Transcription:
Cataract Surgery in Uveitis Patients

Melanie Cole (Host): Welcome to Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole, and I invite you to listen as we explore options for cataract surgery in uveitis patients. Joining me is Dr. Anjum Koreishi. He's an assistant professor of ophthalmology at Northwestern Medicine. Dr. Koreishi, it's a pleasure to have you join us today. I'd like you to tell us a little bit about uveitis and how common cataracts are in these patients.

Dr Anjum Koreishi: Sure. And first, thank you so much for having me on here and hosting this. Hopefully, this will be a helpful program for people. As people know, cataracts are very common in patients with uveitis. And the main reasons for that are that most, if not all, patients with uveitis require some steroid therapy at some point. And as we know, steroids contribute to cataract formation. Also, the inflammation itself that comes along with uveitis creates cataracts. So while everybody gets cataracts as we get older, patients with uveitis almost always develop them earlier in life and can be fairly significant to their vision and functioning.

Melanie Cole (Host): Well, thank you for that. So let's start by discussing some preoperative management for cataract surgery in uveitis patients.

Dr Anjum Koreishi: Sure. So the preoperative management and the planning that goes in is very important. I think a lot of the points that I'm going to make are important no matter what in any cataract surgery. But I stress that some of these are even more important and require more time in patients with uveitis. So in terms of determining a plan to go forward with cataract surgery, we want to make sure that they have a truly visually significant cataract really affecting them. I often stress that this is not a refractive procedure when it's done in patients with complicated disease. Importantly, we need to have three months of control of the uveitis, so the inflammation needs to be quiet for three months and sometimes we're tempted to proceed more quickly, but that three months is really key to help prevent issues and complications after surgery.

Melanie Cole (Host): So then expand a little on indications for when you do consider surgery in these patients and any contraindications.

Dr Anjum Koreishi: Yeah, absolutely. So in terms of indications for surgery, it's really when it is significantly impacting the patient's ability to function. And just like with a patient with cataracts without uveitis, that's very individualized. Patient with the same type of cataract, one may be affected significantly and the other may not be. Also importantly, we have to have a good handle on the uveitis and make sure that co-morbidities are addressed before we go ahead and perform a surgery. There aren't all that many contraindications to doing surgery, just things that require more careful planning and more careful discussion with the patient.

One thing that we always talk to the patients about in terms of counseling in any cataract surgery is the lens implant. And one thing I shy away from using in patients with uveitis is the more premium lens, like the multifocal extended depth-of-focus lenses that provide really great options for some patients, but because of potential issues with anatomy in these patients, I don't like to use those. I think there's a higher risk in using those kinds of lenses with these patients.

Melanie Cole (Host): So interesting. And I'm glad that you brought up counseling patients and setting expectations, because as we're going to discuss a little bit more, Dr. Koreishi, it's a bit challenging this condition. So tell us a little bit about that counseling when you're planning to perform that cataract surgery for the uveitic eye, and explaining that visual prognosis, why that is so important that you explain all of this to the patients.

Dr Anjum Koreishi: Absolutely. And obviously, in any Surgical patient or medical patient, any patients at all, we want to counsel, we want to talk about risks, benefits, alternatives, pluses, and minuses, so that goes without saying. However, in patients with uveitis, the counseling is a different beast. It takes a lot more time. We have to be more careful with these patients, so they know what to expect getting into things.

Patients will have heard about cataract surgery. And a lot of times they hear it was a 10-minute procedure, "I was off of drops in a week and my vision was just like it was 20 years ago after." and while that may be the case, a lot of these patients have significant disease in their eyes that limits the amount of vision they may get back afterwards. The uveitis itself requires additional followup visits after, requires more anti-inflammatory therapy before and afterwards, potentially other procedures. So the course of the cataract surgery is hugely different. And I think we do a disservice to our patients if we are not open and honest about that going in to surgery.

So the keys are making sure the patients are aware of the more questionable outcome or variable outcome, the increase in visits pre and postoperatively, increase in medications and potential for other types of surgeries as well. And we had already discussed the selection of lenses before as well.

Melanie Cole (Host): What great points that you've made here, Dr. Koreishi. So tell us a little bit why uveitic eyes are often challenging for cataract surgery and intraoperative and postoperative complications. Tell us a little bit about why that is.

Dr Anjum Koreishi: Sure. I'll start with the intraoperative, the more technical aspects of surgery that can be more difficult. So a lot of patients with uveitis have distorted anatomy that adds to the technical complexity of surgery. They may have posterior synechiae with a pupil scar down to the lens, they may have issues with the zonules, and variable lens density. So the key is that we need to recognize these things before and plan for being able to take care of these.

My key is that we plan for the worst and work towards the best, so that we're prepared for any type of complication that can occur. Now ,in terms of the posterior synechiae and potentially small pupils, we need to break that scar tissue. And I like to do that very gently because if we release a lot of pigments from the iris, that pigment is proinflammatory, can result in more aggressive inflammation afterwards.

