|Year : 2022 | Volume
| Issue : 1 | Page : 43-48
Outcome of cataract surgery in pediatric uveitis (experience at King Khalid Eye Specialist Hospital)
Ahmad Mohammed AlAmeer1, Mohammed Al Shamrani2
1 Department of Ophthalmology, King Khaled Eye Specialist Hospital; Department of Surgery, Division of Ophthalmology, King Abdullah bin Abdulaziz University Hospital, Riyadh, Saudi Arabia
2 Department of Ophthalmology, King Khaled Eye Specialist Hospital; Department of Ophthalmology, King Saud University Medical City, Riyadh, Saudi Arabia
|Date of Submission||14-Jan-2021|
|Date of Decision||26-Jun-2021|
|Date of Acceptance||11-Oct-2021|
|Date of Web Publication||02-Mar-2022|
Dr. Mohammed Al Shamrani
Department of Ophthalmology, King Saud University Medical City, Riyadh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
BACKGROUND: Cataract is a major complication of uveitis in children that requires timely management to restore good vision and prevent amblyopia. In surgical management of uveitic pediatric cataracts, published literature has shown a variety of clinical factors affecting the final visual outcome. The aim of this study is to investigate and report the clinical outcomes of cataract surgery and contributing factors impacting such outcomes in children with uveitis.
MATERIALS AND METHODS: A retrospective case series of all pediatric patients (<18 years) who were diagnosed with uveitis and had cataract surgery at a tertiary eye institutions, between January 2000 and October 2016. Outcomes measures include best-corrected visual acuity (BCVA) and postoperative complications. Success was defined as BCVA of ≥20/60. Factors related to successful outcome were analyzed.
RESULTS: The study sample was comprised of 26 patients (39 eyes). The median postoperative follow-up was 6.4 years. At the last follow-up, only 2 eyes had active uveitis, 3 eyes were controlled without medications, and 34 eyes were controlled with systemic or topical medications. At the last follow-up, 64% of eyes had BCVA ≥20/60. Anterior uveitis and postoperative aphakia were two determinants, in statistically significant manner, found to be positively related to clinical success (P = 0.01 and 0.04, respectively). Etiology of uveitis and use of preoperative intravenous methylprednisolone were not related to the success of obtaining BCVA ≥20/60 (P = 0.5 and 0.99, respectively).
CONCLUSIONS: Cataract surgery improves the visual function of children with clinically significant uveitic cataracts. In this study, we found diagnosis of anterior uveitis and postoperative aphakia to be associated with better final postoperative visual outcomes.
Keywords: Cataract surgery, pediatric cataract, pediatric uveitis
|How to cite this article:|
AlAmeer AM, Al Shamrani M. Outcome of cataract surgery in pediatric uveitis (experience at King Khalid Eye Specialist Hospital). Oman J Ophthalmol 2022;15:43-8
|How to cite this URL:|
AlAmeer AM, Al Shamrani M. Outcome of cataract surgery in pediatric uveitis (experience at King Khalid Eye Specialist Hospital). Oman J Ophthalmol [serial online] 2022 [cited 2022 Aug 15];15:43-8. Available from: https://www.ojoonline.org/text.asp?2022/15/1/43/338874
| Introduction|| |
Uveitis in children is less common than in adults with a reported prevalence of approximately 30 cases per 100,000, compared to 93 per 100,000 in adults. It is, however, a major cause of blindness in children. Based on the duration of disease, the prevalence of legal blindness due to uveitis in a large multicenter, multiethnic study in the US ranges from 3.17% to 15.15%.
