- Email: [email protected]
Phacoemulsification cataract extraction and intraocular lens implantation in patients with uveitis
J CATARACT REFRACT SURG - VOL 33, FEBRUARY 2007
Phacoemulsification cataract extraction and intraocular lens implantation in patients with uveitis Tatsushi Kawaguchi, MD, Manabu Mochizuki, MD, Kazunori Miyata, MD, Norio Miyata, MD
PURPOSE: To analyze the outcomes of phacoemulsification cataract extraction and intraocular lens (IOL) implantation in patients with uveitis. SETTING: Miyata Eye Hospital, Miyakonojo, Miyazaki, Japan. METHODS: The records of 95 patients (131 eyes) with uveitis who had phacoemulsification cataract extraction and IOL implantation between 1990 and 2001 were retrospectively examined. The postoperative visual outcomes and complications were analyzed. RESULTS: The mean age of the 36 men and 59 women was 61.7 years (range 30 to 87 years) At the final follow-up examination, 111 eyes (84.7%) had improved visual acuity and 97 eyes (74.0%) had a final visual acuity of 0.5 or better. Patients with Behc¸et’s disease had significantly worse visual outcomes than patients with other clinical etiologies of uveitis such as human T-lymphotropic virus type 1 uveitis and Vogt–Koyanagi–Harada disease. In 17 eyes (13.0%), relapse of intraocular inflammation occurred within 6 months after surgery; the rate of relapse was highest in patients with Behc¸et’s disease (35.2%). Posterior synechias occurred in 8 eyes (6.1%), pupillary capture in 1 eye (0.8%), intraocular pressure elevation in 11 eyes (8.4%), and cystoid macula edema in 8 eyes (6.1%). In 31 eyes (23.7%), posterior capsule opacification required neodymium:YAG capsulotomy. CONCLUSIONS: The outcomes of phacoemulsification cataract extraction and IOL implantation in patients with uveitis were satisfactory. Patients with Behc¸et’s disease related to intraocular inflammation, however, appeared to have a higher risk for complications and therefore worse outcomes than patients with other clinical etiologies of uveitis. J Cataract Refract Surg 2007; 33:305–309 Q 2007 ASCRS and ESCRS
Cataract formation is one of the most common causes of vision loss in patients with uveitis. It is primarily related to intraocular inflammation or secondary to the administration of corticosteroids. Cataract surgery and intraocular lens (IOL) implantation in eyes with uveitis are
Accepted for publication October 25, 2006. From the Department of Ophthalmology & Visual Science (Kawaguchi, Mochizuki), Tokyo Medical and Dental University Graduate School, Tokyo, and the Meiwakai Medical Foundation (K. Miyata, N. Miyata), Miyata Eye Hospital, Miyakonojo, Miyazaki, Japan. No author has a financial or proprietary interest in any method or material mentioned. Corresponding author: Tatsushi Kawaguchi, MD, Department of Ophthalmology & Visual Science, Tokyo Medical and Dental University Graduate School, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan. E-mail: [email protected]. Q 2007 ASCRS and ESCRS Published by Elsevier Inc.
controversial procedures.1–4 Although newer surgical techniques and IOL designs have improved the outcomes of cataract surgery in patients with intraocular inflammation, management of postoperative inflammation and ocular complications remains difficult. Phacoemulsification with simultaneous IOL implantation is now the standard method of cataract surgery for most patients with uveitis5–14; however, the outcomes have been evaluated in small groups of patients only. In this study, we evaluated the outcomes of phacoemulsification cataract extraction and IOL implantation in a large population of patients with uveitis.
PATIENTS AND METHODS The clinical records of 95 patients (131 eyes) with uveitis who had phacoemulsification cataract extraction and IOL implantation were retrospectively reviewed. Surgery was performed at 0886-3350/07/$-see front matter doi:10.1016/j.jcrs.2006.10.038
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Miyata Eye Hospital, Miyakonojo, Miyazaki, Japan, between July 1990 and April 2001. Before surgery, a complete uveitis-oriented history and ophthalmic and systemic examinations were performed in all patients. Laboratory assays included a full blood cell count; assays for renal and liver function, serum angiotensin-converting enzyme, serum lysozyme, rheumatoid factor, antinuclear antibody, Treponema pallidum hemagglutination, Toxoplasma gondii antibody, and human T-lymphotropic virus type 1 (HTLV-1) antibody; chest X-ray; and a tuberculosis skin test. Data collected include sex, age at surgery, cause of uveitis, preoperative findings, frequency and duration of quiescent periods of intraocular inflammation before surgery, length of follow-up, and presence of surgical complications and postoperative complications. Postoperative complications included a relapse of inflammation within 6 months after surgery, posterior synechias, pupillary capture of the IOL, intraocular pressure (IOP) elevation (by applanation tonometry) over 21 mm Hg within 1 month after surgery that required treatment, posterior capsule opacification (PCO) that required neodymium:YAG (Nd:YAG) laser capsulotomy, and postoperative cystoid macular edema (CME). Best