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Uveitis patients require more attention before, during and after surgery
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 Richard L. Lindstrom |
The presence of uveitis has a significant impact on the preparation for, performance of and outcomes of all intraocular surgical procedures. I am a believer in the Steve Foster-taught mantra that for any elective anterior segment intraocular surgical procedure such as phacoemulsification; IOL implantation, removal or exchange; glaucoma tube or trabeculectomy; or keratoplasty, “uveitis remission is the mission” prior to surgery.
Remission to me is absence of keratic precipitates, cells and significant injection, especially ciliary flush. I have personally found that in many patients with chronic uveitis, total elimination of flare is often an impossible goal to achieve. Many patients with chronic recurrent uveitis have permanent damage to the tight junctions in the endothelium of their blood vessels, and some leakage of protein into the anterior chamber is always present.
However, aggressive therapy to eliminate any keratic precipitates, cells or ciliary flush is a realistic goal in these patients. Actually, this is my goal for any uveitis patient, whether presurgical or not, but it is especially critical in the patient whose eye is about to be entered surgically. In some cases this will require the use of therapy as aggressive as systemic antimetabolites or steroids.
Many patients have associated ocular surface disease, and this should be treated preoperatively. I always start topical steroids and usually an NSAID at least a week before surgery and also use both drops more frequently and longer after surgery. My indication to stop drops is the same as my indication to perform surgery: no keratic precipitates, no cells, no ciliary flush and no other complication such as cystoid macular edema.
In sicker eyes, I do not hesitate to inject subconjunctival steroid, watching carefully for steroid-induced glaucoma. Some utilize intraocular triamcinolone as a routine. In addition, many of these patients have a damaged corneal endothelium with reduced healing reserve. I perform specular microscopy and pachymetry preoperatively and utilize a viscoelastic such as Viscoat (chondroitin sulfate, sodium hyaluronate, Alcon) and an endocapsular nucleus removal with extra care to avoid endothelial trauma.
It is not uncommon to see a fibrin plug on the first postoperative day in the uveitis patient, especially when pupil stretching, removal of a pupillary margin fibrotic membrane, or use of a pupil expander or hooks is required. I have found that the addition of 1 mL of 1:1000 heparan sulfate along with my usual 0.5 mL of methylparaben-free epinephrine is helpful in reducing this complication.
Postoperative pressure spike is a concern. A topical beta-blocker and, in high-risk cases, a short course of acetazolamide may be appropriate, and in some patients a combined procedure with a tube shunt or mitomycin trabeculectomy is indicated.
In the current system of reimbursement in the U.S., the surgeon is expected to accept the significant extra work of these cases without additional compensation, as the “easy cases” are supposed to balance them out. For this reason, as well as the special skills required to obtain the best outcome, prudent comprehensive ophthalmologists should consider referring these patients to a consultative ophthalmologist when surgery is required.