Cataract is a major vision-threatening problem that, when presenting in early childhood, can lead to irreversible amblyopia. Fifty to seventy percent of children with chronic uveitis develop cataract during the course of the disease, usually secondary to the prolonged use of corticosteroids, chronic nature of inflammatory process, or after intraocular surgery, including glaucoma surgeries or pars plana vitrectomy (PPV).,,,
Advancement in the techniques of cataract surgery and implantation of intraocular lenses (IOLs) improve the final visual outcomes in nonuveitic pediatric cataract.,,, However, exacerbation of intraocular inflammation, posterior synechiae, glaucoma, and macular edema have been reported to be major postoperative complications in uveitis related pediatric cataract which limit the outcome in some cases.,,, In the surgical management of pediatric uveitic cataract, IOL implantation remains a significant point of controversy.,,, Poor visual outcome after IOL implantation has been reported in children with juvenile idiopathic arthritis (JIA)-associated uveitis., However, several studies reported favorable surgical and visual outcomes of IOL implantation in selected cases of pediatric uveitis.,,,,, Most of these studies stressed the importance of meticulous perioperative control of intraocular inflammation and concluded that primary IOL implantation is an option in pediatric uveitic cataract.
The aim of this study is to report the long-term clinical outcomes, in terms of best-corrected visual acuity (BCVA) and postoperative complications of cataract surgery and investigate contributing factors related to successful visual outcome in pediatric uveitic cataract at King Khalid Eye Specialists Hospital (KKESH) in Riyadh, Saudi Arabia.
| Materials and Methods|| |
This retrospective case series enrolled all pediatric patients diagnosed with uveitis who underwent cataract surgery at KKESH between January 2000 and October 2016. At least 1 year postoperative follow-up was required to be included in the study. Patients were excluded if they were older than 18 years at the time of cataract surgery or had cataract surgery elsewhere.
The study adhered to the general ethical standards and approved by our institutional review board. A chart review was performed to collect data on patient demographics, type of uveitis, age at diagnosis, preoperative BCVA, intraocular pressure (IOP), previous surgeries, preoperative steroid treatment, date of cataract surgery, type of surgery, IOL placement, and complications.
The routine protocol in the hospital is to admit the patient 3 days before the surgery, start frequent topical steroids with/without systemic steroids, and keep systemic immunomodulators. Intraocular inflammation must be controlled for at least 3 months prior to cataract surgery. Cataract extraction was performed by multiple experienced surgeons using anterior lens aspiration or phacoemulsification techniques.
Postoperative BCVA, IOP, control of uveitis, and retinal status were documented at 6 months, 1 year, 2 years and/or at the last follow-up visit. Data were collected on postoperative complications. Visual acuity was classified according to the World Health Organization International Classification of Disease and Related Health Problems. Surgical success was considered if there was mild or no visual impairment, defined as BCVA of 20/60 or better at last follow-up.
Data were analyzed with SPSS software (IBM Corp., Armonk, NY, USA). Descriptive statistics are reported for demographic data and disease characteristics including, percentage, median, mean, and standard deviation. The Chi-square test was used for categorical data, and the t-test and/or Mann–Whitney test was used to compare numerical data. P < 0.05 was considered statistically significant.
| Results|| |
A total of 26 patients (39 eyes) were enrolled in this study. The mean age at the time of diagnosis of uveitis was 7.9 years (range, 4.8–13.5 years), and the mean age at the time of cataract surgery was 10.1 years (range, 5–16.9 years). The median time between diagnosis of uveitis and cataract surgery was 44.3 months (range, 4.3–324 months). The female-to-male ratio was 1.8:1. Preoperative and intraoperative clinical characteristics are shown in [Table 1]. The median duration of follow-up was 6.4 years (1.6–12 years).
|Table 1: Preoperative and intraoperative clinical characteristics of patients with uveitic cataract|
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Twenty-five eyes (64%) had preoperative BCVA <20/400 and 25 eyes (64%) had BCVA of 20/60 or better at last follow-up. [Figure 1] presents the preoperative BCVA, postoperative BCVA and BCVA at last follow up. The mean preoperative IOP was 16.6 ± 5.6 mmHg. [Figure 2] presents the mean IOP before and after cataract surgery and at last follow up. Glaucoma surgery was performed in 5 (13%) eyes prior to cataract surgery and in 10 (26%) eyes after cataract surgery. All patients were on systemic steroid or immunomodulatory agents and had controlled uveitis for at least 3 months prior to cataract surgery. Only 2 (5%) had uncontrolled uveitis at last follow-up. Preoperative, postoperative, and last follow-up numbers of IOP lowering medications, glaucoma surgeries, and control of uveitis are shown in [Table 2].