corrected visual acuity (BCVA) was recorded at the immediate preoperative visit and postoperative follow-up examinations. The degree of the anterior chamber cell was graded according to the method of Hogan et al.15 Surgery was performed by 1 of 2 surgeons (K.M., N.M.). Every 30 minutes, starting 2 hours before surgery, patients were given eyedrops containing diclofenac sodium 0.1% (Dichlod), tropicamide 0.5%–phenylephrine hydrochloride 0.5% (Mydrin-P), and phenylephrine hydrochloride 5% (Neosynesin). After retrobulbar or eyedrop anesthesia was administered, a 4.1 to 6.0 mm scleral tunnel or a 3.0 mm corneal incision was created. Small pupils were managed by synechiolysis; the iris was stretched with iris hooks or iris retractors. Multiple sphincterotomies were performed as required. After continuous curvilinear capsulorhexis (CCC) was complete, the lens nucleus was removed by phacoemulsification and the cortical material by mechanical irrigation/aspiration. With the aid of an ophthalmic viscosurgical device (OVD), an IOL was implanted in the capsular bag and the incision was closed. Upon the completion of surgery, a subconjunctival injection of 2 mg betamethasone was administered. Postoperative care included topical ofloxacin 0.3% (Tarivid) 4 times daily, topical betamethasone 0.1% (Rinderon) between 4 and 8 times daily according to the intensity of the anterior chamber reaction, diclofenac sodium 0.1% (Dichlod) 4 times daily or bromfenac sodium 0.1% (Bronuck) 2 times daily, and tropicamide 0.4% (Mydrin-M) once daily for 2 to 3 months. Patients receiving systemic immunosuppressants before cataract surgery maintained their dosages at therapeutic levels. Patients were seen on the first, second, and third postoperative days; weekly for 2 weeks; monthly for 3 months; and every 3 months thereafter. At each postoperative visit, BCVA, IOP by applanation tonometry, anterior chamber reaction, vitreous haze, and retinal lesions were evaluated. If severe inflammatory episodes occurred, patients were given subconjunctival injections of betamethasone (2 mg) or sub-Tenon’s injections of triamcinolone (20 mg) and, if necessary, systemic administration of corticosteroids. Patients with postoperative observation periods shorter than 12 months were excluded from the study. Visual acuity was measured using a decimal chart and calculated geometrically. Differences in mean preoperative visual acuity between clinical etiologies were tested for statistical significance using the Kruskal-Wallis test, and differences in mean postoperative visual acuity were examined using the Mann-Whitney U test.
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Differences in relapse of inflammation and PCO with Nd:YAG capsulotomy were analyzed using the chi-square test for independence. A P value less than 0.05 was considered statistically significant. RESULTS
The mean age of the 36 men and 59 women was 61.7 years (range 30 to 87 years). The mean follow-up was 57 months (range 12 to 168 months). There were no significant intraoperative complications. Table 1 shows the clinical etiologies of uveitis. The main diagnosis was idiopathic uveitis followed Behc¸et’s disease, Vogt–Koyanagi–Harada (VKH) disease, and HTLV-1 uveitis. The mean period of quiescence of inflammation before surgery was 24.3 months (range 0 to 172 months). Of 9 eyes with a quiescent period of fewer than 3 months, 3 had relapse of inflammation within 6 months after surgery. Two eyes were mildly inflamed at the time of surgery. One of them was in a patient with Behc¸et’s disease who had a relapse of inflammation 4 months postoperatively and a final visual acuity of 0.01 because of optic nerve atrophy and macular degeneration. The other eye was in a patient with idiopathic uveitis who had the complication of bullous keratopathy secondary to IOP elevation and a final visual acuity of counting fingers. Figure 1 shows a comparison of preoperative and postoperative BCVAs. The mean preoperative visual acuity was 0.09 (range hand motions to 0.8). The mean visual acuity was 0.59 (range 0 to 1.5) 12 months after surgery and 0.51 (range 0 to 1.5) at the last medical visit. At the last visit, 111 eyes (84.7%) had an improvement of 0.3 or more logMAR units. A final visual acuity of 0.5 or better was achieved in 97 eyes (74.0%) and of 0.7 or better, in 87 eyes (66.4%). Visual acuity decreased in 5 eyes (3.8%) because of optic nerve atrophy (3 eyes), macular degeneration Table 1. Clinical etiologies of uveitis.
Clinical Etiology HTLV-1 uveitis Behc¸et’s disease Vogt–Koyanagi–Harada disease Sarcoidosis Other* Idiopathic uveitis
Number of Patients (%)
Number of Eyes (%)
14 (14.7) 11 (11.6) 9 (9.5)
16 (12.2) 17 (13.0) 16 (12.2)
6 (6.3) 16 (16.8) 39 (41.1)
11 (8.4) 20 (15.3) 51 (38.9)
HTLV-1 uveitis Z human T-cell lymphotropic virus type-1-associated uveitis *Ocular toxoplasmosis (4 eyes), herpetic iridocyclitis (4 eyes), leprosy (3 eyes), ulcerative colitis (3 eyes), sympathetic ophthalmia (2 eyes), toxocariasis (2 eyes), uveal effusion (2 eyes)
J CATARACT REFRACT SURG - VOL 33, FEBRUARY 2007
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Table 2. Best corrected visual acuity before and after surgery.
