Medical and Surgical Pearls for Cataract Surgery in Uveitis Patients

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Corey Bond
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1 Medical and Surgical Pearls for Cataract Surgery in Uveitis Patients Kaiser Permanente Ophthalmology Symposium Anaheim, CA 9/12/15 Olivia L. Lee, MD Assistant Professor Doheny Eye Institute David Geffen School of Medicine University of California Los Angeles

2 Disclosures Allergan: C, S I do not have a financial interest in any of the products mentioned in this presentation Off-label use of FDA approved medications will be discussed

5 Cataract Formation in Uveitis Common complication in patients with uveitis, typically due to: Chronic inflammation Long term steroid usage Younger age than senile cataracts Incidence related to diagnosis: 83% in JRA 80% in Fuchs heterochromic iridocyclitis 50% in pars planitis 21% in HLA-B27 associated uveitis

6 Cataract Formation in Uveitis Management is complicated, given relevant sequelae of chronic inflammation: Mature or hypermature cataract Poor dilation Posterior synechiae Iris atrophy Pupillary membranes Band keratopathy

7 Indications for cataract surgery Phacoantigenic uveitis Visually significant cataract in quiet eye Impaired view of fundus Amblyopia

8 10 Pearls for Successful Uveitic Cataract Surgery

9 Pearl 1 Expect the unexpected and stay calm

10 Uveitic cataracts: associated complications Rubeosis Fibrotic capsule Zonular instability Glaucoma Vitreous opacities Cystoid Macular Edema Epiretinal membrane Band keratopathy Posterior synechiae Anterior synechiae Iridocorneal adhesions Pupillary membrane Iris atrophy

11 What to have on hand Trypan blue Needle and empty syringe Kuglen hook Iris hooks or Malyugin ring Retinal scissors and forceps MVR blade Capsular tension ring Anterior Vitrectomy Lens loop

13 Pearl 2 Wait for a period of documented quiescence before taking your patient to the OR

15 Pre-operative inflammatory control Achieve remission by any means At least 3 months of quiescence No anterior chamber cells Less than 1+ flare No retinitis No CME Infectious cause completely addressed Sometimes greater than 3 months is recommended If risk of amblyopia, less than 3 months

16 Pearl 3 Give perioperative steroids

17 Pre-surgical medical management Do not make drastic changes to regimen immediately prior to surgery Consider pre-treating NSAIDs for history of CME Treatment dose antivirals for viral uveitis High dose oral corticosteroids (1mg/kg/day) Stress dose IV steroids on the day of surgery

18 Typical peri-operative regimen Example: 70kg adult patient with non-infectious anterior uveitis Pre-op Continue any pre-op meds (topical, systemic) Topical NSAIDs: begin 4 days before Prednisone 70mg daily: begin 2 days before At time of surgery Intravenous Solumedrol 250mg Post-op Prednisone 70mg daily for first 2 days, reduce 10mg Q2 days until off Topical steroid (Prednisolone) Q2 hours, do not taper until quiet Topical NSAID and cycloplegia for several weeks Topical antibiotic as per usual

19 Typical peri-operative regimen Example: 70kg adult patient with non-infectious anterior uveitis Pre-op Continue any pre-op meds (topical, systemic) Topical NSAIDs: begin 4 days before Prednisone 70mg daily: begin 2 days before At time of surgery Intravenous Solumedrol 250mg Post-op Prednisone 70mg daily for first 2 days, reduce 10mg Q2 days until off Topical steroid (Prednisolone) Q2 hours, do not taper until quiet Topical NSAID and cycloplegia for several weeks Topical antibiotic as per usual

20 Pearl 4 Don t use topical anesthesia alone.

21 Anesthesia Avoid topical except in very straightforward cases Retrobulbar or peribulbar block if iris manipulation expected General anesthesia for children General anesthesia for combined cases

