1. Cataract and Uveitis
Mohammad Ghoreishi, MD

2. Cataract and Uveitis Uveitis , as complication of cataract
Cataract, as complication of uveitis
Cataract surgery
and uveitis

3. Uveitis as complication of cataract
Phacoanaphylactic endophthalmitis
Phacotoxic uveitis
Phacolythic glaucoma and uveitis

4. Phacoanaphylactic endophthalmitis
Immunologic type response to lens protein release after injury to the lens capsule or after cataract surgery
Rarely spontaneous lens capsule rapture may cause the disease

5. Pathogenesis
Autologous lens protein may become autoantigenic after exposure to the aqueous humor
Usually abrupt onset, but may be insidious
Early onset in previously sensitized patients

6. Pathology
Zonal granulomatous inflammation centered at the site of lens injury

7. Clinical findings Mutton-fat KPs Congested iris vessels
Posterior synechiae
Dense flare and cells

8. Treatment Corticosteroids Cycloplegic
Surgical removal of lens material

9. Phacotoxic uveitis? Supposed toxic effect of lens material
May be a less severe form of phacoanaphlaxis

10. Phacolytic glaucoma (PG)
Phacolytic glaucoma (PG) is the sudden onset of open-angle glaucoma caused by a leaking mature or hypermature (rarely immature) cataract
It is cured by cataract extraction

11. Phacolytic glaucoma
Occurs in cataractous lenses with intact lens capsules
Direct obstruction of outflow pathways by high molecular weight lens proteins released from microscopic defects in the lens capsule
Macrophagic response to lens protein in the anterior chamber, but not the cause of the outflow obstruction

12. History
History of slow vision loss for months or years prior to the acute onset of pain, redness, and sudden decrease in vision (vital clue to the correct diagnosis)
Symptoms mimic acute angle-closure glaucoma

13. Clinical findings Severly elevated IOP
Microcystic corneal edema, and the anterior chamber contains
Intense AC reaction, flare and large cells (macrophages)
Aggregates of white material, and iridescent or hyperrefringent particles in AC (calcium oxalate and cholesterol crystals liberated from the degenerating cataractous lens)
No keratic precipitates (unlike phacoanaphylactic uveitis

14. Clinical findings
The anterior capsule of the lens frequently is dotted with patches of soft white material
In contrast to some forms of lens-induced glaucomas (eg, lens particle glaucoma, phacoanaphylactic glaucoma), the lens capsule is grossly intact
Gonioscopy findings usually are normal; however, evidence of old angle recession was found in 25% of eyes in one study

15. Causes Mature cataract (totally opacified)
Hypermature cataract (liquid cortex and free-floating nucleus)
Focal liquefaction of immature cataract (rare)
Dislocated cataractous lens in vitreous

16. Differential diagnosis
Intumescent Lens Glaucoma
Acute Angle Closure Glaucoma
Lens-Particle Glaucoma
Uveitic Glaucoma (Pahcoanaphylactic)
Neovascular Glaucoma
Phacomorphic Glaucoma
Dislocated cataractous lens in vitreous

17. Treatment
Aggressive antiglaucoma therapy Corticosteroid Cataract surgery as soon as IOP is controlled and inflammation subsided

18. Cataract caused by uveitis
Cataract formation is a common complication of chronic or recurrent uveitis.
It is caused by the inflammation itself, or by the steroid and glaucoma
The incidence of cataract approaches 50%.
The most common type of cataract in uveitis patients is the posterior subcapsular opacity

19. Physiopathology
Thought to be the result of prolonged breakdown of the blood-ocular barriers caused by intraocular inflammation.
The entry of plasma phospholipids, or its precursor, into the eye is thought to increase lens epithelial permeability

20. Cataract surgery in uveitis
Preopperative measures
Intraoperative
postoperative

21. Cataract surgery in uveitis
The clinical course, management, complications and visual outcome of uveitic cataract are directly related to the type and cause of uveitis
Preoperative diagnosis of the etiology and proper management of uveitis and its etiology, are essential prognostic factors for treating cataract