Mean Visual Acuity Clinical Etiology HTLV-1 uveitis Behc¸et’s disease Vogt–Koyanagi–Harada disease Sarcoidosis Other Idiopathic uveitis Total
Preoperative
12 Months
Last Visit
Mean Follow-up G SD (Mo)
0.08 0.07 0.18 0.21 0.04 0.08 0.09
0.86 0.24* 0.93* 0.69 0.42 0.55 0.59
0.64 0.19 0.89 0.71 0.34 0.54 0.51
40.4 G 22.8 72.5 G 22.9 57.8 G 16.0 40.0 G 28.1 51.3 G 23.1 62.7 G 37.7 57.0 G 0.8
HTLV-1 uveitis Z human T-cell lymphotropic virus type-1-associated uveitis *P!.05 (Mann-Whitney U test) between HTLV-1 and Behc¸et’s disease groups and between Vogt-Koyanagi-Harada disease and Behc¸et’s disease groups
(1 eye), and bullous keratopathy secondary to glaucoma (1 eye). Table 2 shows the mean visual acuity before and after cataract surgery by clinical etiology; there was no significant difference in preoperative mean visual acuity between clinical etiologies. Twelve months after surgery, the mean visual acuity was 0.93 in eyes with VKH disease, 0.86 in eyes with HTLV-1 uveitis, 0.69 in eyes with sarcoidosis, 0.55 in eyes idiopathic uveitis, and 0.24 in eyes Behc¸et’s disease. At 12 months, there was a significant difference between patients with Behc¸et’s disease and patients with VKH disease (P Z.01) and between patients with Behc¸et’s disease and patients with HTLV-1 uveitis (P Z .04). But there was no difference between patients with VKH disease and patients with sarcoidosis. Relapse of inflammation within 6 months after surgery occurred in 17 eyes (13.0%). The mean visual acuity in these eyes was 0.10 preoperatively and 0.52 12 months after surgery. The mean visual acuity in the other eyes was
0.09 before surgery and 0.61 12 months after surgery. There was no difference between the 2 groups before or after surgery. Table 3 shows the rate of relapse of inflammation within 6 months after surgery by clinical etiology. The highest percentage of relapse occurred in patients with Behc¸et’s disease. There was a significant difference in relapse of inflammation between clinical etiologies (P Z.04). Forty-seven eyes had postoperative complications (35.9%) (Table 4). The most common complication was PCO requiring Nd:YAG laser posterior capsulotomy. Of the 8 eyes that developed posterior synechias after surgery, 7 had posterior synechias before surgery. All 7 eyes had single-handed synechiolysis with an iris hook; 5 required sphincterotomy to dilate the pupil, and 2 required iris retractors to stretch the pupil. Eleven eyes had IOP elevation after surgery; in 1, the inflammation was quiescent for only 1 month preoperatively and the eye required filtration surgery. Posterior capsule opacification after surgery occurred significantly less frequently in patients with an acrylic IOL than in patients with IOLs of other materials (P Z .001) (Table 5).
Visual acuity at the last visit
DISCUSSION 1.0
Cataract formation is a major cause of vision loss in patients with uveitis. Successful surgical treatment is essential for good visual rehabilitation and adequate assessment of
0.1
Table 3. Relapse of intraocular inflammation after surgery.
Clinical Etiology
0.01 n.d m.m m.m n.d
0.01
0.1
1.0
Preoperative visual acuity Figure 1. Visual prognosis in patients who had phacoemulsification and IOL implantation.
Behc¸et’s disease Vogt–Koyanagi–Harada disease Sarcoidosis HTLV-1 uveitis Other Idiopathic uveitis
Number of Relapse Eyes/Total (%) 6/17 4/16 2/11 1/16 0/20 4/51
(35.2) (25.0) (18.2) (6.3) (0) (7.8)
HTLV-1 uveitis Z human T-cell lymphotropic virus type-1-associated uveitis
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PHACOEMULSIFICATION AND IOL IMPLANTATION IN PATIENTS WITH UVEITIS
Table 4. Postoperative complications.
Complications
Number of Eyes (%)
Posterior synechias Pupillary capture Intraocular pressure elevation Posterior capsule opacification Cystoid macular edema
8 1 11 31 8
(6.1) (0.8) (8.4) (23.7) (6.1)
Table 5. Posterior capsule opacification and IOL materials.
IOL Material PMMA Acrylic Silicone
Number of Surgeries 34 93 4
Number of PCO (%) 15 14 2
(44.1) (15.1) (50.0)
PMMA Z poly(methyl methacrylate)
the posterior segment. Previously, cataract surgery in eyes with intraocular inflammation was considered a high-risk procedure or a contraindication because of the high number of postoperative complications such as severe inflammatory reaction, IOP elevation, or glaucoma. These complications can lead to poor visual outcomes. Intracapsular cataract extraction, a surgical method in which the cortical material is completely removed within the capsular bag, was the preferred method because it was thought to reduce the risk for postoperative inflammatory response.1,2 New technologies, including phacoemulsification and aspiration equipment, high-quality OVDs, and foldable IOLs, have been introduced.16–18 Safer surgical techniques have also been developed; these include CCC, the divideand-conquer phaco method, and in-the-bag IOL implantation. As a result, phacoemulsification and IOL implantation are now the most common cataract surgery procedures in patients with uveitis. Ninety-five patients (131 eyes) with uveitis had phacoemulsification cataract extraction and IOL implantation at the Miyata Eye Hospital over the past 10 years. To our knowledge, this is one of the largest reported cohorts to have surgery by a limited number of surgeons. Among defined etiologies, HTLV-1 uveitis (14 patients, 14.7%) was the leading cause of uveitis at the hospital. This high number of patients with HTLV-1 uveitis is explained by the high incidence of HTLV-1 in the endemic area of Miyata Eye Hospital.19–21 The overall visual prognosis was favorable in 84.7% of eyes (111 of 131); acuity improved by 0.3 or more logMAR units, and 74.0% of eyes attained a final visual acuity of 0.5 or better. These results are comparable to those in other reports of phacoemulsification and IOL implantation in uveitic eyes.8,10 In this and other studies,7,9,22 patients with Behc¸et’s disease had a significantly worse visual
