F. Kianersi M.D 1387 / 12 / 1

 Patients with uveitis have cataracts: More often, and at an Earlier Age than the general population.  Main etiological agents : Intraocular inflammatory phenomena, The drugs used to control inflammation.

 The handling of these patients is very difficult because of: The existence of an underlying systemic pathology, The many technical difficulties, The poor tolerance of intraocular lenses (IOLs) observed in some cases, and The uncertainty of the postoperative process.

 Cataract surgery in the patient with uveitis presents a number of challenges in the: Pre-Surgical, Intra-Operative, and Post-Surgical stages.

Pre-Surgical Considerations

Control of Underlying Systemic Disorder In many cases, the presence of a base inflammatory pathology with long standing and unpredictable evolution will condition the existence of recurrent inflammation.

Control of the Ocular Inflammation Prior to the Surgical Procedure  It is then very important that the surgery should be performed in: An “Undisturbed" Eye with an inflammatory reaction that has been controlled for at least: 3 Months prior to surgery.

Control of the Ocular Inflammation  The treatment should be aimed at achieving: Reduction in Cellularity in the Anterior chamber, as well as little or no vitreous activity.  The inflammatory activity should be assessed only by : the presence of Cells in the Anterior chamber and not just by the amount of flare present.

 Preoperative control may require the use of: T opical, Peri-Ocular, Intra- Ocular Systemic Steroids, or Immunosuppressive Drugs. Cyclosporin A, Methrotexate, Azathioprin, Cyclophophamid.

The following schedule is recommended: 1)Prednisolone 1 % should be added eight times a day starting 1 week before surgery. 2)1 mg/kg/ day of oral prednisone should be administered starting 1-2 week prior to the surgery. 3)Topical (Diclofenac 0.1%) and Systemic use of NSAIDs is considered in cases of CME.

Control of IOP  Proper control of the intraocular pressure is recommended 2 to 3 weeks prior to surgery.  Control is generally obtained by using Beta Blockers and topical or occasionally systemic Carbonic Anhydrase Inhibitors.

Preoperative Hypotony  Preoperative Hypotony in patients with uveitis can also be found and is frequently due to the: Formation of Cyclitic membranes, Ciliary Body dialysis, and Severe Inflammation causing severe decrease in Aqueous Production.  Preoperative Hypotony may causes Phthysis Bolbi after intra-ocular surgery.

Intra-Operative Considerations

Patient Preparation Good Pupillary Dilation must be achieved when possible to avoid manipulation of the iris during surgery.

Surgical Technique  Phacoemulsification is procedure of choice.  Clear Corneal Incision is preferred approach.  If an important Lens-Induced Inflammation was present in a prior contralateral surgery: Intra-Capsular Surgery (ICCE) may be used.

The surgery is certainly more difficult because: Presence of Iris Atrophy, Sclerosis of the Pupillary Sphincter, Posterior and Anterior Synechiae, Anterior Capsular Fibrosis & Sclerosis, Cyclitic Membranes, Hemorrhage from the Iris and Angle Neovascularization, Glaucoma and Hypotony.

The combination of Hyaluronic Acid and Condroitin Sulphate (Vis- coatR) is preferred. Viscoelastic Materials

 For further Mydriasis, Flexible Iris Retractors or meticulous Sphyncteratomy are utilized.  Many patients with uveitis have severe PS, and in these cases Synechiolysis is performed with an Iris Spatula.

 In cases of Uveitis with high tendency for Synechia Formation: Prophylactic Peripheral Iridectomy (PI) may be recommended.

Because of Anterior Capsular Fibrosis & Sclerosis Capsulorhexis is often difficult and frequently needs excision of capsule with scissor.

 In cases where there is an extensive Membrane Formation in the Anterior Vitreous: Anterior Vitrectomy after Posterior Central Capsulorhexis must be considered.

 If the Vitreous Cavity shows extensive Fibrosis and Exudate Formation: Transcleral Pars Plana Vitrectomy may be indicated.

Combined Cataract - Vitrectomy Techniques  In cases of Uveitis with Vitreitis refractory to medical treatment such as: Chronic Juvenile Rheumatoid Arthritis, and Pars Planitis. Pars Plana Vitrectomy combined with Lensectomy can be the procedure of choice.

