|Year : 2004 | Volume
| Issue : 2 | Page : 158-9
Late Recurrent Uveitis after Phacoemulsification
Pradeep K Saraf
Shivam Nethralaya, Kolkata, India
Pradeep K Saraf
Shivam Nethralaya, Kolkata
Source of Support: None, Conflict of Interest: None
It is now assumed that recurrent late onset uveitis after phacoemulsification with intraocular lens (IOL) is due to indolent infection. Fifteen such cases were observed after uncomplicated phacoemulsification with-in-the-bag IOL implant. These cases were considered noninfective and treated medically with good visual recovery.
Keywords: Late onset uveitis, phacoemulsification, endophthalmitis
|How to cite this article:|
Saraf PK. Late Recurrent Uveitis after Phacoemulsification. Indian J Ophthalmol 2004;52:158
Any intraocular procedure causes postoperative inflammation. This is usually treated with topical corticosteroids and nonsteroidal anti-inflammatory drugs (NSAIDs). These are generally tapered over a few weeks depending on the individual situation. Sulcus fixated posterior chamber intraocular lens (IOL), iris fixated intraocular lens (IOL) and poorly designed and manufactured anterior chamber lenses with rough edges, are known to cause chronic iris irritation. This results in chronic uveitis, glaucoma, and hyphaema (UGH syndrome). This responds only to removal and replacement of the offending IOL. With capsular bag IOL fixation, this syndrome is now rarely, if ever seen.,
Late onset uveitis is presently considered to be due to indolent infection. Diagnosis can be made by culture of material from the capsular bag. Treatment consists of antibiotics in the capsular bag vitrectomy, and more commonly requires removal of both the IOL and capsular bag. These steps are recommended in the early stages to avoid chronic cystoid macular oedema .
This retrospective study looks at cases of late onset recurrent uveitis after phacoemulsification and IOL implant treatment only with topical corticosteroids.
| Case report|| |
Six hundred and seventy six uncomplicated phacoemulsification surgeries done by the author between September 1995 and March 2001 were reviewed. Twelve cases with posterior capsular rupture with or without nucleus dislocation were excluded from the study. One surgeon performed all surgeries in the same operating room. Preoperatively all patients had complete cataract work up. All preoperative and postoperative medicines used were similar. All cases were done under peribulbar anaesthesia. A scleral tunnel was used for rigid IOLs and a clear corneal incision was used for foldable IOLs. The anterior chamber was filled with viscoelastic (hydroxypropylmethylcellulose-HPMC), and a capsulorhexis was made. After hydrodissection, the nucleus was removed using the "divide-and-conquer" technique in the first 287 cases and by the stop-and-chop technique in the remaining cases. Cortical cleaning was done by the bimanual technique through two side ports. A foldable acrylic lens was used in 97 cases and 567 cases had implantation of a rigid single piece IOL. The anterior chamber was filled with HPMC before IOL implantation in the bag. HPMC was thoroughly aspirated after IOL implantation from the anterior chamber and not from the back of the IOL. No sutures were used. All patients received subconjuctival gentamicin 10mg and dexamethasone 1mg. The eye was patched until the next day. Only topical betamethasone 0.1% was given. The dosage schedule was 8 times a day for 2 weeks, 6 times a day for 2 weeks, 4 times a day for 2 weeks, after which it was discontinued.
All the patients were asymptomatic for a month, without inflammation after a week. Fifteen patients developed anterior uveitis 4 - 6 weeks after surgery when topical betamethasone was tapered to twice a day or discontinued. The symptoms included decrease in vision, redness, pain and photophobia. Examination showed vision reduced by 2 to 5 lines, no lid oedema, mild conjunctival congestion and minimal aqueous flare and cells. There were no keratic precipitates, hypopyon or vitreous opacities.
