Phacoemulsification:
It is a modern cataract surgical technique, which is a sutureless and most popular method of extracapsular cataract extraction. It needs very small (about 3 mm) corneoscleral incision. In this technique Nucleus of the human crystalline lens will emulsified and aspirated by phacoemulsifier (a 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:
- Acute uveitis: Sudden symptomatic onset and disease lasts for about six weeks to three month
- Chronic uveitis: An insidious onset and asymptomatic, Persist longer than 3 months to even years.
Pathologically it has been classified into two categories:
- Suppurative Uveitis
- Non-Suppurative uveitis: Subdivided into Non-granulomatous and Granulomatous uveitis(Wood’s Classification)
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| Source: PACIFIC CATARACT AND LASER INSTITUTE |
Clinical Facts and Recommendations when Phacoemulsification is scheduled on Uveitic patients:
Things to remember:
- Never operate an angry eye (Unless phagocytic or Phacoanaphylactic).
- The 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
Clinical Facts and Recommendations when Phacoemulsification is scheduled on Uveitic patients:
Things to remember:
- Never operate an angry eye (Unless phagocytic or Phacoanaphylactic).
- The 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 the 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 a 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 the 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 anaesthesia 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.