|Figure 1: Best corrected visual acuity of patients with pediatric uveitis who underwent cataract surgery|
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|Figure 2: Intraocular pressure of patients with pediatric uveitis who underwent cataract surgery|
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|Table 2: Preoperative, postoperative and last follow up number of intraocular pressure lowering medications, glaucoma surgeries and control of uveitis|
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After cataract surgery, 2 eyes underwent PPV for rhegmatogenous retinal detachment and 2 eyes (1 patient) underwent PPV for significant posterior capsular opacity. IOL was explanted in 2 eyes (1 patient) due to iris capture of IOL and a secondary membrane. The most frequent complication was glaucoma and band keratopathy, noted in 15 eyes. Glaucoma developed in 10 (45%) pseudophakic eyes and 5 (29%) aphakic eyes with no statistical difference between the two groups (P = 0.30). Two pseudophakic eyes developed amblyopia in which they were originally unilateral cataract. [Table 3] presents the complications after cataract surgery in aphakic and pseudophakic eyes.
|Table 3: Postcataract surgery complications in patients with uveitic cataract|
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Statistically significant factors raising the risk for unsuccessful outcome were the diagnosis of non-anterior uveitis and primary IOL implantation (P = 0.01) and (P = 0.04), respectively. The etiology of uveitis and preoperative use of intravenous methylprednisolone were not statistically significant factors for achieving successful outcomes (P = 0.5 and P = 0.99, respectively). Factors related to the success in obtaining BCVA ≥20/60 at last follow-up are shown in [Table 4].
|Table 4: Factors related to the success in providing best corrected visual acuity ≥20\60 at last follow up|
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Of 27 eyes with anterior uveitis, 11 underwent IOL implantation and 16 were left aphakic. In other cases of uveitis (other than anterior uveitis; 12 eyes), 11 underwent IOL implantation and 1 was left aphakic. In JIA-associated uveitis, 3 eyes underwent IOL implantation and 13 were aphakic. All pseudophakic (n: 3) and 11 aphakia (85%) in JIA-associated uveitis attained BCVA of 20/60 or better. In patients with unilateral cataract who underwent IOL implantation, 6 out of 9 (67%) had BCVA ≥20/60, while in bilateral cataract, 5 out of 13 (38%) had BCVA ≥20/60 (P = 0.19).
| Discussion|| |
The outcomes of this review of pediatric patients with uveitis who underwent cataract surgery, indicate a satisfactory postoperative visual outcome in most of the cases. For example, approximately 64% of the patients achieved BCVA of 20/60 or better (success) at last follow-up. Many experts have suggested that aggressive control of perioperative inflammation for at least 3 months is the key to obtain good visual outcomes.,, In our series, all patients received perioperative immunosuppression therapy and had controlled uveitis for at least 3 months prior to cataract surgery. BenEzra and Cohen reported a complicated postoperative course in children with JIA-associated uveitis secondary to uncontrolled inflammation. In their study, the main aim of cataract surgery was the prevention of amblyopia without waiting for uveitis to completely settle.
