Perioperative Medical Management

■Preoperatively, risk factors should be analyzed, for example, type of uveitis, course of inflammation, basic diagnostic workup and complications like cystoid macular edema.

■At the time of surgery, the eye should have been completely quiet for approximately 2–3 months.

■Preoperative prophylaxis includes maintenance therapy, under which the eye remains quiet until surgery, and additional anti-inflammatory treatment beginning approximately 1–2 weeks prior to surgery, systemic or topical corticosteroids.

■Intraoperatively, intravenous methylprednisolone or intravitreal triamcinolone acetonide can be very effective in high-risk patients in preventing postoperative complications.

■Postoperative treatment should include systemic and topical corticosteroids, depending on the preoperative and intraoperative situation.

Contents

8.1Preoperative Considerations  . . . . . .   81

8.2Timing of Surgery  . . . . . . . . . .   81

8.3Preoperative Prophylaxis  . . . . . . .   82

8.1Preoperative Considerations

Cataract formation is a common sight-impairing complication of uveitis, occurring in up to 50% of patients depending on the type of uveitis. Cataract surgery is more complex than in nonuveitic patients and has a considerable potential for an unfavourable postoperative course. Remarkable progress has been made recently, but some general considerations should be reviewed regarding patient selection and thorough perioperative monitoring. The first step is the accurate classification of the disease entity, as a specific diagnosis will often guide the surgical strategy and determine the prognosis of cataract surgery. A standardized questionnaire is recommended for a comprehensive ocular and systemic history. This includes patient characteristics, the location of uveitis, and course and onset of intraocular inflammation. Diagnostic examinations should include an updated chest X-ray to disclose tuberculosis and sar-

8.5Postoperative Management  . . . . . .   83

8.6Summary  . . . . . . . . . . . . . .   83

References  . . . . . . . . . . . . . . . . . .   83

coidosis, Lyme disease serology, angiotensin converting enzyme and basic laboratory investigations. Thorough ophthalmic evaluation is essential to identify simultan­ eous ocular pathology that may also be causative for visual impairment and limit postoperative visual rehabilitation. Concomitant cystoid macular edema (CME) or glaucoma should be treated preoperatively before proceeding with cataract surgery [13]. This is even more important in cases of ocular toxoplasmosis, as cataract surgery has shown to cause exacerbation in this specific subset of patients [1].

8.2Timing of Surgery

There is general agreement about achieving complete quiescence of intraocular inflammation for at least 2–3 months before proceeding with surgery [3]. This is usually interpreted as absence of cells in the anterior

chamber, less than 2+ vitreous cells and no active chorioretinal inflammation. Patients suffering from Fuchs heterochromic cyclitis in particular will frequently fail to achieve complete quiescence even after maximal antiinflammatory therapy, yet those patients rarely develop severe postoperative complications [12]. In contrast, other types of uveitis may respond aggressively with recurrent postoperative inflammation even with previously well-controlled disease, for example, Behçet’s disease (BD), sarcoidosis and juvenile idiopathic arthritis (JIA) associated uveitis. This is due to a subclinical chronic inflammation that persists even if the eye seems to be quiescent. The history of the disease may help to evaluate the risk for an unfavourable postoperative

8 course. It has been shown for BD that it is significantly related to the frequency of ocular attacks during the year preceding the surgery [8]. Clinical parameters may further insinuate a subclinically persistent inflammation, for example, preoperative hypotony, vitreous cells and choroidal swelling. In these cases with unfavourable prognostic factors, it has been recommended to postpone surgery until after the period of at least half a year with no ocular attacks [8].

Besides respecting a quiescent interval, supplementary anti-inflammatory treatment has been advocated by most authorities. The improved visual prognosis after cataract surgery in uveitis eyes in recent years seems to be related to the more consistent use of perioperative anti-inflammatory and immunosuppressive treatment regimens.

8.3Preoperative Prophylaxis

The ideal preoperative prophylaxis has not been conclusively defined as yet. While some authors consider a topical prophylaxis with corticosteroid eyedrops as sufficient in most cases, other studies generally recommend systemic immunosuppression to ensure quiescence. In principle, the preoperative prophylaxis is based on three strategies.

First, the maintenance therapy has to be optimized. In cases where inflammation responds insufficiently to low-dose corticosteroid therapy, immunosuppressive treatment has to be considered or adjusted according to the course and severity of uveitis. One should take into account that most immunosuppressive drugs need several months to achieve sufficient effects. Second, after having optimized the maintenance therapy, an addit­ ional anti-inflammatory prophylaxis with topical corticosteroid eyedrops, prednisolone acetate 1% five times daily, is started 1 (and up to 2) weeks prior to surgery. Alternatively, some authors recommend dexametha-

sone phosphate 0.1%, but the use of phosphate-contain- ing eyedrops could be criticized in view of potentially inducing band keratopathy.

