Uveitic Cataract Research Articles

Cataract Surgery with Intraocular Lens Implantation in Juvenile Idiopathic Arthritis-Associated Uveitis: Outcomes in the Era of Biological Therapy.

This study compared the outcomes of cataract surgery with intraocular lens (IOL) implantation in patients with juvenile idiopathic arthritis (JIA)-associated chronic anterior uveitis treated with antimetabolite drugs and systemic corticosteroids (Non-Biological Group) versus patients treated with antimetabolites and biological drugs (Biological Group). A cohort of patients with cataract in JIA-associated uveitis undergoing phacoemulsification with IOL implantation was retrospectively evaluated. The main outcome was a change in corrected distance visual acuity (CDVA) in the two groups. Ocular and systemic complications were also recorded. The data were collected preoperatively and at 1, 12, and 48 months after surgery. Thirty-two eyes of 24 children were included: 10 eyes in the Non-Biological Group and 22 eyes in the Biological Group. The mean CDVA improved from 1.19 ± 0.72 logMAR preoperatively to 0.98 ± 0.97 logMAR at 48 months (p = 0.45) in the Non-Biological Group and from 1.55 ± 0.91 logMAR preoperatively to 0.57 ± 0.83 logMAR at 48 months (p = 0.001) in the Biological Group. The postoperative complications, including synechiae, cyclitic membrane, IOL explantation, glaucoma, and macular edema, were not statistically different between the two groups. An immunosuppressive treatment with biological drugs can improve the visual outcome after cataract surgery in patients with JIA-associated uveitis, but it does not significantly reduce postoperative ocular complications.

Risk of Cataract in Intermediate Uveitis

To determine the incidence of and predictive factors for cataract in intermediate uveitis. Retrospective cohort study. Patients were identified from the Systemic Immunosuppressive Therapy for Eye Diseases Cohort Study, in which medical records were reviewed to determine demographic and clinical data of every eye/patient at every visit at 5 participating US tertiary care uveitis centers. The primary outcome was development of vision-compromising cataract as defined by a decrease in visual acuity to 20/40 or less, or requiring cataract surgery. Survival analysis assessed visually defined cataract to avoid bias due to timing of surgery vis-à-vis inflammatory status. Among 2,190 eyes of 1,302 patients with intermediate uveitis, the cumulative incidence of cataract formation was 7.6% by 1 year (95% confidence interval [CI]=6.2%-9.1%), increasing to 36.6% by 10 years (95% CI=31.2%-41.6%). Increased cataract risk was observed in eyes with concurrent anterior uveitis causing posterior synechiae (hazard ratio=2.68, 95% CI=2.00-3.59, P < .001), and in eyes with epiretinal membrane formation (hazard ratio=1.54, 95% CI=1.15-2.07, P=.004). Higher dose corticosteroid therapy was associated with significantly higher incidence of cataract, especially time-updated use of topical corticosteroids ≥2 times/d or ≥4 periocular corticosteroid injections. Low-dose corticosteroid medications (oral prednisone 7.5 mg daily or less, or topical corticosteroid drops <2 times/d) were not associated with increased cataract risk. Our study found that the incidence of clinically important cataract in intermediate uveitis is moderate. The risk is higher with markers of severity and with higher doses of corticosteroid medications, the latter being potentially modifiable.

Recommendations for the management of childhood juvenile idiopathic arthritis-type chronic anterior uveitis.

Australian- and New Zealand-based, uveitis-specialized ophthalmologists have produced recommendations for the management of juvenile idiopathic arthritis (JIA)-type chronic anterior uveitis. Historically, the visual prognosis of JIA-type chronic anterior uveitis has been poor. New medical advances are likely to improve outcomes, but recently published guidelines are tailored for ophthalmic care in Europe and the United States. This work involved a consensus survey and a panel meeting. The Australian and New Zealand JIA-Uveitis Working Group (29 ophthalmologists) participated in the work. The Delphi technique was used to achieve consensus. This work yielded consensus statements. The Working Group achieved consensus around 18 statements related to clinical evaluation, use of topical and regional corticosteroids, use of systemic corticosteroid and non-corticosteroid immunomodulatory drugs, and management of secondary cataract and glaucoma in childhood JIA-type uveitis. Recommendations of the Australian and New Zealand JIA-Uveitis Working Group provide current and regionally applicable advice for managing chronic anterior uveitis in children with JIA.