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outcome than patients with other etiologies of uveitis such as HTLV-1 uveitis and VKH disease. The main factors limiting postoperative visual acuity in Behc¸et’s disease were optic atrophy and macular degeneration caused by preoperative and postoperative inflammatory episodes. In our study, 17 patients (13.0%) had at least 1 episode of intraocular inflammation within 6 months after surgery. Most achieved good visual outcomes because of prompt treatment. Patients with no quiescence of inflammation before surgery, however, had a poor prognosis. These findings suggest the importance of good control of intraocular inflammation at the time of surgery. In addition, patients with Behc¸et’s disease appeared to have a significantly worse rate of relapse than other patients. Eight eyes (6.1%) with no evidence of preoperative CME developed it postoperatively. It is unclear why the rate of postoperative CME was lower in the present study than in previous studies.8,14 Fluorescein angiography or optical coherence tomography was not always used to diagnose CME in our study, and this might have affected the differences in detection. The frequency of PCO in our study was 23.7%, lower than the rate of PCO in other studies. Estafanous et al.8 report a PCO rate requiring Nd:YAG capsulotomy of 31%, and Okinami10 reports PCO in 33% of eyes. The length of time between follow-up periods does not explain the lower rate because the follow-up was longer in the present study than in the other studies. Our results are similar to the results in eyes with senile cataract.23 Meticulous surgical techniques and removal of cortical materials, in addition to polishing the posterior capsule, might have contributed to the lower rate of PCO. In the present study, PCO occurred less frequently with acrylic IOLs than with IOLs of other materials. Rauz et al.16 report that IOL material is not related to PCO in uveitic eyes. Several factors related to PCO, such as optic material and shape and loop design, have been reported. Considering the inflammatory reaction in uveitic eyes, it might be difficult to explain the relationship between PCO and IOL materials. We conclude that phacoemulsification cataract extraction with IOL implantation in patients with uveitis is well tolerated using advanced techniques and modern surgical devices. Patients with Behc¸et’s disease, however, appear to have a higher risk for complications and therefore worse outcomes. It is important to choose cases cautiously, especially in Behc¸et’s disease, and carefully control inflammation before and after surgery.
REFERENCES 1. Mimura Y, Matsumoto K, Mizuno K. [Surgery of complicated cataract in Behc¸et’s and Harada’s disease]. [Japanese] Rinsho Ganka 1980; 34:1405–1414
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2. Foster CS, Fong LP, Singh G. Cataract surgery and intraocular lens implantation in patient with uveitis. Ophthalmology 1989; 96:281–287; discussion by HJ Kaplan, 287–288 3. Okinami S, Sunakawa M, Arai K, Nihira M. [Surgical outcome of complicated cataract in Behc¸et’s disease]. [Japanese] Rinsho Ganka 1990; 44: 943–946 4. Okinami S, Iwasaki Y, Matsumura M. [Intraocular lens implantation in eyes with uveitis]. [Japanese] Rinsho Ganka 1991; 45:81–84 5. Kanellopoulos AJ, Weintraub J, Rahn E. Phacoemulsification and silicone foldable intraocular lens implantation in a patient with chronic sarcoid uveitis. J Cataract Refract Surg 1995; 21:364–365 6. Monden Y, Arima K, Ikeda E, et al. [Current status of intraocular lens implantation in uveitic eyes in Japan]. [Japanese] Rinsho Ganka 1998; 52:1160–1163 7. Hiraoka M, Fujino Y. [Cataract surgery and intraocular lens implantation in patients with Behc¸et’s disease]. [Japanese] Nippon Ganka Gakkai Zasshi 1999; 103:119–123 8. Estafanous MFG, Lowder CY, Meisler DM, Chauhan R. Phacoemulsification cataract extraction and posterior chamber lens implantation in patients with uveitis. Am J Ophthalmol 2001; 131:620–625 9. Ogasawara K, Takazawa A, Goto M, et al. [Phacoemulsification-aspiration with intraocular lens implantation in patients of Behc¸et’s disease]. [Japanese] Rinsho Ganka 2001; 55:571–574 10. Okinami S. [Surgical treatments for complications of uveitis]. [Japanese] Nippon Ganka Kiyo 2001; 52:361–376 11. Ram J, Kaushik S, Brar GS, et al. Phacoemulsification in patients with Fuchs’ heterochromic uveitis. J Cataract Refract Surg 2002; 28:1372– 1378 12. Alio´ JL, Chipont E, BenEzra D, Fakhry MA. Comparative performance of intraocular lenses in eyes with cataract and uveitis; the International Ocular Inflammation Society Study Group of Uveitic Cataract Surgery. J Cataract Refract Surg 2002; 28:2096–2108
