A Protocol For Uveitis Patients Undergoing Cataract Surgery

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MEETING MORBIDITY : MEETING MORBIDITY : Avoiding failure to Avoiding failure to medically treat eyes medically treat eyes undergoing cataract undergoing cataract surgery with known surgery with known uveitis uveitis Dr. Nick Sargent Dr. Nick Sargent August 2008 August 2008

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This is a protocol developed for St. John Eye Hospital recognising the difficulties faced with referrals from satellite units.

Transcript of A Protocol For Uveitis Patients Undergoing Cataract Surgery

  • 1. MEETING MORBIDITY : Avoiding failure to medically treat eyes undergoing cataract surgery with known uveitis Dr. Nick Sargent August 2008
  • 2. What are we trying to avoid? Why is it important to avoid uveitis?
  • 3.
  • 4.
  • 5.
  • 6. CB detachment.
  • 7. Phthisis
  • 8. Also
    • Fibrin deposits on IOL
    • 2ry glaucoma
    • Corneal oedema
    • Endothelial damage
    • 2ry cataracts
    • CME
    • etc
  • 9. Cataract surgery in the patient with uveitis is one of the challenges with the greatest number of unknown factors faced by the ophthalmologist
  • 10. Difficulties in management pre- and post-op
    • Uncertainty of the post-operative process
    • Existence of an underlying systemic pathology
    • Poor tolerance of IOLs
    • Technical difficulties such as PS
  • 11. Visual prognosis depends on:
    • Presence of pre- and post-surgical inflammation
    • Quality and efficiency of the surgical procedure
    • Rx of complications, e.g. 2ry glaucoma
  • 12. Good control of underlying systemic disorder Multidisciplinary approach.
  • 13. Control of the ocular inflammation needed prior to surgery
    • Topical or systemic steroids
    • Immunosuppressives
    • Aim is to reduce AC and vitreous activity
    • according to number of cells .
  • 14. Difficult intra-op
    • Iris atrophy
    • Sclerosis of pupillary sphincter
    • Cyclitic membranes
    • PS and PAS
    • Anterior capsule sclerosis
    • Iris haemorrhage
    • Angle neovascularisation
    Miotic pupil Synechiae Glaucoma
  • 15. Challenge of IOL selection
    • Must be in bag when possible
    • Construction of IOL
    • Might need to avoid altogether
  • 16. Good post-op control of inflammation
    • Topical, periocular, systemic steroids
    • NSAIDs
  • 17.
    • Iris manipulation: Prostaglandins E2 and F2a
    • Activation of complement by the classic or alternative route: certain polymers such as prolene. Less so with hydrogel.
    • Probably get less inflammation with phaco rather than ECCE
  • 18. Patient preparation
    • Good pupillary dilatation to minimise iris touch
    • Angle neovascularisation: consider Argon laser at the area of surgical incision (enough to blanch vessels in 3 different places)
    • Proper IOP control (avoid pilocarpine as alter blood-aqueous barrier)
    • Pre-operative hypotony: cyclitic membranes, CB dialysis, severe inflammation
  • 19. Preop Control of Inflammation
    • Might just need topical or periocular steroids
    • Systemic steroids controversial: must recommend if required systemic or periocular steroids in a previous uveitis attack
  • 20. Combined Cataract-Vitrectomy
    • PPV with lensectomy can be procedure of choice in cases of uveitis with vitritis refractory to medical treatment.
    • Disadvantage: sulcus fixated IOL, difficulty removing dense nucleus and difficulty removing cortex
  • 21. IOL
    • Avoid ACIOLs & Sulcus fixatation
    • Avoid IOLs with polypropylene haptics
    • Heparin coated IOLs (be careful when gripping)
    • Avoid silicone
    • PMMA and hydrogel better
  • 22.
    • Steroid in irrigation fluids?
    • Intravitreal triamcinolone?
  • 23. Fuchs heterochromatic Cyclitis
    • PS rarely formed
    • Generally do well with surgery but reports of:
      • Vitritis
      • Hyphaema
      • Increase IOP
      • Cyclitic membrane formation
    • Risk of glaucoma (10%); maybe worse after Sx
  • 24. Sarcoidosis
