Combining intravitreal triamcinolone (IVTA) with phacoemulsification for cataract extraction in eyes with a history of posterior uveitis appears to be a useful treatment option. Reporting in the Journal of Cataract and Refractive Surgery,1 Narciss Okhravi FRCOphth, PhD, and colleagues from Moorfields Eye Hospital in London, wrote that the incidence of postoperative macular edema was markedly reduced, and levels of visual acuity following cataract surgery, similar to those in eyes without uveitis, were achieved in eyes with posterior uveitis.

Uveitic eyes commonly develop cataracts; an incidence as high as 77.8% has been reported in cases of Fuchs’ heterochromic cyclitis and 50% in eyes with pars planitis (see sidebar, Treatment Algorithm for Pars Planitis),2-4 Miss Okhravi and colleagues wrote. Some investigators have even suggested that the figure approaches 100% with longer follow-up.

UVEITIS MAKES CATARACT SURGERY MORE COMPLICATED
The extraction of cataracts in these eyes can be more difficult technically, and the risk for postoperative exacerbation of inflammation and macular edema is increased. Clinicians recommend controlling intraocular inflammation for ≥12 weeks before performing cataract surgery for the best results in visual acuity.5-8 Miss Okhravi and colleagues previously published a study investigating oral corticosteroid prophylaxis for controlling intraocular inflammation. They now sought to determine if intraoperative IVTA would be useful without the adverse effects of systemic therapy.

“We included 19 eyes of 17 patients with posterior uveitis thought to require systemic corticosteroid prophylaxis for cataract surgery,” the authors wrote. Seven of the patients had systemic hypertension, and it was thought that systemic corticosteroid use would be problematic. Three of these seven patients also had diabetes; all were unhappy with the use of oral corticosteroids.

The mean visual acuity 1 day postoperatively was 20/40 (range, 20/20-counting fingers). At the final follow-up (mean 25.2 months; range 7-41 months) 17 eyes (89.5%) achieved visual acuity of ≥20/40. “Two eyes failed to achieve a final visual acuity of ≥20/40; one as a result of preexisting optic atrophy and the other as a result of macular edema which developed >4 months postoperatively (after the IVTA had left the eye),” Miss Okhravi and colleagues wrote. No patient lost acuity and no eye developed macular edema within 4 months of cataract surgery.

The investigators also reported that postoperative intraocular pressure elevation occurred in three eyes and all three were controlled by topical medication that was discontinued after 3 months of treatment. One patient developed severe intraocular inflammation after surgery that resolved with 1 week of intensive topical corticosteroid therapy, they wrote.

CONTROLLED MACULAR EDEMA
“The reported incidence of macular edema in eyes with uveitis having cataract surgery may be as high as 56%,”9,10 the Moorfield’s team wrote. “Even with intensive preoperative care and meticulous postoperative management, the incidence has not fallen below 20%.”

In the discussion portion of the report, the investigators went on to say that uveitis in the 3-month postoperative period can be associated with increased macular edema. “Once macular edema is present, even with intensive treatment, visual acuity may fail to improve within 6 months in up to 50% of cases.”6 The investigators said that it follows that if postoperative uveitis and macular edema can be prevented, visual outcomes would improve.

Phacoemulsification with intraoperative IVTA injection appears a reasonable treatment alternative to systemic corticosteroid prophylaxis, the researchers concluded. “In this study, it was found to be safe and efficacious, prevented postoperative macular edema, and permitted the achievement of levels of visual acuity in eyes with uveitis similar to those without uveitis,” Miss Okhravi and colleagues said.

Narciss Okhravi, FRCOphth, PhD, is a Consultant Ophthalmologist in the Medical Retina and Uveitis Service at Moorfields Eye Hospital, London. She may be reached at narciss.okhravi@moorfields.nhs.uk.

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