13. Ganesh SK, Padmaja MS, Babu K, Biswas J. Cataract surgery in patients with Vogt-Koyanagi-Harada syndrome. J Cataract Refract Surg 2004; 30:95–100 14. Ganesh SK, Babu K, Biswas J. Phacoemulsification with intraocular lens implantation in cases of pars planitis. J Cataract Refract Surg 2004; 30:2072–2076 15. Hogan MJ, Kimura SJ, Thygeson P. Signs and symptoms of uveitis. I: anterior uveitis. Am J Ophthalmol 1959; 47(5, pt 2):155–170 16. Rauz S, Stavrou P, Murray PI. Evaluation of foldable intraocular lens in patients with uveitis. Ophthalmology 2000; 107:909–919 17. Abela-Formanek C, Amon M, Schauersberger J, et al. Results of hydrophilic acrylic, hydrophobic acrylic, and silicone intraocular lenses in uveitic eyes with cataract; comparison to a control group. J Cataract Refract Surg 2002; 28:1141–1152 18. Abela-Formanek C, Amon M, Schild G, et al. Inflammation after implantation of hydrophilic acrylic, hydrophobic acrylic, or silicone intraocular lenses in eyes with cataract and uveitis; comparison to a control group. J Cataract Refract Surg 2002; 28:1153–1159 19. Mochizuki M, Yamaguchi K, Takatsuki K, et al. HTLV-1 and uveitis [letter]. Lancet 1992; 339:1110 20. Mochizuki M, Watanabe T, Yamaguchi K, et al. Uveitis associated with human T-cell lymphotropic virus type I. Am J Ophthalmol 1992; 114:123–129 21. Yoshimura K, Shimada N, Sirao M, et al. [Uveitis in human T-lymphotropic virus type I (HTLV-1) carriers. 2. An analysis of clinical features]. [Japanese] Nippon Ganka Gakkai Zasshi 1993; 97:733– 740 22. Kadayifc¸ilar S, Gedik xS , Eldem B, _Irkec¸ M. Cataract surgery in patients with Behc¸et’s disease. J Cataract Refract Surg 2002; 28:316–320 23. Ando H, Ando N, Oshika T. Cumulative probability of neodymium:YAG laser posterior capsulotomy after phacoemulsification. J Cataract Refract Surg 2003; 29:2148–2154
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Phacoemulsification cataract extraction and intraocular lens implantation in patients with uveitis Tatsushi Kawaguchi, MD, Manabu Mochizuki, MD, Kazunori Miyata, MD, Norio Miyata, MD
PURPOSE: To analyze the outcomes of phacoemulsification cataract extraction and intraocular lens (IOL) implantation in patients with uveitis. SETTING: Miyata Eye Hospital, Miyakonojo, Miyazaki, Japan. METHODS: The records of 95 patients (131 eyes) with uveitis who had phacoemulsification cataract extraction and IOL implantation between 1990 and 2001 were retrospectively examined. The postoperative visual outcomes and complications were analyzed. RESULTS: The mean age of the 36 men and 59 women was 61.7 years (range 30 to 87 years) At the final follow-up examination, 111 eyes (84.7%) had improved visual acuity and 97 eyes (74.0%) had a final visual acuity of 0.5 or better. Patients with Behc¸et’s disease had significantly worse visual outcomes than patients with other clinical etiologies of uveitis such as human T-lymphotropic virus type 1 uveitis and Vogt–Koyanagi–Harada disease. In 17 eyes (13.0%), relapse of intraocular inflammation occurred within 6 months after surgery; the rate of relapse was highest in patients with Behc¸et’s disease (35.2%). Posterior synechias occurred in 8 eyes (6.1%), pupillary capture in 1 eye (0.8%), intraocular pressure elevation in 11 eyes (8.4%), and cystoid macula edema in 8 eyes (6.1%). In 31 eyes (23.7%), posterior capsule opacification required neodymium:YAG capsulotomy. CONCLUSIONS: The outcomes of phacoemulsification cataract extraction and IOL implantation in patients with uveitis were satisfactory. Patients with Behc¸et’s disease related to intraocular inflammation, however, appeared to have a higher risk for complications and therefore worse outcomes than patients with other clinical etiologies of uveitis. J Cataract Refract Surg 2007; 33:305–309 Q 2007 ASCRS and ESCRS
Cataract formation is one of the most common causes of vision loss in patients with uveitis. It is primarily related to intraocular inflammation or secondary to the administration of corticosteroids. Cataract surgery and intraocular lens (IOL) implantation in eyes with uveitis are
Accepted for publication October 25, 2006. From the Department of Ophthalmology & Visual Science (Kawaguchi, Mochizuki), Tokyo Medical and Dental University Graduate School, Tokyo, and the Meiwakai Medical Foundation (K. Miyata, N. Miyata), Miyata Eye Hospital, Miyakonojo, Miyazaki, Japan. No author has a financial or proprietary interest in any method or material mentioned. Corresponding author: Tatsushi Kawaguchi, MD, Department of Ophthalmology & Visual Science, Tokyo Medical and Dental University Graduate School, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan. E-mail: [email protected]. Q 2007 ASCRS and ESCRS Published by Elsevier Inc.
controversial procedures.1–4 Although newer surgical techniques and IOL designs have improved the outcomes of cataract surgery in patients with intraocular inflammation, management of postoperative inflammation and ocular complications remains difficult. Phacoemulsification with simultaneous IOL implantation is now the standard method of cataract surgery for most patients with uveitis5–14; however, the outcomes have been evaluated in small groups of patients only. In this study, we evaluated the outcomes of phacoemulsification cataract extraction and IOL implantation in a large population of patients with uveitis.
