Challenges of cataract surgery in uveitis patients

Cataracts are a common complication of intraocular inflammation and unless they are removed with care vision can be compromised postoperatively by chronic inflammation, macular oedema, glaucoma or posterior capsular opacity. In the vast majority of patients excellent results can be achieved by meticulous surgical technique and attention to increased immunosupression. The cause of the uveitis is unimportant but patients with anterior or panuveitis are more likely to have problems because of miotic pupils and synechiae. Post operative complications result from damage to the blood-aqueous barrier and it is essential that iris trauma in particular is minimised by careful surgical technique: factors which are of subclinical importance in normal eyes become clinically important in these compromised eyes. Surgery should be performed when the eye is as quiet as possible, this implies no cells in the anterior chamber although chronic flare may be present from long term blood aqueous barrier damage. Some surgeons use increased immunosuppression prior to surgery. We found a 2 week course of systemic steroids was preferable to IV methyl prednisone at surgery but the results were not greatly different and I have recently changed to using an intravitreal injection of triamcinalone at surgery which produces very quiet eyes. The incision should be clear corneal avoiding blood vessels and vascular leakage. I use a viscoelastic soft shell technique to maintain the AC and protect the iris and cornea. Posterior synechiae are divided. I like to segment cyclitic fibrosis around the pupil, trying to tear this off the pupil margin can result in iris trauma. I use Gill's scissors for forward cutting and vitreoretinal guillotine scissors to segment under the incision, this allows a full 360 degree segmentation to be performed. The purpose is to segment the cyclitic tissue and avoid cutting into the iris itself which is unnecessary. Multiple small segmentations are made and the pupil is then gently stretched using two Hirschman hooks. This is done with care to avoid tearing the iris. Pupils can always be dilated to 4–5mm and maintained with Viscocoat or Healon 5 for capsulorhexis. I find this is enough and iris hooks are never necessary as these carry the risk of over dilating the pupil and tearing the iris. It is important to have ample viscoelastic available. Vision Blue can be used if necessary without increasing postoperative inflammation. The nucleus is removed using a stop and chop technique, most uveitic nuclei are relatively gelatinous and easily removed. My preferred IOL is an Acrysof, I have had no significant foreign body response to this and the PCO rate is of course very low. Bag placement is absolutely essential. If the rhexis is small I make a small relieving incision after IOL insertion to prevent later capsular phimosis, viscoelastic is removed, the AC reformed and the incision checked. 4mg of Triamcinalone is then given intravitreally.