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Facts about Phacoemulsification on Uveitic patients

Phacoemulsification:

It is a modern cataract surgical technique, which is sutureless and most popular method of extracapsular cataract extraction. It need very small (about 3 mm) corneoscleral incision. In this technique Nucleus of human crystalline lens will emulsified and aspirated by phacoemulsifier (machine that sends ultrasonic vibrations to a tiny probe), after aspirated of cloudy lens material, foldable Intra Ocular Lens will be used. 

Uveitis:

Uveitis is the inflammation of Uveal tissue (which consist of iris, ciliary body and choroid). Clinically it has been classified into two categories:
  1. Acute uveitis:Sudden symptomatic onset and disease lasts for about six weeks to three month
  2. Chronic uveitis:An insiduous onset and asymptomatic, Persist longer than 3 months to even years.

Pathologically it has been classified into two categories:

  1. Suppurative Uveitis
  2. Non-Suppurative uveitis:Subdivided into Non-granulomatous and Granulomatous uveitis(Wood's Classification)
uveitis
Source: PACIFIC CATARACT AND LASER INSTITUTE

Clinical Facts and Recommendations when Phacoemulsification is scheduled on Uveitic patients:

Never operate angry eye (Unless phacolytic or Phacoanaphylactic).
Eye must be quiet for 3 months at least except in previously mentioned situation should receive immediate surgery.
Prophylactic iridectomy is recommended to prevent presumed pupillary block from synechia.
IOL implantation

  • Heparin coated or acrylic IOL is used ( Bag implantation). 
  • one piece or 3 pieces is ok .
  • Avoid the plate- haptic IOL as it has risk of dropping and slipping into the vitreous after YAG laser capsulotomy ( if needed).
  • Avoid mutlifocal IOL as the pupil is not regular and there is high risk of decentration due to inflammation with intolerable image blurt and glare.
  • Avoid Silicon IOL as possible specially if there is retinal pathology with subsequent presumed retinal surgery. 

Meticulously removal of any cortex 

Avoid touching angry 😠 iris 

Consider IOL explanation ( if postoperative Endo or chronic persistent Uveitis ) 

Pre and post operative  frequent topical steroid  is highly recommended with gradual tapering 

Consider using topical NSAIDs for 2 months after the 1st postoperative week to prevent pseudophakic CME ( high risk) 

Look for PCO sooner 

  • Posterior capsular opacification (PCO) occurs earlier in uveitic eyes
  • Nd:YAG laser capsulotomy may need to be performed sooner after surgery in symptomatic patients 
  • The capsulotomy should be deferred if the uveitis is still active or if there is CME.

Anatomical challenges to be expected to face with proper managing 

  • Narrow pupil 
  • Floppy iris 
  • Severe synechia 
  • Weak zonules 
  • Bad view under the surgical microscope ( bad cornea or cyclitic membrane)
Combined Phaco-trab is an option in if patient is strong steroid responder and can’t tolerate long term steroids therapy 

Juvenile cataract 

  • Relatively contraindicated to IOL implant ( debatable issue) in Juvenile idiopathic arthritis in young patient, due to persistent chronic postoperative Uveitis with cyclitic membrane formation with subsequent phthisis bulbi
  • Young children are the only uveitis patients who are often left aphakic after cataract removal to allow development of the eye and the visual system before an IOL is implanted, which usually takes place when the child reaches school age. 
  • Until then, any refractive error is corrected with ultra-soft extended-wear contact lenses (or, in bilateral cases, with aphakic spectacles)
  • When it’s time for an IOL, primary posterior capsulotomy should be performed when the IOL is implanted. PCO is common in young children, and a secondary Nd:YAG capsulotomy would expose them to the risks of general anesthesia again ( if not cooperative)
  • Some surgeons prefer to use a 3 pieces  IOL in this situation, leaving the haptics in the capsular bag and capturing the optic posterior to the capsular opening.

About the Author

Dr. Reda Gomah, Consultant ophthalmologist , Egypt


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