MEETING MORBIDITY :MEETING MORBIDITY :

Avoiding failure to medically Avoiding failure to medically treat eyes undergoing cataract treat eyes undergoing cataract

surgery with known uveitis surgery with known uveitis

Dr. Nick SargentDr. Nick Sargent

August 2008August 2008

What are we trying to avoid?What are we trying to avoid?

Why is it important to avoid Why is it important to avoid uveitis?uveitis?

CB detachment. CB detachment.

PhthisisPhthisis

AlsoAlso Fibrin deposits on IOLFibrin deposits on IOL

2ry glaucoma2ry glaucoma

Corneal oedemaCorneal oedema

Endothelial damageEndothelial damage

2ry cataracts2ry cataracts

CMECME

etcetc

Cataract surgery in the patient Cataract surgery in the patient with uveitis is one of the with uveitis is one of the challenges with the greatest challenges with the greatest number of unknown factors faced number of unknown factors faced by the ophthalmologistby the ophthalmologist

Difficulties in management pre- and post-opDifficulties in management pre- and post-op

Uncertainty of the post-operative process Uncertainty of the post-operative process

Existence of an underlying systemic Existence of an underlying systemic pathologypathology

Poor tolerance of IOLsPoor tolerance of IOLs

Technical difficulties such as PSTechnical difficulties such as PS

Visual prognosis depends on:Visual prognosis depends on:

Presence of pre- and post-surgical Presence of pre- and post-surgical inflammationinflammation

Quality and efficiency of the surgical Quality and efficiency of the surgical procedureprocedure

Rx of complications, e.g. 2ry glaucomaRx of complications, e.g. 2ry glaucoma

Good control of underlying Good control of underlying systemic disordersystemic disorder

Multidisciplinary approach.Multidisciplinary approach.

Control of the ocular inflammation Control of the ocular inflammation needed prior to surgeryneeded prior to surgery

Topical or systemic steroidsTopical or systemic steroids ImmunosuppressivesImmunosuppressives

Aim is to reduce AC and vitreous activity Aim is to reduce AC and vitreous activity

according to number of cellsaccording to number of cells..

Difficult intra-op Difficult intra-op

Iris atrophyIris atrophy Sclerosis of pupillary sphincterSclerosis of pupillary sphincter Cyclitic membranesCyclitic membranes PS and PASPS and PAS Anterior capsule sclerosisAnterior capsule sclerosis Iris haemorrhageIris haemorrhage Angle neovascularisation Angle neovascularisation

Miotic pupil

Synechiae

Glaucoma

Challenge of IOL selectionChallenge of IOL selection

Must be in bag when possibleMust be in bag when possible

Construction of IOLConstruction of IOL

Might need to avoid altogetherMight need to avoid altogether

Good post-op control of inflammationGood post-op control of inflammation

Topical, periocular, systemic steroidsTopical, periocular, systemic steroids

NSAIDs NSAIDs

Iris manipulation: Prostaglandins E2 and Iris manipulation: Prostaglandins E2 and F2aF2a

Activation of complement by the classic or Activation of complement by the classic or alternative route: certain polymers such as alternative route: certain polymers such as prolene. Less so with hydrogel.prolene. Less so with hydrogel.

Probably get less inflammation with phaco Probably get less inflammation with phaco rather than ECCErather than ECCE

Patient preparationPatient preparation Good pupillary dilatation to minimise iris Good pupillary dilatation to minimise iris

touchtouch

Angle neovascularisation: consider Argon Angle neovascularisation: consider Argon laser at the area of surgical incision (enough laser at the area of surgical incision (enough to blanch vessels in 3 different places)to blanch vessels in 3 different places)

Proper IOP control (avoid pilocarpine as Proper IOP control (avoid pilocarpine as alter blood-aqueous barrier)alter blood-aqueous barrier)

Pre-operative hypotony: cyclitic membranes, Pre-operative hypotony: cyclitic membranes, CB dialysis, severe inflammationCB dialysis, severe inflammation

Preop Control of InflammationPreop Control of Inflammation

Might just need topical or periocular Might just need topical or periocular steroidssteroids

Systemic steroids controversial: must Systemic steroids controversial: must recommend if required systemic or recommend if required systemic or periocular steroids in a previous uveitis periocular steroids in a previous uveitis attackattack

Combined Cataract-Vitrectomy Combined Cataract-Vitrectomy

PPV with lensectomy can be procedure of PPV with lensectomy can be procedure of choice in cases of uveitis with vitritis choice in cases of uveitis with vitritis refractory to medical treatment. refractory to medical treatment.

Disadvantage: sulcus fixated IOL, difficulty Disadvantage: sulcus fixated IOL, difficulty removing dense nucleus and difficulty removing dense nucleus and difficulty removing cortexremoving cortex

IOLIOL

Avoid ACIOLs & Sulcus fixatationAvoid ACIOLs & Sulcus fixatation

Avoid IOLs with polypropylene hapticsAvoid IOLs with polypropylene haptics

Heparin coated IOLs (be careful when gripping)Heparin coated IOLs (be careful when gripping)

Avoid siliconeAvoid silicone

PMMA and hydrogel betterPMMA and hydrogel better

Steroid in irrigation fluids?Steroid in irrigation fluids?