Cataract surgery in a patient with bilateral necrotising scleritis and peripheral ulcerative keratitis associated with granulomatosis with polyangiitis (Wegener’s granulomatosis)

Introduction. We report a rare case of cataract surgery in a patient with an extreme, widespread anterior staphyloma following severe bilateral necrotising anterior scleritis associated with granulomatosis with polyangiitis (GPA). Case report. A 61-year-old man with a history of GPA developed bilateral, rapidly progressive necrotising scleritis and peripheral ulcerative keratitis (PUK). Inflammation compromised the entire anterior globe and peripheral cornea in both eyes. More than 90% of the surface area healed within 8 weeks, following the treatment with 3 pulsed doses of methylprednisolone in addition to the cyclophosphamide treatment. Systemic steroid therapy was slowly tapered over a period of 6 months. Extraordinary scleral loss with a uveal bulge developed, following severe necrotising anterior scleritis associated with PUK. Once the full remission had been achieved after 6 months, uncomplicated phacoemulsification was performed in his left eye, the only functional one. Conclusion. Preoperative and postoperative control of inflammation, careful surgical planning, and meticulous surgical techniques are critically important for optimal surgical outcome in such patients. To our knowledge, phacoemulsification in a patient with coexisting uveitic cataract and severe anterior staphyloma has not been previously reported.

Combined Phacoemulsification and Pars Plana Vitrectomy for the Treatment of Cataract in Patients With Noninfectious Uveitis.

This work evaluates the role of combined phacoemulsification and vitrectomy surgery in the management of cataract associated with noninfectious uveitis. A retrospective chart review was conducted of all patients aged 7 years or older who underwent a combined surgical approach from 2005 to 2018. Eighty-five eyes of 67 patients were included in the study; 10.7% of eyes had a best-corrected visual acuity (BCVA) of 20/40 or better at time of surgery. At 1-year follow-up, 63.4% of eyes had a BCVA 20/40 or better and 7.6% had a BCVA of 20/200 or worse. There was an overall decrease in cystoid macular edema after surgery compared with preoperatively (47.6% vs 34.5% presurgery and postsurgery, respectively). Complete inflammatory disease remission off immunomodulatory therapy and systemic steroids was achieved in 21.1% of patients. A combined surgical approach is effective in visual rehabilitation in patients with uveitic cataracts and may promote inflammatory disease remission specifically in intermediate uveitis.

A Cross-Sectional Online Survey Identifies Subspecialty Differences in the Management of Pediatric Cataracts Associated with Uveitis.

IntroductionTo determine if differences exist between pediatric ophthalmologists and uveitis ophthalmologists in the treatment of pediatric uveitic cataracts and placement of intraocular lenses.MethodsUveitis ophthalmologists and pediatric ophthalmologists were surveyed via an online poll regarding their therapeutic management of pediatric uveitic cataract and intraocular lens (IOL) placement.ResultsSixty-two responses from uveitis ophthalmologists and 47 responses from pediatric ophthalmologists were recorded. According to 79% of all responses, uveitis was not a contraindication for primary IOL implantation in patients with controlled intraocular inflammation. Pediatric ophthalmologists were more likely to respond that the presence of chronic juvenile idiopathic arthritis-associated iridocyclitis, pars planitis, or recurrent acute anterior uveitis is a contraindication for primary IOL implantation in pediatric cases with full control of intraocular inflammation. There was no consensus within either specialty with regard to the preferred IOL material for lens implantation. Uveitis ophthalmologists were more likely to report the use of intravenous and intravitreal steroids for perioperative treatment. In cataract surgery for a child with recurrent acute anterior uveitis, a higher percentage of uveitis ophthalmologists (71%) than pediatric ophthalmologists (50%) responded that the posterior capsule should be primarily opened. A higher percentage of uveitis ophthalmologists also stated that anterior vitrectomy should be performed at the time of cataract surgery in all three uveitis types.ConclusionsPediatric ophthalmologists and uveitis ophthalmologists have similar approaches to the management of pediatric uveitic cataract removal and IOL insertion, but several differences remain between these subspecialties. Continued collaboration between the subspecialties would be helpful to better develop consistent criteria to improve patient care.Electronic supplementary materialThe online version of this article (10.1007/s40123-020-00245-x) contains supplementary material, which is available to authorized users.