PATIENTS AND METHODS The clinical records of 95 patients (131 eyes) with uveitis who had phacoemulsification cataract extraction and IOL implantation were retrospectively reviewed. Surgery was performed at 0886-3350/07/$-see front matter doi:10.1016/j.jcrs.2006.10.038
305
PHACOEMULSIFICATION AND IOL IMPLANTATION IN PATIENTS WITH UVEITIS
Miyata Eye Hospital, Miyakonojo, Miyazaki, Japan, between July 1990 and April 2001. Before surgery, a complete uveitis-oriented history and ophthalmic and systemic examinations were performed in all patients. Laboratory assays included a full blood cell count; assays for renal and liver function, serum angiotensin-converting enzyme, serum lysozyme, rheumatoid factor, antinuclear antibody, Treponema pallidum hemagglutination, Toxoplasma gondii antibody, and human T-lymphotropic virus type 1 (HTLV-1) antibody; chest X-ray; and a tuberculosis skin test. Data collected include sex, age at surgery, cause of uveitis, preoperative findings, frequency and duration of quiescent periods of intraocular inflammation before surgery, length of follow-up, and presence of surgical complications and postoperative complications. Postoperative complications included a relapse of inflammation within 6 months after surgery, posterior synechias, pupillary capture of the IOL, intraocular pressure (IOP) elevation (by applanation tonometry) over 21 mm Hg within 1 month after surgery that required treatment, posterior capsule opacification (PCO) that required neodymium:YAG (Nd:YAG) laser capsulotomy, and postoperative cystoid macular edema (CME). Best corrected visual acuity (BCVA) was recorded at the immediate preoperative visit and postoperative follow-up examinations. The degree of the anterior chamber cell was graded according to the method of Hogan et al.15 Surgery was performed by 1 of 2 surgeons (K.M., N.M.). Every 30 minutes, starting 2 hours before surgery, patients were given eyedrops containing diclofenac sodium 0.1% (Dichlod), tropicamide 0.5%–phenylephrine hydrochloride 0.5% (Mydrin-P), and phenylephrine hydrochloride 5% (Neosynesin). After retrobulbar or eyedrop anesthesia was administered, a 4.1 to 6.0 mm scleral tunnel or a 3.0 mm corneal incision was created. Small pupils were managed by synechiolysis; the iris was stretched with iris hooks or iris retractors. Multiple sphincterotomies were performed as required. After continuous curvilinear capsulorhexis (CCC) was complete, the lens nucleus was removed by phacoemulsification and the cortical material by mechanical irrigation/aspiration. With the aid of an ophthalmic viscosurgical device (OVD), an IOL was implanted in the capsular bag and the incision was closed. Upon the completion of surgery, a subconjunctival injection of 2 mg betamethasone was administered. Postoperative care included topical ofloxacin 0.3% (Tarivid) 4 times daily, topical betamethasone 0.1% (Rinderon) between 4 and 8 times daily according to the intensity of the anterior chamber reaction, diclofenac sodium 0.1% (Dichlod) 4 times daily or bromfenac sodium 0.1% (Bronuck) 2 times daily, and tropicamide 0.4% (Mydrin-M) once daily for 2 to 3 months. Patients receiving systemic immunosuppressants before cataract surgery maintained their dosages at therapeutic levels. Patients were seen on the first, second, and third postoperative days; weekly for 2 weeks; monthly for 3 months; and every 3 months thereafter. At each postoperative visit, BCVA, IOP by applanation tonometry, anterior chamber reaction, vitreous haze, and retinal lesions were evaluated. If severe inflammatory episodes occurred, patients were given subconjunctival injections of betamethasone (2 mg) or sub-Tenon’s injections of triamcinolone (20 mg) and, if necessary, systemic administration of corticosteroids. Patients with postoperative observation periods shorter than 12 months were excluded from the study. Visual acuity was measured using a decimal chart and calculated geometrically. Differences in mean preoperative visual acuity between clinical etiologies were tested for statistical significance using the Kruskal-Wallis test, and differences in mean postoperative visual acuity were examined using the Mann-Whitney U test.
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Differences in relapse of inflammation and PCO with Nd:YAG capsulotomy were analyzed using the chi-square test for independence. A P value less than 0.05 was considered statistically significant. RESULTS
The mean age of the 36 men and 59 women was 61.7 years (range 30 to 87 years). The mean follow-up was 57 months (range 12 to 168 months). There were no significant intraoperative complications. Table 1 shows the clinical etiologies of uveitis. The main diagnosis was idiopathic uveitis followed Behc¸et’s disease, Vogt–Koyanagi–Harada (VKH) disease, and HTLV-1 uveitis. The mean period of quiescence of inflammation before surgery was 24.3 months (range 0 to 172 months). Of 9 eyes with a quiescent period of fewer than 3 months, 3 had relapse of inflammation within 6 months after surgery. Two eyes were mildly inflamed at the time of surgery. One of them was in a patient with Behc¸et’s disease who had a relapse of inflammation 4 months postoperatively and a final visual acuity of 0.01 because of optic nerve atrophy and macular degeneration. The other eye was in a patient with idiopathic uveitis who had the complication of bullous keratopathy secondary to IOP elevation and a final visual acuity of counting fingers. Figure 1 shows a comparison of preoperative and postoperative BCVAs. The mean preoperative visual acuity was 0.09 (range hand motions to 0.8). The mean visual acuity was 0.59 (range 0 to 1.5) 12 months after surgery and 0.51 (range 0 to 1.5) at the last medical visit. At the last visit, 111 eyes (84.7%) had an improvement of 0.3 or more logMAR units. A final visual acuity of 0.5 or better was achieved in 97 eyes (74.0%) and of 0.7 or better, in 87 eyes (66.4%). Visual acuity decreased in 5 eyes (3.8%) because of optic nerve atrophy (3 eyes), macular degeneration Table 1. Clinical etiologies of uveitis.
