripheral iridectomy was not performed in any case, postoperative inflammation was relatively mild in both groups. In a series of 103 eyes with complicated cataract after FHI and ECCE or phacoemulsification with posterior chamber IOL implantation, Tejwani et al 13 did not find any case with severe postoperative inflammation, although 3 eyes had persistent vitreous haze at final follow-up. Most studies report excellent visual outcomes after cataract surgery in FHI. In the present study, 92.8% of patients in the phacoemulsification group and 92.1% of patients in the SICS group achieved a CDVA of 20/63 or better at 6 months. However, the mean SIA was significantly higher in the SICS group (P < 0.001). Presumably, this was a result of the larger incision used in the manual SICS group. These results were comparable to the studies by Budak et al 14 and Gee and Tabbara. 11 Some degree of endothelial cell loss is inevitable after any type of cataract surgery but may be much higher in complicated cataracts, as additional maneuvers like the use of iris hooks are often required in these eyes. This may be of significance in manual SICS where manipulation of the nucleus is done in the AC close to the endothelium. 15 In the present study, although the mean endothelial cell loss 6 months postoperatively was significantly higher as compared with age-related cataract (20.5% in the phacoemulsification group and 19.2% in the SICS group), the difference between the 2 study groups at 6 months was not significant (P = 0.234). Posterior capsule opacification is a common complication in FHI, with an incidence of 20% to 40%. 16,17 The incidence of PCO in our study was 18.6% and 21% in the phacoemulsification and SICS groups, respectively (P = 0.678). The incidence of PCO is significantly higher with polymethyl metha acrylate IOLs as compared with acrylic IOLs, and PCO rates do not significantly differ between hydrophobic or hydrophilic acrylic IOLs at 6months follow-up. 18,19 The lower incidence of PCO in the present study could be explained by the fact most cases had acrylic IOLs implanted within the capsular bag. A shortcoming of the present study is that only 1 technique of phacoemulsification and manual SICS were compared. The results and complications like endothelial cell loss may vary slightly with the technique of nucleus delivery or chopping used. Second, there may be a learning curve, and scleral tunnel construction by beginners may cause more distortion of angle structures, potentially rupturing fragile vessels in the angle and increasing chances of intraoperative hyphema. Lastly, surgical speed may vary from surgeon to surgeon and may result in bias when comparing surgical time. In conclusion, we found manual SICS to be a safe and effective alternative to phacoemulsification for the management of cataract in patients with FHI, with no significant difference in 2016 Asia Pacific Academy of Ophthalmology 333

5 Bhargava et al Asia-Pacific Journal of Ophthalmology Volume 5, Number 5, September/October 2016 complications or final visual outcomes. As manual SICS is significantly faster, it may be preferred in settings with high surgical volume or regions with limited access to phacoemulsification (subcontinent countries). REFERENCES 1. Suzuki J, Goto H, Komase K, et al. Rubella virus as a possible etiological agent of Fuchs heterochromic iridocyclitis. Graefe Arch Clin Exp Ophthalmol. 2010;248: Ram J, Kaushik S, Brar GS, et al. Phacoemulsification in patients with Fuchs heterochromic uveitis. JCataractRefractSurg.2002;28: Ganesh SK, Babu K, Biswas J. Phacoemulsification with intraocular lens implantation in cases of pars planitis. JCataractRefractSurg.2004;30: Tan WJ, Poh EW, Wong PY, et al. Trends in patterns of anterior uveitis in a tertiary institution in Singapore. Ocul Immunol Inflamm. 2013;21: Foster CS, Rashid S. Management of coincident cataract and uveitis. Curr Opin Ophthalmol. 2003;14: Murthy SI, Pappuru RR, Latha KM, et al. Surgical management in patients with uveitis. Indian J Ophthalmol. 2013;52: Bhargava R, Kumar P, Prakash A, et al. Estimation of mean ND: YAG laser capsulotomy energy levels for membranous and fibrous posterior capsular opacification. Nepal J Ophthalmol. 2012;4: Bhargava R, Kumar P, Bashir H, et al. Manual suture less small incision cataract surgery in patients with uveitic cataract. Middle East Afr J Ophthalmol. 2014;21: Kimura SJ, Hogan MJ, Thygeson P. Fuchs syndrome of heterochromic cyclitis. AMA Arch Ophthalmol. 1955;54: Hogan MJ, Kimura SJ, Thygeson P. Signs and symptoms of uveitis. I. Anterior uveitis. Am J Ophthalmol. 1959;47: Gee SS, Tabbara KF. Extracapsular cataract extraction in Fuchs heterochromic iridocyclitis. Am J Ophthalmol. 1989;108: Bhargava R, Kumar P, Sharma SK, et al. Phacoemulsification versus small incision cataract surgery in patients with uveitis. Int J Ophthalmol. 2015;8: Tejwani S, Murthy S, Sangwan V. Cataract extraction outcomes in patients with Fuchs heterochromic cyclitis. JCataractRefractSurg.2006;32: Budak K, Akova YA, Yalvac I, et al. Cataract surgery in patients with Fuchs heterochromic iridocyclitis. Jpn J Ophthalmol. 1999;43: Bhargava R, Kumar P, Sharma SK, et al. Small-incision cataract surgery in patients with Fuchs heterochromic iridocyclitis. Nepal J Ophthalmol. 2014;6: Javadi MA, Jafarinasab MR, Araghi AA, et al. Outcomes of phacoemulsification and in-the-bag intraocular lens implantation in Fuchs heterochromic iridocyclitis. J Cataract Refract Surg. 2005;3: Kosker M, Sungur G, Celik T, et al. Phacoemulsification with intraocular lens implantation in patients with anterior uveitis. J Cataract Refract Surg. 2013;39: Leung TG, Lindsley K, Kuo IC. Types of intraocular lenses for cataract surgeryineyeswithuveitis.cochrane Database Syst Rev. 2014;3: CD Mehta S, Linton MM, Kempen JH. Outcomes of cataract surgery in patients with uveitis: a systematic review and meta-analysis. Am J Ophthalmol. 2014;158: e7. The eye of a human being is a microscope, which makes the world seem bigger than it really is. Kahlil Gibran Asia Pacific Academy of Ophthalmology