Posterior uveitis: Vitrectomy on eyes with bag‐in‐the‐lens IOL

AbstractImplication of the bag‐in‐the‐lens IOL implantation into uveitic cataract surgery became an alternative approach that has change the course of postoperative period. The use of bag‐in‐the‐lens IOL in patients with uveitis has certain advantages, including less postoperative inflammatory reaction and decreased risk of posterior synechia. In combined surgery the clear optic IOL area allows for improved visualization during the vitrectomy. However, the uveitic eyes can present with additional challenges which have to be reconsiderd.

Intravitreal dexamethasone implant as an alternative to systemic steroids as prophylaxis for uveitic cataract surgery: a randomized trial.

To determine the utility of the dexamethasone implant (IVD) as an alternative to systemic steroids as prophylaxis against cystoid macular edema (CMO) in patients with chronic, recurrent CMO associated intermediate or posterior uveitis (IU/PU), and cataract undergoing cataract surgery. This was a randomized, parallel design, and clinical trial. Patients with IU/PU and cataract scheduled for cataract surgery were randomly assigned to receive the IVD concurrently with cataract surgery (Group 1: 20 patients) or systemic steroids (Group 2: 23 patients) tapered over 4-6 weeks along with uneventful cataract surgery and routine postoperative care. Patients with glaucoma/contraindications to steroids were excluded. All patients were followed up for 6 months. Primary-incidence of postoperative CMO. Secondary-the change in BCVA (corrected distance visual acuity) and Central Subfield thickness (CST) and complications. Appropriate statistical analysis was done. The median age was 47.3 ± 4.23 years (group 1) and 49.12 ± 5.32 years (Group 2). One patient (Group 1) and two (Group 2) developed CMO. The BCVA improved significantly in both groups (p = 0.013). The CST change was insignificant. Four patients (Group 1) required intraocular pressure (IOP) lowering medications. Three patients (Group 2) required early steroid taper. IVD is a good alternative as prophylaxis in IU/PU and cataract in preventing postoperative CMO.

Phacoemulsification in uveitic cataract at a tertiary care teaching center

Phacoemulsification in uveitic cataract at a tertiary care teaching center

Phacoemulsification in uveitic cataract at a tertiary care teaching center

Introduction: Due to variation in etiology and presentation, it is difficult to predict the outcomes of phacoemulsification in patients suffering from uveitis. The present study evaluated outcomes of surgery at a tertiary care teaching hospital. Materials and Methods: 64 eyes of 64 patients with uveitis were retrospectively studied for vision related outcome and complication rate after phacoemulsification surgery. However, after exclusion, 46 eyes were analysed. Results: The mean age of patients with uveitis enrolled was 46.7±2.3 (range, 28-56 years). The mean duration of follow-up was 12.6±3.4 (range, 8-16 months). Improvement in vision was significantly better in males (P=0.05). Uveitis was silent for 6.3±2.6 months prior to performing surgery. Tuberculosis was the most commonly identified etiological factor followed by Fuch’s iridocyclitis and Vogt’s Koyanagi Harada disease, respectively. The frequent complications of surgery were recurrent uveitis, cystoid macular edema and after-cataract. Factors influencing vision were location of uveitis, intake of preoperative steroids and posterior segment pathology. At final follow-up, the vision was 0.24±0.07 Log MAR units. Conclusion: Thorough control of inflammation prior to performing surgery is the key to good visual outcome in uveitis. Phacoemulsification with posterior chamber IOL implantation provided good vision when the inflammation is confined to the anterior segment of the eye. Visual prognosis compromise in diseases involving the central fundus. Keywords: Cataract, Cystoid macular oedema, Intraocular lens implantation, Posterior capsule opacification, Uveitis, Vision.