Previous studies have reported that children with JIA-associated uveitis are likely to have poor visual outcome compared with other causes of uveitis. This observation may be due to younger age at presentation (most of the cases were younger than 5 years), established ocular inflammatory sequelae, and severe persistent intraocular inflammation.,, In our study however, the etiology of uveitis was not a significant predictor of visual outcome (P = 0.5). In the current study, 87.5% of JIA-associated uveitis eyes attained BCVA of 20/60 or better. This successful outcome can be attributed to meticulous perioperative control of inflammation and older age at the time of diagnosis of uveitis and cataract surgery (mean age at diagnosis of JIA-associated uveitis was 7.6 years and 10.3 years at the time of cataract surgery). Quiñones et al. found no statistically significant difference in the outcome of cataract surgery between patients with posterior segment pathology and those without. However, in our study, nonanterior uveitis was associated with poor visual outcome at last follow-up.
Numerous studies have reported successful visual outcomes after primary IOL implantation in selected cases of pediatric uveitis.,,,,, However, some have reported poor visual outcomes in JIA-associated uveitis as a result of significant inflammation, development of intractable glaucoma, posterior synechia, macular edema, cyclitic membrane, hypotony, and phthisis.,, We found better visual outcomes in aphakic eyes. This might be related to a greater number of patients (11 patients) with nonanterior uveitis in the pseudophakic group compared to the aphakic group (only 1 patient). A recent retrospective study reported that secondary IOL implantation after cataract surgery in children with JIA-related uveitis was associated with a significantly lower incidence of secondary glaucoma and retrolental membrane formation. However, no patient in our series underwent secondary IOL implantation.
The most common complications in our series were glaucoma and band keratopathy followed by cystoid macular edema. There was no statistically significant difference between aphakic and pseudophakic patients in the development of glaucoma and band keratopathy (P = 0.3) which concurs with previous literature., Our study shares the same limitations as previous studies on this topic including, the retrospective nature and the small sample size which can affect the statistical power of our outcomes. Also, the small number of cases in each subgroup limits the ability to draw a solid conclusion and provide recommendations.
| Conclusion|| |
Cataract surgery in pediatric patients with uveitis improved visual outcome in most of the cases. Anterior uveitis is associated with a favorable visual outcome after cataract surgery. Primary implantation of IOL can be an option in selected cases of pediatric uveitis with aggressive control of perioperative and postoperative inflammation. However, aphakia is still a good choice for children with uveitic cataract, especially in bilateral cases where anisometropia is not a major concern as in unilateral cataract. Further prospective studies with a larger sample size are warranted to explore the controversial areas in management of these blinding entities of ocular disease.
We would like to appreciate the endless support of the research department at King Khaled Eye Specialist Hospital. Special thanks to Dr. Rajiv Khandekar for his support and help in data analysis.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Kump LI, Cervantes-Castañeda RA, Androudi SN, Foster CS. Analysis of pediatric uveitis cases at a tertiary referral center. Ophthalmology 2005;112:1287-92.
Smith JA, Mackensen F, Sen HN, Leigh JF, Watkins AS, Pyatetsky D, et al.
Epidemiology and course of disease in childhood uveitis. Ophthalmology 2009;116:1544-51.
Tugal-Tutkun I, Havrlikova K, Power WJ, Foster CS. Changing patterns in uveitis of childhood. Ophthalmology 1996;103:375-83.
Rosenberg KD, Feuer WJ, Davis JL. Ocular complications of pediatric uveitis. Ophthalmology 2004;111:2299-306.
Okhravi N, Lightman SL, Towler HM. Assessment of visual outcome after cataract surgery in patients with uveitis. Ophthalmology 1999;106:710-22.
Menezo JL, Taboada JF, Ferrer E. Complications of intraocular lenses in children. Trans Ophthalmol Soc U K 1985;104:546-52.
Morgan KS. Pediatric cataract and lens implantation. Curr Opin Ophthalmol 1995;6:9-13.
Knight-Nanan D, O'Keefe M, Bowell R. Outcome and complications of intraocular lenses in children with cataract. J Cataract Refract Surg 1996;22:730-6.
Malukiewicz-Wisniewska G, Kaluzny J, Lesiewska-Junk H, Eliks I. Intraocular lens implantation in children and youth. J Pediatr Ophthalmol Strabismus 1999;36:129-33.