Finally, additional systemic corticosteroid prophyl­ axis using prednisolone 1 mg/kg approximately1 week prior surgery is recommended by many authors, although the prophylactic value is still under debate. Other authorities consider topical prophylaxis to be sufficient in most patients and use preoperative oral corticosteroids only in selected cases with previous or current CME, with intermediate or posterior uveitis or with known attacks of severe inflammation after previous intraocular surgery [4]. Recent studies, however, have shown that administration of preoperative oral corticosteroids results in a higher proportion of patients with a visual acuity of 20/40 or better at 3 months [10]. Alternatively, an intravenous pulse therapy using methylprednisolone or prednisolone succinate 3–5 mg/kg the day before surgery has been proposed. In contrast, nonsteroidal anti-inflammatory drugs (NSAIDs) have been less favoured in recent years. Topically applied NSAID eyedrops have little effect on inflammation, while the systemic application might increase risk of intraoperative bleeding [4].

8.4Intraoperative Management

Minimizing damage of the blood–aqueous barrier (BAB) in uveitis patients is achievable through the use of modern surgical techniques and biocompatible implants. However, uveitis patients are at higher risk for early postoperative complications like fibrin formation, synechiae and CME. Therefore, a sub-Tenon injection of dexamethasone 4 mg should be applied at the end of surgery. In high-risk patients with a history of frequent intraocular inflammation and recurrent development of CME, intravenous methylprednisolone 250 mg may be injected additionally. Alternatively, intravitreal triamcinolone acetonide 4 mg has been proposed. In a recent study, it was shown that a single injection of triamcinolone acetonide into the anterior chamber during cataract surgery was an effective prophylaxis against fibrin formation after cataract surgery in patients with juvenile idiopathic arthritis-associated uveitis. They found less fibrin formation, CME and hypotony compared to patients who received a short-term systemic steroid treatment postoperatively [7].

Another study advocates the use of heparin-sodium 10 IU/ml as an adjunct in the irrigation solution. The authors found a lower inflammatory reaction in the early postoperative period without increasing the risk of intraoperative bleeding [6].

Perioperative Medical Management

8.5Postoperative Management

Postoperatively, the first 3 months are most critical and notably determine the long-term outcome. It has been shown that the BAB may be compromised for several months even after uncomplicated cataract surgery in nonuveitic patients [11]. Uveitic patients are more susceptible to developing complications due to the combination of pre-existing and surgically induced breakdown of the BAB. Hence, high-dose anti-inflammatory treatment is especially important to maintain intraocular quiescence during the critical period by slowly tapering the perioperative treatment for up to 3 months [2]. Oral corticosteroids have been proven to effectively reduce the postoperative BAB damage. In most situations, the postoperative treatment of intraocular surgery of uveitic patients is handled like a recurrence, that is, treated with 1 mg/kg/day of prednisolone, and reduced by 10 mg/week, finally resulting in an individual maintenance dosage.

Meacock and colleagues found that perioperative long-term treatment (prednisolone 0.5 mg/kg/day, starting 2 weeks before surgery, reduced by 5 mg/week) was more effective than a single dose of methylprednisolone 15 mg/kg/h before surgery. However, no beneficial effect on CME incidence could be shown [9].

Postoperatively, oral corticosteroids are tapered off over a period of 8–10 weeks. The dosage depends on the severity and type of uveitis, underlying complications and the individual surgical trauma. In most cases, prednisolone 1 mg/kg/day might be a suitable dose that is reduced by 10 mg/week, finally resulting in an individual maintenance dosage.

Topical corticosteroid therapy may be reduced earlier but should be continued at a low-dose level, as this acts as an effective prophylaxis against intraocular lens deposits. One should bear in mind that visually significant giant cell deposits frequently recur as soon as corticosteroids are tapered off. Therefore, long-term maintenance of low-dose topical corticosteroids may be required. A suitable topical treatment regimen might be to start with prednisolone acetate eyedrops every 2 h, then continue five times daily for 2 weeks and taper it as required to finally achieve a maintenance dose of once a day. In patients with postoperative fibrin formation, prednisolone acetate eyedrops are given hourly, and sub-Tenon corticosteroids are injected. In cases of a persistent fibrin membrane (> 3 days), a single intracameral injection of recombinant tissue plasminogen activator (10 µg) has shown to be effective [5].

Finally, one should bear in mind that these patients are under long-term immunosuppressive treatment and consequently may have a higher risk of postsurgical bac-

terial infections. Therefore, a meticulous topical postoperative antibiotic prophylaxis must be considered. We found it very helpful to continue treatment with topical broad-spectrum antibiotics as long as higher dosages of topical steroids were applied.

8.6Summary

With improvement in microsurgical techniques, biocompatible implants and consequent perioperative medical management, a successful and lasting visual recovery after cataract surgery can be achieved in most uveitic patients. Unclear at the moment is the optimal systemic steroid regimen and the role of intravitreal ster­ oid application intraoperatively. Following preoperative precautions will lead to a high level of safety regarding postoperative inflammation.

References

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6.Kohnen T, Dick B, Hessemer V, Koch DD, Jacobi KW. Effect of heparin in irrigating solution on inflammation following small incision cataract surgery. J Cataract Refract Surg 1998; 24: 237–243

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