Long-term outcomes of cataract surgery in children with uveitis.

Purpose:To evaluate the long-term outcomes of cataract surgery in children with uveitis.Methods:Retrospective, noncomparative review of medical records of children (≤16 years) with uveitic cataract who had undergone cataract surgery between January 2001 and December 2014 at a tertiary care center was done. The main outcome measures were visual acuity and postoperative complications.Results:We recruited 37 children (58 eyes) who were diagnosed with uveitic cataract and underwent cataract surgery. The etiology of uveitis included juvenile idiopathic arthritis (n = 19), presumed intraocular tuberculosis (n = 8), idiopathic (n = 4), Behçet's disease (n = 2), Vogt–Koyanagi–Harada syndrome (n = 2), human leukocyte antigen B-27 associated uveitis (n = 1), and toxocariasis (n = 1). Phacoemulsification with intraocular lens (IOL) implantation was performed in 17 patients (27 eyes; 46.55%), while 20 patients (31 eyes; 53.44%) were left aphakic after pars plan lensectomy and vitrectomy. At an average follow-up of 3.69 ± 7.2 (SD) years, all cases had significant improvement in corrected distance visual acuity post cataract extraction; visual acuity of 20/40 or more was achieved in 32 eyes (55.17%). The most common complication was capsular opacification (37.93%). Incidence of secondary procedures as well as glaucoma was not statistically different in patients undergoing IOL implantation from those who were aphakic.Conclusion:Even though number of secondary procedures was more in pseudophakic group, meticulous choice of surgical technique and adequate immunosuppression lead to a modest gain of visual acuity in children undergoing IOL implantation in uveitis. However, scrupulous case selection and aggressive control of pre- and postoperative intraocular inflammation are the key factors in the postoperative success of these patients.

Decision making in surgical management of Uveitic cataracts

Decision making in surgical management of Uveitic cataracts

Safety and efficacy of dexamethasone implant along with phacoemulsification and intraocular lens implantation in children with juvenile idiopathic arthritis associated uveitis.

Purpose:To assess the safety and efficacy of intraoperative intravitreal dexamethasone implant in patients of juvenile idiopathic arthritis (JIA)-associated uveitis undergoing phacoemulsification with posterior chamber intraocular lens (PCIOL) implantation.Methods:Retrospectively, data of patients with JIA-associated uveitis undergoing phacoemulsification with PCIOL implantation with intraoperative dexamethasone implant injection were analyzed. Patients with a minimum follow-up of 6 months were included. Primary outcome measures were ocular inflammation, intraocular pressure (IOP), best-corrected visual acuity (BCVA), and worsening of uveitis.Results:8 eyes of 6 patients were included. BCVA was significantly improved at 1, 3, and 6 months postoperatively 0.20 ± 0.09, P = 0.008; 0.18 ± 0.11, P = 0.008; and 0.24 ± 0.11, P = 0.01, respectively. No statistical difference noted in mean IOP at various follow-up visits. None developed worsening of uveitis or Cystoid macular edema.Conclusion:Intraoperative intravitreal dexamethasone implant is a safe and effective in preventing and managing the postoperative inflammation in children with JIA-associated uveitic cataract.

