Avoiding surgical complications

Boston-With careful planning and surgical technique, phacoemulsification can be performed with good safety and efficacy outcomes in eyes with post-uveitic cataracts, said Manish Mahendra, MD, at the annual meeting of the American Society of Cataract and Refractive Surgery.

Dr. Mahendra presented a retrospective review of 56 eyes (48 patients) he operated on for post-uveitic cataract between Jan. 1, 2007, and April 1, 2009. Although a number of complications were encountered during the procedures and postoperatively, the intraoperative events were negligible and overall visual acuity outcomes were favorable, with best-corrected visual acuity of 20/40 or better achieved in 78.5% of eyes, said Dr. Mahendra, Khairabad Eye Hospital, Kanpur, India.

"Cataract surgery has become very demanding as all patients are expecting to be operated on with a no-injection, no-stitch, no-patch procedure and to achieve a perfect refractive outcome without any complications," Dr. Mahendra said. "However, our ability to meet these demands is challenged by various situations, including in eyes with post-uveitic cataracts."

Categorization of the clinical features of the 56 cases highlights the challenges that are faced by the cataract surgeon when operating on eyes with post-uveitic cataract. There were 26 (46.4%) eyes with a festooned pupil, 19 (33.9%) eyes with a nondilating miotic pupil, 5 (8.9%) eyes with post-trabeculectomy cataract, 4 (7.1%) with a mature hard white cataract, and 2 (1.8%) with occlusio pupillae.

In all cases, cataract surgery was withheld until the eye had demonstrated at least three months of quiescence. To control the level of surgery-induced inflammation, patients were treated 1 week preoperatively with a standard regimen of corticosteroids consisting of oral prednisone 1 mg/kg body weight and topical prednisolone acetate 1% (Pred Forte, Allergan) q.i.d.

Both the systemic and topical corticosteroid were continued after surgery on a tapering schedule, and perioperatively, patients continued treatment with existing medications being used to treat any systemic disease.

All phaco procedures were performed through a clear corneal temporal incision using peribulbar anaesthesia and the same phaco system (OS3, Oertli) by a single surgeon.

Complications encountered intraoperatively included linear mark imprints at the pupillary border due to use of iris retractors (25 eyes, 44.6%), floppy iris (12 eyes, 21.4%), uncontrolled capsulorhexis formation (two eyes, 3.6%), anterior chamber instability (two eyes, 3.6%) and Descemet's stripping (one eye, 1.8%).

Postoperatively, 23 eyes (41.1%) had corneal edema on the first day after surgery and 11 eyes (19.6%) developed posterior capsule opacification (PCO) after a follow-up of more than 6 months that required Nd:YAG laser capsulotomy. Seven eyes had cystoid macular edema (CME) (12.5%), IOP was elevated in five eyes (8.9%), six eyes had a fibrinous reaction (10.7%), and there was a single case of pupillary capture (1.8%).

"More complications were observed in eyes with hard uveitic cataracts than in those with a softer lens," Dr. Mahendra said. "However, some of the complications resolved in due course of time."

Postoperative corneal edema gradually improved with persistent use of the topical corticosteroid, which was tapered on weekly basis. Visual acuity in the 11 cases of PCO improved following Nd:YAG laser capsulotomy. CME was treated with topical corticosteroids, topical nonsteroidal anti-inflammatory drugs, and oral acetazolamide, although three eyes required a posterior sub-Tenon injection of triamcinolone acetonide to resolve the edema.

IOP also was controlled using anti-glaucomatous drugs and six cases of fibrinous reaction required frequent instillation of topical corticosteroids and use of oral steroids (prednisolone 1 mg/kg body weight in tapering doses) to control the uveitis.

FYI

Manish Mahendra, MDE-mail: manish_shalli@yahoo.co.in

Dr. Mahendra has no financial interest in the subject matter.