Clinical Etiology HTLV-1 uveitis Behc¸et’s disease Vogt–Koyanagi–Harada disease Sarcoidosis Other* Idiopathic uveitis
Number of Patients (%)
Number of Eyes (%)
14 (14.7) 11 (11.6) 9 (9.5)
16 (12.2) 17 (13.0) 16 (12.2)
6 (6.3) 16 (16.8) 39 (41.1)
11 (8.4) 20 (15.3) 51 (38.9)
HTLV-1 uveitis Z human T-cell lymphotropic virus type-1-associated uveitis *Ocular toxoplasmosis (4 eyes), herpetic iridocyclitis (4 eyes), leprosy (3 eyes), ulcerative colitis (3 eyes), sympathetic ophthalmia (2 eyes), toxocariasis (2 eyes), uveal effusion (2 eyes)
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Table 2. Best corrected visual acuity before and after surgery.
Mean Visual Acuity Clinical Etiology HTLV-1 uveitis Behc¸et’s disease Vogt–Koyanagi–Harada disease Sarcoidosis Other Idiopathic uveitis Total
Preoperative
12 Months
Last Visit
Mean Follow-up G SD (Mo)
0.08 0.07 0.18 0.21 0.04 0.08 0.09
0.86 0.24* 0.93* 0.69 0.42 0.55 0.59
0.64 0.19 0.89 0.71 0.34 0.54 0.51
40.4 G 22.8 72.5 G 22.9 57.8 G 16.0 40.0 G 28.1 51.3 G 23.1 62.7 G 37.7 57.0 G 0.8
HTLV-1 uveitis Z human T-cell lymphotropic virus type-1-associated uveitis *P!.05 (Mann-Whitney U test) between HTLV-1 and Behc¸et’s disease groups and between Vogt-Koyanagi-Harada disease and Behc¸et’s disease groups
(1 eye), and bullous keratopathy secondary to glaucoma (1 eye). Table 2 shows the mean visual acuity before and after cataract surgery by clinical etiology; there was no significant difference in preoperative mean visual acuity between clinical etiologies. Twelve months after surgery, the mean visual acuity was 0.93 in eyes with VKH disease, 0.86 in eyes with HTLV-1 uveitis, 0.69 in eyes with sarcoidosis, 0.55 in eyes idiopathic uveitis, and 0.24 in eyes Behc¸et’s disease. At 12 months, there was a significant difference between patients with Behc¸et’s disease and patients with VKH disease (P Z.01) and between patients with Behc¸et’s disease and patients with HTLV-1 uveitis (P Z .04). But there was no difference between patients with VKH disease and patients with sarcoidosis. Relapse of inflammation within 6 months after surgery occurred in 17 eyes (13.0%). The mean visual acuity in these eyes was 0.10 preoperatively and 0.52 12 months after surgery. The mean visual acuity in the other eyes was
0.09 before surgery and 0.61 12 months after surgery. There was no difference between the 2 groups before or after surgery. Table 3 shows the rate of relapse of inflammation within 6 months after surgery by clinical etiology. The highest percentage of relapse occurred in patients with Behc¸et’s disease. There was a significant difference in relapse of inflammation between clinical etiologies (P Z.04). Forty-seven eyes had postoperative complications (35.9%) (Table 4). The most common complication was PCO requiring Nd:YAG laser posterior capsulotomy. Of the 8 eyes that developed posterior synechias after surgery, 7 had posterior synechias before surgery. All 7 eyes had single-handed synechiolysis with an iris hook; 5 required sphincterotomy to dilate the pupil, and 2 required iris retractors to stretch the pupil. Eleven eyes had IOP elevation after surgery; in 1, the inflammation was quiescent for only 1 month preoperatively and the eye required filtration surgery. Posterior capsule opacification after surgery occurred significantly less frequently in patients with an acrylic IOL than in patients with IOLs of other materials (P Z .001) (Table 5).
Visual acuity at the last visit
DISCUSSION 1.0
Cataract formation is a major cause of vision loss in patients with uveitis. Successful surgical treatment is essential for good visual rehabilitation and adequate assessment of
0.1
Table 3. Relapse of intraocular inflammation after surgery.
Clinical Etiology
0.01 n.d m.m m.m n.d
0.01
0.1
1.0
Preoperative visual acuity Figure 1. Visual prognosis in patients who had phacoemulsification and IOL implantation.
Behc¸et’s disease Vogt–Koyanagi–Harada disease Sarcoidosis HTLV-1 uveitis Other Idiopathic uveitis
Number of Relapse Eyes/Total (%) 6/17 4/16 2/11 1/16 0/20 4/51
(35.2) (25.0) (18.2) (6.3) (0) (7.8)
HTLV-1 uveitis Z human T-cell lymphotropic virus type-1-associated uveitis
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Table 4. Postoperative complications.
Complications
Number of Eyes (%)
Posterior synechias Pupillary capture Intraocular pressure elevation Posterior capsule opacification Cystoid macular edema
8 1 11 31 8
(6.1) (0.8) (8.4) (23.7) (6.1)
Table 5. Posterior capsule opacification and IOL materials.