We need to be adept at using different techniques to dilate the pupils. Our usual options are Malyugin rings and iris hooks. I tend towards using iris hooks because I think I have more control, especially in iris tissue that's not as healthy. We need to be adept at using other instruments like retina scissors and intraocular forceps that I use oftentimes to cut membranes. We need to be able to use other approaches for our incision, such as a scleral tunnel instead of the normal clear corneal. For example, I use that when the patient's anatomy is more complicated. For example, if they have iris bombe or they have a pupillary membrane that I need to access a different way. Also, the capsulorrhexis itself can be much more difficult. If it's fibrotic and there is a lot of scar tissue there, we need to be able to expand our techniques and not just do the continuous capsulorhexis. We may need to use scissors to cut it, for example, go to a can opener, different techniques need to be at our disposal.

So again, I think that any good cataract surgeon really has all of these skills in their armamentarium. The key is to be able to easily pull them out, use them when we think they may be necessary to prevent other issues during surgery. And again, I make the point that the technical success of surgery is only part of the battle. I think a lot of good cataract surgeons can get out of the operating room with great success. But the key in these patients, and you mentioned post-operatively, the key in these patients is to keep them seeing well six months, a year, five years later. And that's where I think the postoperative issues really rear their head and make us need to be very vigilant about those.

Melanie Cole (Host): Well, thank you for telling us about those anatomic considerations in surgical planning. So as long as we're talking about postoperative inflammation, tell us what's involved with management and followup and why you just said that that is so vital.

Dr Anjum Koreishi: Sure. And I think the postoperative inflammation goes along with preoperative inflammation and how we address the whole surgical experience as one. We want to treat it proactively, not reactively. So the number one thing of course, as I had mentioned, is that three months of control of the uveitis prior to surgery, and that can be achieved with systemic therapy, like immunomodulation that we use very frequently in our chronic uveitis patients. It may be with more aggressive use of steroids beforehand, but whatever we need to do to keep things quiet.

Now, as we head into surgery, we know there is going to be more inflammation after. So we can't just rely on the regimen that we have been on to control inflammation, we need to augment that. So we always increase steroids around the time of cataract surgery and there's different ways of doing this and it really depends on the type of uveitis, whether it's anterior, intermediate, posterior panuveitis, and depends on the severity of the uveitis. Our options generally are increased topical steroids, periocular steroid injections, intravitreal steroid injections, and systemic steroids, both oral and intravenous during the time of cataract surgeries. I'm not going to go into the decision-making of all of that, because it's very, very individualized and that's a one hour talk on its own. But being able to go through these different options with the patients and determining which is best, according to the uveitis, as well as the patient's comorbidities like diabetes or glaucoma is very important. And then this flows into postoperative control.

So by treating people aggressively around surgery, we ideally limit the amount of postoperative flares that we would have. However, we still need to be very aggressive in controlling. I never see increased inflammation and say, "Well, hopefully, it'll just get better and we may not need to increase things," because then if it gets worse, you need to be very aggressive to get rid of it. So we want to be aggressive early on in trying to control postoperative inflammation using the same techniques that we discussed, topical, periocular, intravitreal, and systemic steroid therapy.

The other quick point is for patients that have infectious uveitis, for example, or interocular lymphoma, I take that into account and oftentimes we'll pretreat patients with the appropriate antiinfective or chemotherapeutic agents to prevent flares of those particular diseases as well.

Melanie Cole (Host): Such an interesting topic we're discussing here today, Dr. Koreishi. As we get ready to wrap up, can you please summarize options and information for optimizing outcomes for cataract surgery in uveitis patients, the multidisciplinary approach, because you just briefly touched on comorbidities, and so who might be involved in that and any other technical considerations that you would like to share with other providers to achieve better outcomes?

Dr Anjum Koreishi: Absolutely. So the main point is meticulous planning and meticulous discussion with the patient. One other quick point is you don't want to minimize the postoperative care and have the patient skip appointments and things like that. So we really need to be honest and upfront with them. So number one is meticulous planning, look at the patients preoperatively in terms of their anatomy, their uveitis, determine the technical steps that we are going to need to take, plan for the worst, have everything available in the operating room so that we don't run into significant complications there.

Second is the inflammatory aspect, which is aggressively treating inflammation, pre and perioperatively to reduce the issues we run into postoperatively. But at the same time, having a low threshold for being very aggressive in the postoperative stage. I have had many patients referred to me who had uncomplicated cataract surgery, but then six months later significantly lost vision because of uncontrolled uveitis and scar tissue formation around the lens implant that really permanently decreased the visual outcome of these patients.

So planning and aggressive inflammatory control are really the two main points that I would bring up. And the other thing is at any point that we feel things are getting a little bit out of hand, again, it doesn't hurt to reach out, talk to colleagues and things like that, so that we do what we can in the best interest of the patient.

Melanie Cole (Host): Great information. Thank you so much, Dr. Koreishi, for joining us today and really sharing your incredible expertise. To refer your patient or for more information, please visit our website at breakthroughsforphysicians.nm.org/ophthalmology to get connected with one of our providers. And that concludes this episode of Better Edge, a Northwestern medicine podcast for physicians. For updates on the latest medical advancements and breakthroughs, please follow us on your social channels. I'm Melanie Cole. Thanks so much for listening