Holland GN. Intraocular lens implantation in patients with juvenile rheumatoid arthritis-associated uveitis: An unresolved management issue. Am J Ophthalmol 1996;122:255-7.
Probst LE, Holland EJ. Intraocular lens implantation in patients with juvenile rheumatoid arthritis. Am J Ophthalmol 1996;122:161-70.
BenEzra D, Cohen E, Karshai I. Phakic posterior chamber intraocular lens for the correction of anisometropia and treatment of amblyopia. Am J Ophthalmol 2000;130:292-6.
Lam LA, Lowder CY, Baerveldt G, Smith SD, Traboulsi EI. Surgical management of cataracts in children with juvenile rheumatoid arthritis-associated uveitis. Am J Ophthalmol 2003;135:772-8.
Foster CS, Barrett F. Cataract development and cataract surgery in patients with juvenile rheumatoid arthritis-associated iridocyclitis. Ophthalmology 1993;100:809-17.
Heiligenhaus A, Szurman P, Heinz C. Current cataract surgery for uveitis in childhood. Ophthalmologe 2007;104:572-6.
BenEzra D, Cohen E. Cataract surgery in children with chronic uveitis. Ophthalmology 2000;107:1255-60.
Heiligenhaus A. When should intraocular lenses be implanted in patients with juvenile idiopathic arthritis-associated iridocyclitis? Ophthalmic Res 2006;38:316-7.
Lundvall A, Zetterström C. Cataract extraction and intraocular lens implantation in children with uveitis. Br J Ophthalmol 2000;84:791-3.
Zaborowski AG, Quinn AG, Gibbon CE, Banerjee S, Dick AD. Cataract surgery with primary intraocular lens implantation in children with chronic uveitis. Arch Ophthalmol 2008;126:583-4.
Kotaniemi K, Penttila H. Intraocular lens implantation in patients with juvenile idiopathic arthritis-associated uveitis. Ophthalmic Res 2006;38:318-23.
Nemet AY, Raz J, Sachs D, Friling R, Neuman R, Kramer M, et al.
Primary intraocular lens implantation in pediatric uveitis: A comparison of 2 populations. Arch Ophthalmol 2007;125:354-60.
Terrada C, Julian K, Cassoux N, Prieur AM, Debre M, Quartier P, et al.
Cataract surgery with primary intraocular lens implantation in children with uveitis: Long-term outcomes. J Cataract Refract Surg 2011;37:1977-83.
World Health Organization. International Statistical Classification of Diseases and Related Health Problems. 10th
edition: World Health Organization; 2016.
Phatak S, Lowder C, Pavesio C. Controversies in intraocular lens implantation in pediatric uveitis. J Ophthalmic Inflamm Infect 2016;6:12.
Quiñones K, Cervantes-Castañeda RA, Hynes AY, Daoud YJ, Foster CS. Outcomes of cataract surgery in children with chronic uveitis. J Cataract Refract Surg 2009;35:725-31.
Angeles-Han S, Yeh S. Prevention and management of cataracts in children with juvenile idiopathic arthritis-associated uveitis. Curr Rheumatol Rep 2012;14:142-9.
Magli A, Forte R, Rombetto L, Alessio M. Cataract management in juvenile idiopathic arthritis: Simultaneous versus secondary intraocular lens implantation. Ocul Immunol Inflamm 2014;22:133-7.
Sijssens KM, Los LI, Rothova A, Schellekens PA, van de Does P, Stilma JS, et al.
Long-term ocular complications in aphakic versus pseudophakic eyes of children with juvenile idiopathic arthritis-associated uveitis. Br J Ophthalmol 2010;94:1145-9.
Yangzes S, Seth NG, Singh R, Gupta PC, Jinagal J, Pandav SS, et al.
Long-term outcomes of cataract surgery in children with uveitis. Indian J Ophthalmol 2019;67:490-5.
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