Intravitreal triamcinolone?Intravitreal triamcinolone?

Fuch’s heterochromatic CyclitisFuch’s heterochromatic Cyclitis

PS rarely formedPS rarely formed Generally do well with surgery but reports of:Generally do well with surgery but reports of:

VitritisVitritis HyphaemaHyphaema Increase IOPIncrease IOP Cyclitic membrane formationCyclitic membrane formation

Risk of glaucoma (10%); maybe worse after Sx Risk of glaucoma (10%); maybe worse after Sx

SarcoidosisSarcoidosis

Phaco has been performed with good resultsPhaco has been performed with good results

MiosisMiosis

Pars planitisPars planitis

PS rarePS rare

Glaucoma is the exceptionGlaucoma is the exception

40% get cataracts40% get cataracts

50% obtain 6/12 or better50% obtain 6/12 or better

Pars planitisPars planitis

Pars planitis does not seem to increase the risk Pars planitis does not seem to increase the risk of complications in routine cataract surgeryof complications in routine cataract surgery

Often get low grade post-op uveitis resulting in Often get low grade post-op uveitis resulting in accumulation of debris and membranes on the accumulation of debris and membranes on the back surface of the IOL and posterior capsule. back surface of the IOL and posterior capsule. Might need YAG. Might need YAG.

Membranes tend to return and can be controlled Membranes tend to return and can be controlled with subconj and frequent topical steroidswith subconj and frequent topical steroids

JICJIC May also have amblyopia, band keratopathy, May also have amblyopia, band keratopathy,

hypotony, glaucoma, PShypotony, glaucoma, PS

Average age at time of surgery varies between Average age at time of surgery varies between 10 -19 years.10 -19 years.

Uveitis is exacerbated by SxUveitis is exacerbated by Sx

Many get vitreous loss and retained cortical Many get vitreous loss and retained cortical matter.matter.

60% get 6/60 or worse vision60% get 6/60 or worse vision

JICJIC

Performing a mid-portion vitrectomy is Performing a mid-portion vitrectomy is recommended by some authorsrecommended by some authors

IOL not recommendedIOL not recommended

Most common post-op complications:Most common post-op complications: GlaucomaGlaucoma HypotonyHypotony CMECME

Combine with vitrectomy if vitritis or vitreous Combine with vitrectomy if vitritis or vitreous opacitiesj opacitiesj

Behcet’s Disease, VKH and Behcet’s Disease, VKH and Multifocal ChorioretinitisMultifocal Chorioretinitis

Few reports on phaco in these patientsFew reports on phaco in these patients

The incidence of phthisis bulbi and hypotony has been The incidence of phthisis bulbi and hypotony has been reported to decrease from 25-2% when limited reported to decrease from 25-2% when limited vitrectomy was performed with cataract extraction vitrectomy was performed with cataract extraction (Kanski J, et al. Ophthalmology 1984;91:1247-1252)(Kanski J, et al. Ophthalmology 1984;91:1247-1252)

Visual prognosis significantly worse with Behcet’s Visual prognosis significantly worse with Behcet’s (severe post. segment complications)(severe post. segment complications)

Multifocal chorioretinitis: VA returns to pre-op values Multifocal chorioretinitis: VA returns to pre-op values within 6 months.within 6 months.

HZ uveitisHZ uveitis

VA better than 6/12 in 90%VA better than 6/12 in 90% 18% get chronic uveitis18% get chronic uveitis

Idiopathic iritisIdiopathic iritis

Favourable prognosisFavourable prognosis

Also good when associated with Also good when associated with ankylosing spondylitis, Crohns disease ankylosing spondylitis, Crohns disease and toxoplasmosis.and toxoplasmosis.

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-opG.Predfortex8 for 3 months and G.Diclofenacx4 for 2 weeksG. Tropicamide 1% x 3 x 4 weeks and G.Phenylephrinex 3x 4 weeksIf raised IOP: timolol, trusopt or oral acetazolamideOral 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)

SurgeryPhaco, not ECCE. Acrylic PCIOL.SynechiolysisConsider prohylactic PI if high risk of seclusio pupillaeSuture incision and periocular triamcinoloneIf persistent CME or vitritis or extensive exudates or membranes in vitreous, consider comibining with PPV

Other considerations

JIA <18 years, defer surgery or no IOL

Avoid >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 PROTOCOL FOR UVEITIS PATIENTS UNDERGOING PATIENTS UNDERGOING

CARATACT SURGERYCARATACT SURGERY

If no pre-op medical work up

Consider:

1) Postponing surgery2) Cancel if active uveitis3) Admit and Rx intensely after

consulting senior by phone on admission.IV methylprednisolone 250-500mg when arrives in theatre.

ReferencesReferences

Jorge L. Alio Y Sanz and Enrique Jorge L. Alio Y Sanz and Enrique Chipont Chipont (Phacoemulsification in (Phacoemulsification in Difficult and challenging cases)Difficult and challenging cases)