Cataract surgery achieves qualified success in uveitic eyes

A square-edged, foldable hydrophobic acrylic IOL produced less posterior capsule opacification than a rigid PMMA lens, a study author says.

Jagat Ram

Phacoemulsification and IOL implantation yielded promising outcomes in most patients with cataract and concomitant uveitis, according to a study.

However, treatment resulted in complications such as cystoid macular edema, posterior capsule opacification, glaucoma and recurrence of uveitis. Outcomes and complications depended on the type of IOL used: square-edged, foldable hydrophobic acrylic or rigid PMMA.

IOL fixation in the capsular bag and duration of inflammatory quiescence before surgery significantly influence outcomes and complication rates, Jagat Ram, MS, lead author of the study, told Ocular Surgery News.

“In patients of uveitis, phacoemulsification with capsular bag implantation of a rigid or foldable posterior chamber IOL is a safe procedure and leads to significant improvement in visual outcome, provided the inflammation is controlled for at least 3 months before cataract surgery,” Dr. Ram said.

Patients and parameters

The retrospective study, published in the Journal of Cataract and Refractive Surgery, included 108 eyes of 81 patients (mean age: 42.3 years) with cataract and uveitis types other than Fuchs’ heterochromic. Patients who completed at least 12 months of postoperative follow-up were included. Patients with Fuchs’ heterochromic uveitis with cataract, traumatic cataract and associated diabetes mellitus were excluded.

Anterior uveitis was identified in 39 patients, posterior uveitis in 13 patients, intermediate uveitis in three patients and panuveitis in 26 patients. Uveitis was present for a mean 37.03 months before surgery. The mean preoperative interval of inflammatory quiescence was 12.59 months.

“Proper selection of patients of cataract with uveitis is very important for optimal surgical and visual outcomes,” Dr. Ram said. “The most important factor is control of uveitis. All these patients with uveitis with visually significant cataract were quiet for at least 3 months before surgery.”

A well-centered hydrophobic acrylic IOL in the capsular bag of a 45-year-old male patient with uveitis 14 months after surgery. The eye achieved Snellen best corrected visual acuity 20/20.

PMMA IOL implanted in the eye of a 35-year-old female with uveitis. Four years after surgery, the visual axis is clear, with peripheral lens epithelial cell accumulation after Nd:YAG laser capsulotomy. Irido-capsular adhesion involves a 300° arc at the periphery of the lens optic. The eye still achieved Snellen best corrected visual acuity of 20/40. Images: Ram J

Mean preoperative logMAR corrected distance visual acuity was 1.08 (Snellen equivalent: 20/240).

All patients underwent cataract extraction; 95 eyes received hydrophobic acrylic IOLs and 13 eyes received PMMA IOLs implanted in the capsular bag.

The mean follow-up interval was 21.95 months.

Posterior capsule rupture occurred in one eye during irrigation and aspiration of cortical material; residual lens material was identified in another eye.

Outcomes and observations

Study results showed that mean postoperative logMAR corrected distance visual acuity improved to 0.42 (Snellen equivalent: 20/50 or better); the change was statistically significant (P < .001). Data showed that 77 eyes attained logMAR corrected distance visual acuity of 0 to 0.3 (Snellen equivalent: 20/20 to 20/40).

Six of 13 eyes (46.15%) implanted with rigid PMMA IOLs and 25 of 95 eyes (26.32%) implanted with square-edged, foldable hydrophobic acrylic IOLs developed PCO requiring Nd:YAG capsulotomy. However, the difference was statistically insignificant because of the disproportionately smaller number of eyes implanted with PMMA IOLs, Dr. Ram said.

“IOL optic design is very critical, and we found that posterior capsule opacification in eyes implanted with square-edge, foldable IOLs was almost half compared to those implanted with conventional PMMA IOLs,” he said. “Visual outcome was faster in patients implanted with a square-edge, foldable IOL. However, after 8 weeks, both foldable and PMMA IOL groups had similar visual outcomes.”

The cellular reaction subsided more slowly in eyes that underwent Nd:YAG capsulotomy for visually significant PCO: 2 weeks in 12 eyes, 3 to 4 weeks in 18 eyes and 5 weeks in two eyes. Pharmacologic treatment involved topical betamethasone 0.1% or prednisolone 1% six to eight times for 4 to 6 weeks, along with atropine 1% three times in the same period, Dr. Ram said.

Other complications included posterior synechiae (27 eyes), cystoid macular edema (23 eyes), recurrent uveitis (six eyes) and epiretinal membrane formation, glaucoma and iris bombe (five eyes each), the authors reported.

“Occurrence of complications such as [cystoid macular edema] and glaucoma was not different in eyes implanted with PMMA or foldable IOLs,” Dr. Ram said.

In addition, in-the-bag IOL implantation minimized the recurrence of uveitis.

“We observed that implanting an IOL in the bag is safe and helps to reduce recurrence of uveitis,” Dr. Ram said. “However, implanting an IOL in the sulcus may increase recurrences of uveitis.” – by Matt Hasson

Reference:

• Ram J, Gupta A, Kumar S, Kaushik S, Gupta N, Severia S. Phacoemulsification with intraocular lens implantation in patients with uveitis. J Cataract Refract Surg. 2010;36(8):1283-1288.

• Jagat Ram, MS, can be reached at Advanced Eye Centre Post Graduate Institute of Medical Education and Research, Chandigarh160012, India; e-mail: drjagatram@yahoo.com.