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   Table of Contents      
Year : 2002  |  Volume : 50  |  Issue : 2  |  Page : 103-107

Cataract surgery in uveitis

L V Prasad Eye Institute, L V Prasad Marg, Banjara Hills, Hyderabad-500 034, India

Correspondence Address:
A Hazari
L V Prasad Eye Institute, L V Prasad Marg, Banjara Hills, Hyderabad-500 034
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Source of Support: None, Conflict of Interest: None

PMID: 12194565

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Purpose:To study the visual outcome of cataract surgery in eyes with uveitis.Methods: A retrospective analysis of patients with uveitis operated for cataract. Results: 106 eyes of 89 patients with uveitis were operated for cataract. In 62.3% eyes (66/106), post -operative follow-up was at least 6 months. There was significant improvement (P<0.001) in visual acuity after cataract surgery. Provided the uveitis was well controlled for three months pre-operatively, additional pre-operative anti-inflammatory medications did not significantly affect (P=0.842) post -operative inflammation. Patients who received extracapsular cataract extraction (ECCE) or phacoemulsification with posterior chamber IOL (PCIOL) obtained better visual acuity at 6 weeks (P=0.009 and P=0.032 respectively ) than those with only ECCE without IOL. In 37 eyes vision did not improve due to persistent uveitis (23.9%, 16/67), cystoid macular oedeme (20.9%, 14/67), and posterior capsule opacification (14.9%, 10/67). Conclusion: Cataract extraction and PCIOL implantation is safe in eyes with uveitis. Additional preoperative medications may not alleviate post-operative inflammation if uveitis is well controlled for at least three months before surgery.

Keywords: Cataract surgery, uveitis

How to cite this article:
Hazari A, Sangwan VS. Cataract surgery in uveitis. Indian J Ophthalmol 2002;50:103-7

How to cite this URL:
Hazari A, Sangwan VS. Cataract surgery in uveitis. Indian J Ophthalmol [serial online] 2002 [cited 2020 Oct 31];50:103-7. Available from: https://www.ijo.in/text.asp?2002/50/2/103/14812


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Uveitis is a common problem encountered in diverse forms.[1] It is a chronic and usually protracted condition, requiring long-term treatment with corticosteroid or other immunosuppressive drugs. Cataract formation is a common finding in these patients either as a direct consequence of the disease process or as sequel of long-term corticosteroid use.[2][3][4] The management of cataract associated with uveitis requires special precautions and has its own attendant problems. Cataract surgery in uveitic eyes has been shown to offer good visual rehabilitation, especially with the use of intraocular lenses (IOLs). Modern IOLs are considered safe in most uveitic eyes and do not cause increased postoperative inflammation. The general guidelines for cataract surgery in uveitic eyes include a preoperative control of inflammation for atleast a period of 3 months.

We reviewed the records of all patients with uveitis who underwent cataract surgery at the L V Prasad Eye Institute, Hyderabad, India, between January 1995 and August 1998, to determine the visual outcome of cataract surgery and the factors affecting visual recovery vis-a-vis the post-operative inflammation.

  Materials and Methods Top

A retrospective analysis included patients with uveitis that was either inactive, or under control (anterior chamber cells less than 1+) with medication for at least three months before surgery. The demographic data including the age and gender. The uveitis was classified according to the International Uveitis Study Group (IUSG) classification,[5] i.e., anterior uveitis if only the iris was involved; intermediate if the ciliary body along with the anterior vitreous was involved; posterior if the inflammation was limited to the vitreous and the retina and choroid and panuveitis if all of the above were involved. Definitive diagnosis was noted whenever made. Type of cataract surgery included extracapsular cataract extraction (ECCE), ECCE with posterior chamber intraocular lens (PCIOL) implantation, phacoemulsification with PCIOL implantation, membranectomy, secondary IOL implantation, ECCE, pars plana vitrectomy and endolaser, and intracapsular cataract extraction (ICCE). Pre-operative visual acuity and visual acuity at 6 weeks, 6 months and the final follow-up was noted. For purpose of analysis the visual acuity was later converted from Snellen to LogMAR visual acuity. The cause of decreased vision was noted at 6 weeks and 6 months. Additional preoperative anti-inflammatory medications were noted if given. This did not include eyes receiving maintenance doses of anti-inflammatory medications at the time of surgery. The effect of preoperative anti-inflammatory medications on postoperative inflammation and visual acuity was analysed. Postoperative inflammation was categorised into whether it was excessive or the usual expected with the particular type of surgery.

All patients were examined and graded by fellowship trained uveitis expert (VSS). Increased inflammation was defined as the anterior chamber reaction of more than 2+ cells and presence of fibrinous membrane in the first postoperative week and/or more than 1+ cell in the subsequent 5 postoperative weeks. Patients followed up for less than 6 weeks were not included in the analysis. The reasons for poor vision, non-improvement of vision, or deterioration of vision postoperatively over a period of 6 months were noted. The frequency of these causes their association with the type of uveitis and use of preoperative anti-inflammatory drugs were analysed.