Vitreous tap was done in one case and the specimen was sent for microscopy and was cultured for bacteria and fungus. The patient was also given intraocular vancomycin (1.0mg) and cefotoxim (0.25mg). There was no growth on culture. In the remaining 14 cases vitreous tap or culture was not done. They were treated only with topical betamethasone 0.1%. The topical medication was increased to 4 times a day and tapered each week, over a month. If symptoms recurred topical betamethasone was given 4 times daily for 2 weeks and tapered over 2 months. In case of further recurrence topical fluoromethalone was given for a month and tapered over 4 months. The duration of treatment is given in [Table - 1]. Follow-up was 3 months in 4 cases, up to 1 year in 3 cases and up to 4 years in 8 cases.
Of the 15 cases with chronic uveitis, 4 were male and 11 were female. In total, there were 351 male and 325 female patients, ranging in age from 51 to 77, averaging 65.3. (The average age for the cohort study was 64.7) One case had diabetes. There was no case history of uveitis. Preoperative visual acuity was 6/36 or more in 10 cases and less in 5 cases. No case had mature cataract. Three cases had foldable acrylic IOL and 12 had single piece PMMA IOL. In all cases, symptoms resolved rapidly after restarting or increasing the dose of topical corticosteroid. Vision was felt to be consistent with preoperative macular status in all cases - 12 were 6/9 or better, 2 were 6/12 and one was 3/60 due to the presence of a macular hole preoperatively. There was no case of steroid-induced glaucoma and no cystoid macular oedema.
| Discussion|| |
Uncomplicated phacoemulsification and extracapsular cataract surgery with or without IOL usually result in very little intraocular inflammation that could last from a few days to weeks. Late onset intraocular inflammatory reaction in these eyes is mostly suspected to be due to an indolent infection. Wenkel reported 9 cases of chronic postoperative endophthalmitis after cataract extraction and IOL implantation. In these cases the main clinical findings were hypopyon and infiltrates in the capsule bag. Chronic and recurrent endophthalmitis has also been reported due to contaminated viscoelastic.
Jalali et al reported two such cases wherein one patient who had recurrent hypopyon; vitrectomy after 7 months showed Propionibacterium acnes .
In the present series of 15 patients, intraocular antibiotics and vitrectomy were not required and the patient was cured by topical corticosteroids only, suggesting a noninfectious pathology. The cause of recurrent anterior uveitis in the present cases is unclear. The review of 2000 extracapsular cataract extractions with IOL done by the author previously did not show any such incidence (Unpublished data). So it is presumed to be a complication specific to phacoemulsification. One cause for chronic inflamma-tion is nucleus dislocation into the vitreous. These cases were excluded from this study; however, it is possible that a small nuclear chip could have been present behind the iris and could not be removed even after good clearing.
Jehan et al have reported 10 cases of severe intraocular inflammation associated with Memory Lens. These happened on an average of 7.8 days post-op, and were presumed to be sterile. A definite aetiology was not determined, though they were felt to be due to residual polishing compound on the IOL. The cases in this series were random and could not be related to any specific IOL type . Madhavan reported a mild but significant toxic effect on cell cultures with some viscoelastics. It may be assumed that viscoelastics entrapped behind the IOL in capsular bag may be a cause for recurrent uveitis and it abates after some time when the viscoelastic is cleared.
Metallic dust from the phaco needle is occasionally seen on the iris postoperatively, but appears to be totally inert. It is presumed that it could induce uveitis in some cases.
All the above causes including entrapment of small nucleus piece, viscoelastics and metallic dust from phaco tip, are specific to phacoemulsification and need further study.
To summarise, cases with late recurrent anterior uveitis after phacoemulsification are frequently not of infective origin, and can be reasonably safely treated with topical corticosteroids and careful observation. More invasive procedures, such as vitreous tap and culture, intraocular antibiotics, vitrectomy or IOL explantation can be deferred as long as there is satisfactory resolution. This observation warrants further prospective study.
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[Table - 1]
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