Prevalence and prognostic significance of retinal findings in pediatric cerebral malaria cases at a Tertiary Care Centre in eastern India

Cataract is a major complication of chronic cases of uveitis. Surgeries in cases of uveitic cataracts are often complicated due to various factors like non-dilating pupil, presence of posterior synechiae and recurrence of inflammation in post-op period. Various opinions exist regarding the preferred surgical technique, either SICS or phacoemulsification and the type of IOL used in such cases. This is review article of all the studies conducted so far regarding the surgical management of uveitic cataracts and their visual outcome.

Chemokine and Adhesion Molecule Profiles in Aqueous Humor of Clinically Quiescent Uveitic Cataracts

ABSTRACTPurpose: To investigate the chemokine and adhesion molecule profiles in aqueous humor (AH) of eyes with inactive uveitis and their correlations with inflammation relapse after cataract surgery.Methods: Patients with inactive uveitis who underwent cataract surgery between July 2014 and January 2016 at our center were included. Undiluted AH samples (100–120 µl) were obtained through lateral corneal incisions during surgery, and concentrations of monocyte chemoattractant protein 1 (MCP-1/CCL2), macrophage inflammatory protein 1 (MIP-1), interleukin 8 (IL-8), regulated on activation, normal T cell expressed and secreted (RANTES/CCL5), soluble vascular cell adhesion molecule (sVCAM) and soluble intercellular adhesion molecule (sICAM) were measured by cytometric bead array (BD Bioscience, San Jose, CA). AH levels of these inflammatory factors were compared between different uveitis entities and non-inflammatory control. Risk factors for postoperative inflammation relapse were also analysed in uveitic eyes.Results: As compared with the control group, the panuveitis group had significantly higher aqueous concentrations of MCP-1, IL-8, sVCAM, sICAM; the anterior uveitis group had significantly higher concentrations of MCP-1, MIP-1, sVCAM. Uveitic cataracts with postoperative inflammation relapse had significantly higher levels of MCP-1 and IL-8 in AH than those without. And multivariate cox regression analysis revealed that high AH levels of MCP-1 was an independent predictor for postoperative inflammation relapse.Conclusions: Clinically quiescent uveitic eyes have elevated levels of chemokines and soluble adhesion molecules in AH, of which MCP-1 is associate with inflammation relapses after cataract surgery.

Efficacy of Intravitreal Dexamethasone Implant in Patients of Uveitis Undergoing Cataract Surgery

ABSTRACTPurpose: To assess postoperative inflammation using laser flare photometer, following phacoemulsification with or without single intraoperative intravitreal dexamethasone implant in addition to standard of care, in patients of uveitis with cataract.Methods: Prospectively, 30 eyes with uveitic cataract were randomized into 2 groups (i) standard of care (SOC group) (ii) Dexamethasone implant (DEXA group). Both the groups underwent phacoemulsification with intraocular lens implantation and standard of care treatment for uveitis, but DEXA group additionally received intraoperative intravitreal dexamethasone implant. Patients were followed at least till 6 months.Results: DEXA group had significantly less postoperative flare (LFP values) (P<0.05) as compared to SOC group and also recovery of flare to preoperative value occurred much early in DEXA group. 37.5% cases developed CME in SOC group but none in DEXA group. Mean CMT (267.81±34.26μm) and final logMar BCVA (0.036±0.063) was significantly better in DEXA group (p<0.04).Conclusions: Intraoperative intravitreal dexamethasone implant is a safe and effective option for preventing and managing the postoperative inflammation in uveitic cataract.