  Results Top

In the study there were 44 males and 45 females patients ranged in age from 15 to 74 years (mean 42.7415 years). Of these 106 eyes, 62.3% (66 eyes) had a minimum postoperative follow-up of 6 months. The range of postoperative follow-up was 1.5 to 67 months (mean, 10.2 10.1 months).

The frequencies and the percentages of the various types of the uveitis diagnosed are shown in the [Table - 1]. Only in 21 (19.8%) eyes the cause of uveitis could be established [Table - 2].

Seventy of the 106 eyes (66%), that underwent cataract surgery received preoperative anti-inflammatory medications. These included topical corticosteroids in 61 eyes (87.1%) four times a day, starting 3 days before the surgery, oral corticosteroids in 17 eyes (24.3%) (prednisolone 1 mg/kg body weight), starting 3 days before surgery, periocular corticosteroid injections (depot medroxy progesterone) in 4 eyes (5.7%), and non-steroidal anti-inflammatory drugs (NSAIDS) starting 3 days before surgery in 9 eyes (12.9%).

The various surgeries and their frequencies are given in the [Table - 3]. ECCE with PCIOL was the most common type of cataract surgery done (67.9%) and a single piece polymethyle methacrylate (PMMA) lens was implanted in all patients. In all patients the standard envelope technique of capsulotomy was done, aiming at in-the-bag placement of the PCIOL. Phacoemulsification was done in 11 (10.4%) eyes with a well-dilated pupil.

All eyes received topical corticosteroids in tapered doses over 6 weeks postoperatively. In addition, 26 patients (n = 26 eyes 24.5%) also received oral corticosteroids during this period. Fourteen eyes (13.2%) received periocular corticosteroid injection, 55 patients (51.9%) received oral NSAIDs, and 2 patients were put on systemic immunosuppressive therapy over the 6-month postoperative period depending upon the level of inflammation and the development of postoperative complications. The groups of patients receiving periocular and oral corticosteroids were not mutually exclusive, but depending on the clinical situation, the different routes were used simultaneously, independently or sequentially.

In 29 of 106 eyes increased postoperative inflammation was noted warranting therapy in addition to topical and/or oral carticosteroids. Of the 70 eyes that received pre-operative medications, 23 had increased post-operative inflammation and needed additional medication. Of the 36 eyes that did not receive preoperative medications, 6 developed increased postoperative inflammation [Figure:1]. Statistical analysis was done using Chi-square test, student's t test, and analysis of variance (ANOVA).

Administration of additional preoperative anti-inflammatory medications did not have a significant effect on the development of increased postoperative inflammation (chi-square test; P=0.842). Appearance of post-operative inflammation did not differ significantly with ECCE or ECCE+PCIOL. On the other hand, phacoemulsification with PCIOL implantation was associated with significantly lower incidence of increased postoperative inflammation (chi-square test; P=0.047).

Preoperative visual acuity was compared with the postoperative visual acuity at 6 weeks and at 6 months after surgery. Visual acuity at 6 weeks and 6 months is given in [Figure:2]. There was a substantial improvement in vision in most eyes following cataract surgery. At 6 weeks 86 (81.13%) eyes improved by 3 or more lines on the logMAR visual acuity chart and at 6 months, 92 eyes showed this improvement. The eyes receiving preoperative anti-inflammatory medications had a slightly better visual acuity at 6 weeks (chi-square test; P=0.52), but there was no statistically significant difference in the best corrected visual acuity at 6 months between the two groups (Paired t Test; P=0.955) [Figure:3].

ANOVA was done to study the association between visual acuity at 6 weeks and 6 months with the type of surgery (ECCE; ECCE+PCIOL; Phacoemulsification + PCIOL). There was no statistically significant difference in the visual acuity at 6 months between the three groups (chi-square test; P=0.311); but at 6 weeks the group undergoing ECCE+PCIOL (P=0.009) or Phacoemulsification + PCIOL (P=0.032) had better visual acuity than that which underwent only ECCE. The visual acuities at 6 weeks in the ECCE+PCIOL and Phacoemulsification + PCIOL groups showed no statistically significant difference (LSD t test, P=0.673). In 67 of 106 (63.2%) eyes a definite cause could be found for decreased vision. The various causes are given in [Table:4].The important ones were persistent uveitis and cystoid macular oedema.

  Discussion Top

Over the last two decades it has been conclusively proven in the Western literature that cataract surgery has immense benefit in the visual rehabilitation of patients with uveitis and cataract. [2, 3, 4, 6] Cataract surgery with PCIOL implantation has been established as a safe modality of treating cataract in patients with uveitis. There are of course a few conditions such as juvenile rheumatoid arthritis where PCIOL implantation has been associated with increased inflammation[7] and is therefore not recommended by most uveitis experts. In our series we graded postoperative inflammation according to Hogan's classification of anterior chamber reaction.[8] Postoperative inflammation was treated with increased frequency of topical corticosteroids, sub-Tenons injection of depot corticosteroid, and systemic coritocsteroids depending on the degree of inflammation, in a stepladder manner. If cystoid macular oedema (CME) was detected, a systemic NSAID (Indomethacin) was started.