22. Cataract surgery in uveitis
Patient selection for surgery
Visually significant cataract
Fully controlled inflammation
Predicted substantial improvement in visual acuity

23. First, infectious and treatable causes of uveitis must be identified.
Treatable causes, such as syphilis, TB, Toxo, viral, parasitic …, should be managed before surgery

24. Second, many forms of uveitis are associated with systemic diseases such as HLA-B27-associated diseases, Behcet disease, sarcoidosis, systemic lupus erythematosis, rheumatoid arthritis...
Systemic causes of uveitis must be identified and treated, or controlled preoperatively

25. Third, the surgical outcome may be influenced by the type of uveitis.
Fuchs heterochromic cyclitis has historically been thought to have a good prognosis after cataract surgery even with incomplete control of anterior chamber cell
Conversely, cataract surgery in patients with JIA related uveitis and Behcet disease carries poor visual outcome

26. Controlling inflammation
Clinically significant inflammation has been defined as 1+ cells (5 to 10 cells) according to the criteria of Hogan
Total control of active inflammation (0 to 2 in anterior chamber or vitreous body) for at least 3 months
Aqueous flare in the chronic uveitic patients simply denotes vascular incompetence of the iris and ciliary body, a consequence of vascular damage from the chronic or recurrent uveitis.
Therefore, flare should in general not be used as a
guide for control of inflammation

27. Controlling inflammation
Specific treatment
Treating the infectious etiology: antivirals, antibacterials, antiparasitics..
Treating noninfectious etiology
Nonspecific
Corticosterroids
Cytotoxics and immunosupressants
NSAIDS

28. Concomitant pathologies
Concomitant ocular pathologies should be diagnosed and addressed, including
Retinal detachment
Optic atrophy
Vitreous opacity
Cystoid Macular edema
Epiretinal membranes
Corneal problems such as scarring,band shape keratopathy, stromal thinning, Intra-stromal hyaline- or lipid-like deposits.

29. Intraoperative Proper Surgical technique
Treating iris and pupil abnormalities such as miosis, synechiae, PAS
Managing anterior and posterior capsule
Eradicating all cortical and nuclear material
Avoiding too much manipulation
Avoiding irritant substances
Combined corneal or vitreoretinal surgery
Periocular or intraocular injection

30. Malyugin ring

31. IOL Indications, when to avoid IOL implantation
There is general agreement about avoiding an IOL in, a patient with JRA-associated uveitis.
Behcet disease ?
Recurrent, poorly controlled uveitis

32. Iol Position IOL design and material Minimize haptic-uveal contact
Avoid AC IOL
Avoid sulcus implantation
A PCIOL implant resting on the ciliary body or an
IOL design and material
Single piece
Hydrophobic vs hydrophylic
Capsular and uveal compatibility
Avoid silicone material
Heparine coated IOL

33. Postoperative Uveitis as complication of cataract surgery
Other complications related to cataract surgery and uveitis

34. Complications after cataract surgery
Recurrence of inflammation
CME
PCO and capsular contracture
IOL deposit
Hypotony

35. Uveitis secondary to cataract surgery
Severe postoperative inflammation is more common after cataract surgery in eyes with uveitis
Early onset
TAAS
Lens induced
Late onset
Infectious: Propiony Bacterium Acne
UGH

36. Early postoerative inflammation
Diagnosis and eradicating or treating the causes
In addition to intensive topical, periocular, or even systemic
anti-inflammatory treatment, the injection of recombinant tissue plasminogen activator (10 μg in 0.1 mL buffered saline solution) into the anterior chamber may help disperse
Be caution about early surgical or Yag-Laser manipulation in case of fibrin formation

37. Conclusions
Cataract and glaucoma are frequently associated with each other as cause and effect
Cataract surgery in a patient with uveitis requires thorough diagnostic investigation, diligent perioperative control of inflammation, and meticulous surgical technique
Proper surgical technique, choice of IOL and postoperative control of inflammation and complications can lead to satisfactory visual outcomes after cataract surgery in uveitis patients, and prevention of uveitis in normal subjects