English

INTRODUCTION: Cataract surgery in a patient with uveitis is more complex than senile cataract extraction, because it involves multiple considerations related to the cause of uveitis, prospects of visual rehabilitation, appropriate surgical timing, and technique, the type and material of intra ocular lens used. Establishing the diagnosis, thorough ocular examination, careful patient selection and meticulous control of perioperative inflammation are key elements to a successful visual outcome. AIM OF THE STUDY: 1. To assess intra operative and post operative complications encountered during surgery for uveitic cataract. 2. To assess the factors which affect the visual outcome. MATERIALS AND METHODS: The study was done in Regional Institute of Ophthalmology and Government Ophthalmic Hospital, Egmore, Chennai from August 2005 to October 2007. The patients who attended the out patient and uvea clinic were included for the study. A total of 60 patients were taken up for the study. A detailed history and a complete ophthalmic examination was done. Inclusion criteria : 1. Patients with chronic uveitis and complicated cataract. 2. A quite eye (without inflammation) for atleast 3 months. Exclusion criteria : 1. Complicated cataract due to causes other than uveitis. 2. Patients with posterior segment pathology (by Bscan). RESULTS: The visual acuity after 6 wks ranged from 6/6 to 6/18 in 34 patients, 6/24 to 6/60 in 26 patients. The most common cause for decrease in vision was posterior capsular opacification. CONCLUSION: Cataract development is a very common occurrence in any form of anterior and intermediate uveitis, because of chronic intraocular inflammation, frequent relapses and long term use of corticosteroids. The reported incidence of cataract in uveitic patients is about 50% in juvenile rheumatoid arthritis and upto 75% in chronic anterior uveitis.

Recent Principles and Trends of Management of Uveitic Cataract

Recent Principles and Trends of Management of Uveitic Cataract

Long-term results of cataract surgery in patients with anterior uveitis.

This study was aimed to assess the long-term results of phacoemulsification and posterior chamber intraocular lens implantation in patients with anterior uveitis. Patients with complicated cataract secondary to anterior uveitis who underwent phacoemulsification and posterior chamber intraocular lens implantation were included in this study. Long-term results and all complications were evaluated throughout the postoperative 4years. A total of 55 eyes of 48 patients were identified in this study. Cases with anterior uveitis were categorised into four aetiologic groups. Of the 55 eyes, 22 (19 patients) had idiopathic anterior uveitis, 10 (9 patients) had viral anterior uveitis, 10 (9 patients) had Fuchs' anterior uveitis and 13 (11 patients) had anterior uveitis associated with collagen vascular diseases. Preoperative macular oedema was more frequent (63.6%) in the idiopathic group than in the other groups (p<0.001). The success rates of the best corrected visual acuity of 20/40 or better ranged from 80.0 to 100.0% in the groups. While postoperative increased intraocular pressure rate was statistically significantly higher in the Fuchs' group (p=0.047), there was no statistically significant difference in other complication rates between the groups. The long-term outcomes of phacoemulsification with intraocular lens implantation in patients with uveitic cataract were satisfactory with excellent visual acuity and relatively low complication rates.

Decision-making and management of uveitic cataract.

The visual outcome of uveitic cataract surgery depends on the underlying uveitic diagnosis, the presence of vision-limiting pathology and perioperative optimization of disease control. A comprehensive preoperative ophthalmic assessment for the presence of concomitant ocular pathology, with particular emphasis on macula and optic nerve involvement, is essential to determine which patients will benefit from improved vision after cataract surgery. Meticulous examination in conjunction with adjunct investigations can help in preoperative surgical planning and in determining the need for combined or staged procedures. The eye should be quiescent for a minimum of 3 months before cataract surgery. Perioperative corticosteroid prophylaxis is important to reduce the risk of cystoid macular edema and recurrence of the uveitis. Antimicrobial prophylaxis may also reduce the risk of reactivation in eyes with infectious uveitis. Uveitic cataracts may be surgically demanding due to the presence of synechiae, membranes, and pupil abnormalities that limit access to the cataract. This can be overcome by manual stretching, multiple sphincterotomies or mechanical dilation with pupil dilation devices. In patients <2 years of age and in eyes where the inflammation is poorly controlled, intraocular lens implantation should be deferred. Intensive local and/or oral steroid prophylaxis should be given postoperatively if indicated. Patients must be monitored closely for disease recurrence, excessive inflammation, raised intraocular pressure, hypotony, and other complications. Complications must be treated aggressively to improve visual rehabilitation. With proper patient selection, improved surgical techniques and optimization of peri- and post-operative care, patients with uveitic cataracts can achieve good visual outcomes.