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Management of the uveitic cataract, and ocular toxoplasmosis

02/10/2017
Given that surgery is a pro-inflammatory event, the need for cataract surgery in an individual suffering from inflammation of the uvea – a relatively common requirement – means that management is complex. Such management needs to be tailored to the individual and needs to follow a surgical plan.

In uveitic cataract cases, the most common pattern of uveitis is chronic anterior uveitis (80%), Fuchs’ cyclitis (50%), intermediate cyclitis (45%), and posterior/panuveitis (40%). Approximately 20% of uveitis patients are a direct result of steroid therapy.

Any uveitis needs to be well controlled (quiet) for a minimum of three months before surgery and the treatment regimen needs to be stable beforehand in order to achieve surgical success. The patient also needs to be made aware of the risks.

McCluskey noted that biologics were especially useful in chronic uveitis in children and adults. Systemic immunomodulatory therapy (IMT) may also be required in some cases, such as in cataracts associated with Juvenile Idiopathic Arthritis (JIA), a condition in which cataract surgery should be delayed for as long as possible.


Furthermore, peri-operative steroid cover may be essential in some cases, such as those following a poor outcome in the first eye, the monocular patient, those with a history of cystoid macular oedema (CMO), posterior uveitis, and chronic anterior uveitis.

Steroid cover is not essential in quiescent anterior uveitis and is not needed in Fuchs’ uveitis. There is no steroid regimen that is accepted universally but suggestions include: oral, intravenous, and topical applications before surgery, at the time of surgery, and post-surgically. McCluskey cautioned that the use of intravenous steroids had adverse effects on bones.

Pre-operatively, McCluskey suggested accurate biometry, selection of an experienced surgeon, the use of corneal rather than conjunctival incisions to preserve the conjunctiva, and the use of a viscoelastic to protect the endothelium. He also suggested that a surgical plan for the iris and pupil be formulated beforehand, and his preference is for the use of iris hooks rather than a Malyugin ring.

McCluskey observed that paediatric uveitic cataract was particularly challenging and by calling it an ‘art’, he further suggested that only an expert be called upon. It was recommended that acrylic rather than silicone IOLs be implanted, while he also preferred square-edged, monofocal lenses in either one-piece or three-piece configurations with a UV blocker.

He deployed toric IOLs only in carefully selected patients and advised against multifocal IOLs. IOL implantation is being used increasingly in JIA uveitis, especially in older children, despite the fact that traditionally, IOL implantation in JIA cases was contra-indicated.

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This is due largely to improvements in uveitis control offered by systemic Rxs, IMT, and biologics. IOL implantation also halves the risk of glaucoma in paediatric aphakes (cf. congenital cataracts), but that risk is still realised in about 25% of cases.

Intensive topical steroids and NSAIDs are required post-surgically, before being tapered to pre-operative levels. If fibrin deposition is an issue, intraocular rTPA (recombinant tissue plasminogen activator) and intensive topical steroids are used. Based on his team’s work, McCluskey gave post-phacoemulsification complications as severe uveitis (21%), CMO (20%), elevated IOP (5%), and posterior capsule opacification (45%).

Maximum topical steroid dosing, orbital floor steroids, intravitreal triamcinolone or dexamethasone, systemic steroids, and possibly immunosuppression were some of the suggested treatments to address those problems.

Poorer outcomes could often be traced to a pre-existing maculopathy, optic nerve disease, or pre-existing posterior uveitis, despite good visual outcomes (77% had 6/12 or better at six months) being reported generally. In finishing, McCluskey noted that VA can decrease over time from uveitis and any report of flare is indicative of a breakdown of the blood-eye barrier.


Professor PETER MCCLUSKEY is Chair of Ophthalmology in Sydney Medical School at the University of Sydney and Director of the Save Sight Institute at Sydney Eye Hospital. He has 30 years of experience as an inflammatory eye disease specialist, and is actively involved in clinical research and clinical trials.

 

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