    • Phaco has been performed with good results
    • Miosis
  • 25. Pars planitis
    • PS rare
    • Glaucoma is the exception
    • 40% get cataracts
    • 50% obtain 6/12 or better
  • 26. Pars planitis
    • Pars planitis does not seem to increase the risk of complications in routine cataract surgery
    • Often get low grade post-op uveitis resulting in accumulation of debris and membranes on the back surface of the IOL and posterior capsule. Might need YAG.
    • Membranes tend to return and can be controlled with subconj and frequent topical steroids
  • 27. JIC
    • May also have amblyopia, band keratopathy, hypotony, glaucoma, PS
    • Average age at time of surgery varies between 10 -19 years.
    • Uveitis is exacerbated by Sx
    • Many get vitreous loss and retained cortical matter.
    • 60% get 6/60 or worse vision
  • 28. JIC
    • Performing a mid-portion vitrectomy is recommended by some authors
    • IOL not recommended
    • Most common post-op complications:
      • Glaucoma
      • Hypotony
      • CME
    • Combine with vitrectomy if vitritis or vitreous opacitiesj
  • 29. Behcets Disease, VKH and Multifocal Chorioretinitis
    • Few reports on phaco in these patients
    • The incidence of phthisis bulbi and hypotony has been reported to decrease from 25-2% when limited vitrectomy was performed with cataract extraction (Kanski J, et al. Ophthalmology 1984;91:1247-1252)
    • Visual prognosis significantly worse with Behcets (severe post. segment complications)
    • Multifocal chorioretinitis: VA returns to pre-op values within 6 months.
  • 30. HZ uveitis
    • VA better than 6/12 in 90%
    • 18% get chronic uveitis
  • 31. Idiopathic iritis
    • Favourable prognosis
    • Also good when associated with ankylosing spondylitis, Crohns disease and toxoplasmosis.
  • 32.
    • At listing: ensure:
    • MUST HAVE 3-6 months with complete quiescence of uveitis ideally with no
    • need for steroids. List for most experienced phaco surgeons.
    • Discuss with senior and surgeon at listing (by phone or referra to their clinic)
    • Discuss with VR surgeon if Behcets, JIA, Posterior Uveitis, Vitritis, Vitreous
    • opacities
    • Post-op
    • G.Predfortex8 for 3 months and G.Diclofenacx4 for 2 weeks
    • G. Tropicamide 1% x 3 x 4 weeks and G.Phenylephrinex 3x 4 weeks
    • If raised IOP: timolol, trusopt or oral acetazolamide
    • Oral prednisolone 1mg/kg/day for 2 weeks, tapering it down for another
    • 2 weeks for a total of 1 month (may need for 3 months depending on case)
    If ever needed systemic steroids or pericoular steroids 1mg/kg/day prednisolone starting 2 weeks preop. Consider starting immunosuppressives at least 2 weeks preop (Methotrexate, Azathioprin, Cyclosporin A)
    • Surgery
    • Phaco, not ECCE. Acrylic PCIOL.
    • Synechiolysis
    • Consider prohylactic PI if high risk of seclusio pupillae
    • Suture incision and periocular triamcinolone
    • If persistent CME or vitritis or extensive exudates or membranes in vitreous,
    • consider comibining with PPV
    • Other considerations
    • JIA 3/12 systemic steroids in Children
    • Consider PPV-lensectomy with JIC and
    • pars planitis
    • In patients with only 1 functional eye,
    • consider leaving aphakic
    • Pre-op
    • G. Predforte x8x1 week pre-op and G.Diclofenac x4x1 week pre-op
    • 1mg/kg/day of oral prednisolone 1 week pre-op with Rantidine
    • Consider oral NSAID
    • Consider periocular triamcinolone steroid injection 1-4 weeks
    • pre-op if difficult to control
    • If Hx of frequent relapses, 250-500mg IV methylprednisoloneon morning of Sx
    PROTOCOL FOR UVEITIS PATIENTS UNDERGOING CARATACT SURGERY
    • If no pre-op medical work up
    • Consider:
    • Postponing surgery
    • Cancel if active uveitis
    • Admit and Rx intensely after
    • consulting senior by phone on
    • admission.IV methylprednisolone
    • 250-500mg when arrives in
    • theatre.
  • 33. References
    • Jorge L. Alio Y Sanz and Enrique Chipont (Phacoemulsification in Difficult and challenging cases)