22 Pearl 5 Use the Healon cannula to perform synechiolysis, but be ready with a Kuglen hook

23 Video 1 insert video of synechiolysis techniques

24 Video 1 insert video of synechiolysis techniques

25 Pearl 6 Beware of pupillary membrane, even if you did not notice it on slit lamp exam

26 Video 2 insert video of Eleazar pupillary membrane

27 Pearl 7 Be prepared for a floppy iris. Don t be afraid of using hooks. Just a few or many.

28 Pupil Management Pupillary dilation difficult in uveitic eyes Presence of posterior synechiae Atrophy of iris sphincter Little to no response with pharmacologic dilation Methods Post. synechiolysis, excise pupillary membrane Viscomydriasis Iris hooks Malyugin ring Intracameral epinephrine Do not suture the iris for cosmesis

29 Video 3 insert video of iris hooks

31 Pearl 8 Beware of a fibrotic anterior capsule. Have many capsulorrhexis techniques in your armamentarium.

32 Capsulorrhexis Trypan blue often needed for visualization Elastic capsule in children Anterior capsular rim tears associated with higher inflammatory response Fibrosis of anterior capsule may need to be cut with scisssors or vitector

33 Video 4 insert video of capsullorhexis techniques

34 Pearl 9 Place a 3 piece monofocal IOL Leave the patient aphakic in some circumstances.

35 IOL implantation IOL or no IOL? With modern techniques and newer lenses, most patients receive IOLs If chronic inflammation is expected- leave aphakic

36 IOL implantation Choice of IOL Consider zonular instability Hydrophilic acryllic well tolerated Possible benefit of heparin coated IOL Prolene haptics activate complement Avoid silicone lens Avoid ACIOL

37 insert photo of subluxated IOL

38 Pearl 10 The end of the surgery is not the end of the story

39 Postoperative Medical Management Monitor more frequently than non-uveitic Typical post-op regimen: Continue immunosuppression Intense topical steroids Taper oral steroids according to exam Topical NSAIDs Pupillary dilation

40 Typical peri-operative regimen Example: 70kg adult patient with non-infectious anterior uveitis Pre-op Continue any pre-op meds (topical, systemic) Topical NSAIDs: begin 4 days before Prednisone 70mg daily: begin 2 days before At time of surgery Intravenous Solumedrol 250mg Post-op Prednisone 70mg daily for first 2 days, reduce 10mg Q2 days until off Topical steroid (Prednisolone) Q2 hours, do not taper until quiet Topical NSAID and cycloplegia for several weeks Topical antibiotic as per usual

41 Postoperative Medical Management If unable to control inflammation Regional steroid injection Intracameral TPA to dissolve fibrin Adjust systemic immunosuppression Explant IOL

42 Cataract Complications in Uveitis Yoeruek E, et al. Long-term visual acuity and its predictors after cataract surgery in patients with uveitis. Eur J Ophthal 2010;20 (4):

43 Manage post-op complications CME intravitreal steroid IOL precipitates/deposits YAG Cocoon IOL explant IOL PCO YAG capsulotomy Dislocated IOL suture fixation

44 Bonus Pearls Tips for specific cases 44

45 Specific Cases JRA Usually have exacerbation after surgery Immunosuppression generally used in these cases IOL implantation not contraindicated Ankylosing spondylitis Trendelenburg positioning Fuchs heterochromic iridocyclitis Expect bleeding and hyphema Scleritis Clear corneal incision Toxoplasmosis Increase rate of reactivation after cataract surgery Consider prophylactic treatment Behcets May benefit from longer duration of remission prior to surgery May benefit from limited vitrectomy

46 What about combined surgery? Minimize number of surgeries per eye Minimize surgical trauma/manipulation EDTA chelation of band K to improve view Planned posterior capsulotomy and AV in children PPV for vitreous opacification Surgical iridotomy prefered over laser

53 Insert photo of Julie Castle

54 Thank you for your attention

Cataract Testing. What a Patient undergoes prior to surgery

Cataract Testing. What a Patient undergoes prior to surgery Cataract Testing What a Patient undergoes prior to surgery FINANCIAL DISCLOSURE I have no financial interest or relationships to disclose What do most Technicians find to be the most mundane yet very important