Handling Inflammation with Care

Even uncomplicated cataract surgery induces inflammation, but certain pre-existing conditions put patients at risk for developing a more exuberant and prolonged reaction. Understanding the aetiology for inflammation after cataract surgery can be infectious or non-infectious and arise from an exogenous or endogenous source is the foundation for implementing appropriate preventive and therapeutic strategies, according to Harminder S Dua MD, PhD.

“And, when thinking about the pathway to successful diagnosis and management, always remember that we must examine and treat the patient as a whole and not just the eye,” he said.

Professor Dua noted chronic or recurrent intraocular inflammation after cataract surgery reportedly occurs between 0.1% and 2.0% of cases. Risk factors for these events include prolonged/complicated surgery, retention of lens material, capsular bag infection, and pre-existing uveitis.

“It is very important to understand the cataract surgery age group is a population of patients who have a higher rate of uveitic conditions, and uveitis is commonly associated with cataract development,” he explained. “Therefore, patients with a history of uveitis must be identified so you can take the appropriate precautions to avoid serious complications.”

To illustrate, he discussed patients with collagen vascular disorders, such as rheumatoid arthritis, who can have ocular inflammation as a manifestation of their autoimmune disease.

Even if the rheumatoid arthritis and any associated uveitis appear under control, these patients are at risk of developing corneal and scleral inflammation with subsequent melts after cataract surgery. In these cases, Prof Dua recommended considering operating through a sclerocorneal tunnel incision.

He also encouraged involving the patient’s rheumatologist/immunologist because these patients should also be treated with systemic steroids and immunosuppression.

Prof Dua also highlighted the need for caution when performing cataract surgery in patients with a history of ocular cicatricial pemphigoid, taking care not to manipulate the conjunctiva to avoid triggering a flare of the ocular surface autoimmune disease. He recommended placing a fixation ring to avoid using forceps to hold the conjunctiva, starting patients on immunosuppressive therapy preoperatively, and continuing steroid treatment for longer than usual after surgery.

Of other inflammatory ocular surface conditions possibly exacerbated by or capable of compromising cataract surgery outcomes, Prof Dua noted blepharitis is a risk factor for postoperative dry eye disease and infectious endophthalmitis—most commonly caused by entry into the eye through commensal bacteria on the lids and conjunctiva. He emphasised the importance of using povidone-iodine 5% preoperatively for disinfecting the ocular surface and periocular skin along with appropriate draping. A temporal incision can be particularly beneficial in eyes with blepharitis because it avoids tangling with eyelashes that harbour bacteria.

Although anterior basement membrane dystrophy is not an inflammatory condition, when the epithelium is disturbed because of cataract surgery, eyes with this disorder are at risk for developing recurrent corneal erosion syndrome accompanied by chronic, recurrent inflammation.

“Recognise these eyes and handle them with care,” said Prof Dua, suggesting alcohol delamination is the simplest and most effective treatment for this dystrophy.

Prof Dua spoke at the 2023 ESCRS Congress in Vienna.

Harminder S Dua MD, PhD is Chair and Professor of Ophthalmology, University of Nottingham, England, United Kingdom. harminder.dua@nottingham.ac.uk