In all patients, the uveitis was well controlled (anterior chamber less than 1+ cells) for at least three months before surgery. Our study did not demonstrate a statistically significant benefit of additional preoperative anti-inflammatory medications in any form to prevent increased postoperative inflammation. The overall incidence of increased postoperative inflammation was 27.35% and the use of a standard one piece PMMA PCIOL placed in the capsular bag was not associated with a higher degree of inflammation. This furthers the management principle that there should be 'Zero tolerance' to pre-operative inflammation before attempting cataract surgery in such patients.[9] Phacoemulsification was associated with a significantly lower incidence of increased postoperative inflammation but this could be because the eyes that underwent phacoemulsification were quieter and had a well-dilated pupil. Also, the number of eyes that underwent phacoemulsification was too low to conclusively state that it was indeed associated with a reduced postoperative inflammation. Other investigators have reported decreased inflammation in uveitic eyes undergoing phacoemulsification as compared to ECCE and PCIOL implantation.[6],[8]

Preoperative anti-inflammatory medicines were not found to have an added beneficial effect on the final visual acuity at 6 months. However, they may help achieve an earlier stable vision postoperatively. While the pseudophakic group had better visual acuity at 6 weeks, there was no statistically significant difference in visual acuity at 6 months between the aphakic and pseudophakic eyes. Persistent uveitis was the most common cause of decreased vision both at 6 weeks and at 6 months. This is similar to the recent findings of Okhravi et al.[6] The increased postoperative inflammation required additional anti-inflammatory treatment which was given in a stepladder fashion (systemic corticosteroids, followed by low dose maintenance systemic corticosteroids or NSAID). Two patients needed long-term immunosuppressive therapy (Methotrexate). The 13.2% angiographically confirmed CME was less than reported by various authors (20-50%)[2]. This perhaps underscores the importance of preoperative control of uveitis. Posterior capsular opacification in 9.43% eyes required intervention within the 6-month postoperative period. This is comparable to the incidence reported by other authors[10]. The incidence of PCO has been found to increase with increasing duration follow up, reaching almost 50% by the end of four years.[9]

In summary ECCE with implantation of PCIOL is a safe procedure in properly selected cases of uveitic cataract and can give a predictably good visual results. Phacoemulsification with PCIOL implantation is also safe and may be associated with less severe inflammation postoperatively. In all cases strict preoperative control of inflammation for a substantial period ( 3 months) is essential to have a smooth and quiet postoperative period. If preoperative inflammation is well controlled, additional preoperative anti-inflammatory medications do not give any added benefit of reduced post-operative inflammation or improved visual outcome. Persistent uveitis is an important cause of decreased vision and can occur in and late postoperative period. Thus, long-term, regular and reasonably frequent follow-up of these patients with prompt treatment of any flare up of uveitis is essential.

  References Top

Dandona L, Dandona R, John RK, McCarty CA, Rao GN. Population based assessment of uveitis in an urban population in southern India. Br J Ophthalmol. 2000;84:706-09.  Back to cited text no. 1
Rojas B, Zafirakis P, Foster CS. Cataract surgery in patients with uveitis Curr Opin Ophthalmol 1997;8:6-12.  Back to cited text no. 2
Tabbara KF, Chavis PS. Cataract extraction in patients with chronic posterior uveitis. Int Ophthalmol Clin 1995;35:121-31.  Back to cited text no. 3
Hooper PL, Rao NA, Smith RE. Cataract extraction in uveitis patients. Surv Ophthalmol 1990;35:120-445.  Back to cited text no. 4
Bloch-Michel E, Nussenblatt RB. International Uveitis Study Group recommondation for the evaluation of intraocualr inflammatory disease. Am J Ophthalmol 1987;103:234-35.  Back to cited text no. 5
Okhravi N, Lightman SL, Towler HM. Assessment of visual outcome after cataract surgery in patients with uveitis. Ophthalmology 1999;106:710-22.  Back to cited text no. 6
Foster CS, Barret F. Cataract development and cataract surgery in patients with juvenile rheumatoid arthritis -associated iridocyclitis. Ophthalmology 1992;100:809-17.  Back to cited text no. 7
Hogan MJ, Kimura SJ, Thygeson P. Signs and symptoms of uveitis. Am J Ophthalmol 1959;47:155-70.  Back to cited text no. 8
Foster CS, Fong LP, Singh G. Cataract surgery and intraocular lens implantation in patients with uveitis. Ophthalmology 1989;96:281-88.  Back to cited text no. 9
Dana MR, Chatzistefanou K, Schaumberg DA, Foster CS.Posterior capsule opacification after cataract surgery in patients with uveitis. Ophthalmology 1997;104:1387-393; Discussion 1393-394.  Back to cited text no. 10


  [Table - 1], [Table - 2], [Table - 3]

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