 Surgery can exacerbate the underlying inflammatory process by the: Surgical Trauma itself, and by the Release of Lens Material. Very meticulous surgery, and Intensive cortical clean up is mandatory. The posterior surface of the anterior capsule must be vacuumed.

Intra-Ocular Lenses  Until recently, the existence of Chronic Uveitis has been regarded by most surgeons as a Relative Contraindication to IOL implantation.  The introduction of Phacoemulsification, Viscoelastic materials, highly sophisticated Instruments, and new IOL materials has reduced the number of complications in these patients.

 Anterior Chamber & Sulcus mplantation has always been Contraindicated.  Capsular Bag placement has been Controversial. Capsular Bag placement of IOL could reduce the possibility of mechanical irritation as compared with lenses designed for other locations. Capsular Bag versus Other Sites

IOLs Material  PMMA is the most commonly used intraocular lens material. It has proved to be inert and stable.

New technology applied to PMMA lenses has enabled the development of a new generation of Acrylic Foldable Lenses for small incision surgery. The intraocular behavior of this material is known and is perhaps the best of all foldable intraocular lenses at present.

Surface modified IOLs such as the Heparin Coated models have also been introduced. Heparin coated IOLs are recommended for patients with Uveitis as they decrease the number and severity of deposits on the surface of the IOL.

Limited information is available regarding foldable IOL implantation in patients with Chronic Uveitis. Some authors advocate the use of a Single Piece Acrylic Foldable Lenses in an attempt to prevent the activation of the complement which arises with polypropylene haptics.

Periocular injections of Triamcinolone are routinely used after Phacoemulsification procedures in patients with Uveitis.

In patients with only one functional eye, the surgeon may consider not implanting an IOL.

Postoperative Considerations

Post - Operative care should include the maintenance of prior medications required for the control of the disorder with gradual reduction.

Suggested Postoperative Medications 1.Topical Prednisolone 1%, eight times a day for the first week, to be gradually decreased over a period of months. 2.Topical Diclofenac, four times a day for 2 weeks. 3.Tropicamide 1 % four times a day for 4 weeks. 5.Oral Prednisone 1 mg/kg/ day for 2 weeks, tapering it down for another 2 weeks for a total of one month.

 The postsurgical inflammatory reaction can produce a series of complications such as: Increase in Intraocular Pressure (IOP), Decrease in Intraocular Pressure (Hypotony), Corneal Edema, Endothelial Damage, Secondary Cataracts, and Postoperative Macular Edema (CME).

Pre-Operative Glaucoma, NVI (Behcet disease, FHI), Use of topical, periocular and systemic steroids.  Persistent Uncontrolled Glaucoma will require filtration surgery with the use of Mitomycin C 0.02%. Glaucoma

Pupillary Membranes and Secondary Cataract Pupillary membranes after cataract surgery can be removed by: Nd:YAG Lasaer Capsulatomy, and occasionally Pars Plana Vitrectomy.

CME CME is the most serious post-operative complication in patients with chronic uveitis who undergo cataract extraction. This complication occurs in 50% of the cases. CME may be treated with topical & oral NSADEs, oral Acetazolamide, or Topical, Periocular, Intraocular injections, and Systemic Steroids.

 The visual prognosis of the patient with uveitis will depend on: I.The presence of Pre and Post-Surgical Inflammation, II.The status of Retina & Optic nerve, III.On the quality and efficiency of the Surgical procedure, and IV.On the treatment of complications, that is, Secondary Glaucoma. Prognosis

Tips and Pearls I.Uveitis should be inactive for at least 3 months preoperatively, II.Systemic & Topical Steroids should be used prophylactically for 1-2 week preoperatively and continued post operatively, III.Immunosuppressive drugs should be continued,

Tips and Pearls IV.Delicate Surgery, Maximum Mydriasis, and the use of Viscoelastic Material, V.Complete removal of Cortical Material, VI.An anterior vitrectomy can be performed should vitreous opacities be present at the time of surgery, VII.Posterior chamber Bag placement, One Pieces Acrylic Foldable Lenses, VIII.Minimal manipulation on Iris.