IOL Material PMMA Acrylic Silicone
Number of Surgeries 34 93 4
Number of PCO (%) 15 14 2
(44.1) (15.1) (50.0)
PMMA Z poly(methyl methacrylate)
the posterior segment. Previously, cataract surgery in eyes with intraocular inflammation was considered a high-risk procedure or a contraindication because of the high number of postoperative complications such as severe inflammatory reaction, IOP elevation, or glaucoma. These complications can lead to poor visual outcomes. Intracapsular cataract extraction, a surgical method in which the cortical material is completely removed within the capsular bag, was the preferred method because it was thought to reduce the risk for postoperative inflammatory response.1,2 New technologies, including phacoemulsification and aspiration equipment, high-quality OVDs, and foldable IOLs, have been introduced.16–18 Safer surgical techniques have also been developed; these include CCC, the divideand-conquer phaco method, and in-the-bag IOL implantation. As a result, phacoemulsification and IOL implantation are now the most common cataract surgery procedures in patients with uveitis. Ninety-five patients (131 eyes) with uveitis had phacoemulsification cataract extraction and IOL implantation at the Miyata Eye Hospital over the past 10 years. To our knowledge, this is one of the largest reported cohorts to have surgery by a limited number of surgeons. Among defined etiologies, HTLV-1 uveitis (14 patients, 14.7%) was the leading cause of uveitis at the hospital. This high number of patients with HTLV-1 uveitis is explained by the high incidence of HTLV-1 in the endemic area of Miyata Eye Hospital.19–21 The overall visual prognosis was favorable in 84.7% of eyes (111 of 131); acuity improved by 0.3 or more logMAR units, and 74.0% of eyes attained a final visual acuity of 0.5 or better. These results are comparable to those in other reports of phacoemulsification and IOL implantation in uveitic eyes.8,10 In this and other studies,7,9,22 patients with Behc¸et’s disease had a significantly worse visual
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outcome than patients with other etiologies of uveitis such as HTLV-1 uveitis and VKH disease. The main factors limiting postoperative visual acuity in Behc¸et’s disease were optic atrophy and macular degeneration caused by preoperative and postoperative inflammatory episodes. In our study, 17 patients (13.0%) had at least 1 episode of intraocular inflammation within 6 months after surgery. Most achieved good visual outcomes because of prompt treatment. Patients with no quiescence of inflammation before surgery, however, had a poor prognosis. These findings suggest the importance of good control of intraocular inflammation at the time of surgery. In addition, patients with Behc¸et’s disease appeared to have a significantly worse rate of relapse than other patients. Eight eyes (6.1%) with no evidence of preoperative CME developed it postoperatively. It is unclear why the rate of postoperative CME was lower in the present study than in previous studies.8,14 Fluorescein angiography or optical coherence tomography was not always used to diagnose CME in our study, and this might have affected the differences in detection. The frequency of PCO in our study was 23.7%, lower than the rate of PCO in other studies. Estafanous et al.8 report a PCO rate requiring Nd:YAG capsulotomy of 31%, and Okinami10 reports PCO in 33% of eyes. The length of time between follow-up periods does not explain the lower rate because the follow-up was longer in the present study than in the other studies. Our results are similar to the results in eyes with senile cataract.23 Meticulous surgical techniques and removal of cortical materials, in addition to polishing the posterior capsule, might have contributed to the lower rate of PCO. In the present study, PCO occurred less frequently with acrylic IOLs than with IOLs of other materials. Rauz et al.16 report that IOL material is not related to PCO in uveitic eyes. Several factors related to PCO, such as optic material and shape and loop design, have been reported. Considering the inflammatory reaction in uveitic eyes, it might be difficult to explain the relationship between PCO and IOL materials. We conclude that phacoemulsification cataract extraction with IOL implantation in patients with uveitis is well tolerated using advanced techniques and modern surgical devices. Patients with Behc¸et’s disease, however, appear to have a higher risk for complications and therefore worse outcomes. It is important to choose cases cautiously, especially in Behc¸et’s disease, and carefully control inflammation before and after surgery.
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13. Ganesh SK, Padmaja MS, Babu K, Biswas J. Cataract surgery in patients with Vogt-Koyanagi-Harada syndrome. J Cataract Refract Surg 2004; 30:95–100 14. Ganesh SK, Babu K, Biswas J. Phacoemulsification with intraocular lens implantation in cases of pars planitis. J Cataract Refract Surg 2004; 30:2072–2076 15. Hogan MJ, Kimura SJ, Thygeson P. Signs and symptoms of uveitis. I: anterior uveitis. Am J Ophthalmol 1959; 47(5, pt 2):155–170 16. Rauz S, Stavrou P, Murray PI. Evaluation of foldable intraocular lens in patients with uveitis. Ophthalmology 2000; 107:909–919 17. Abela-Formanek C, Amon M, Schauersberger J, et al. Results of hydrophilic acrylic, hydrophobic acrylic, and silicone intraocular lenses in uveitic eyes with cataract; comparison to a control group. J Cataract Refract Surg 2002; 28:1141–1152 18. Abela-Formanek C, Amon M, Schild G, et al. Inflammation after implantation of hydrophilic acrylic, hydrophobic acrylic, or silicone intraocular lenses in eyes with cataract and uveitis; comparison to a control group. J Cataract Refract Surg 2002; 28:1153–1159 19. Mochizuki M, Yamaguchi K, Takatsuki K, et al. HTLV-1 and uveitis [letter]. Lancet 1992; 339:1110 20. Mochizuki M, Watanabe T, Yamaguchi K, et al. Uveitis associated with human T-cell lymphotropic virus type I. Am J Ophthalmol 1992; 114:123–129 21. Yoshimura K, Shimada N, Sirao M, et al. [Uveitis in human T-lymphotropic virus type I (HTLV-1) carriers. 2. An analysis of clinical features]. [Japanese] Nippon Ganka Gakkai Zasshi 1993; 97:733– 740 22. Kadayifc¸ilar S, Gedik xS , Eldem B, _Irkec¸ M. Cataract surgery in patients with Behc¸et’s disease. J Cataract Refract Surg 2002; 28:316–320 23. Ando H, Ando N, Oshika T. Cumulative probability of neodymium:YAG laser posterior capsulotomy after phacoemulsification. J Cataract Refract Surg 2003; 29:2148–2154
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