Postoperative complications of intraocular lens implantation in patients with Fuchs' heterochromic cyclitis

Jagat Ram, M.D., Sandeep Jain, M.D., Surinder Singh Pandav, M.D., Amod Gupta, M.D., Gurmeet Singh Mangat, M.D.

ABSTRACT We studied 29 eyes of 24 patients with Fuchs' heterochromic cyclitis who had extracapsular cataract extraction and posterior chamber intraocular lens implantation. Follow-up ranged from one to four years (mean two years). Intraoperative complications included mild hyphema (n = 4). Early postoperative complications included uveitis (n = 9), glaucoma (n = 7), pigment deposits on the lens surface (n = 8), vitreous opacities (n = 8), and cystoid macular edema (n = 1 ). Late postoperative complications included posterior capsule opacification (n = 6), recurrent uveitis (n = 4), and per­sistent glaucoma (n = 3). Best corrected visual acuity of 20/40 or better was achieved in 24 eyes (82.8%).

Key Words: extracapsular cataract extraction, Fuchs' heterochromic cycli­tis, posterior chamber intraocular lens implantation, uveitis

Fuchs' heterochromic cyclitis, a chronic nongranu­lomatous uveitis that affects patients between 20 and 40 years old, 1 is frequently complicated by cataract formation. The incidence of cataract in these eyes is from 15% to 75%,2

•3 and visual prognosis after cata­

ract surgery varies. 1•4

-10 Although some studies report

good outcomes, 1•5

•6 an increased rate of complications

after iris-supported5 and posterior chamber intraocular lens (IOL) implantation has been reported in these eyes.

We report on postoperative complications and long­term visual outcome after extracapsular cataract ex­traction (ECCE) with posterior chamber IOL implantation in 29 eyes with Fuchs' heterochromic cyclitis.

MATERIALS AND METHODS

We evaluated 29 eyes (24 patients) with Fuchs' heterochromic cyclitis and cataracts that had ECCE with posterior chamber IOL implantation. The Fuchs' heterochromic cyclitis diafinosis, based on the criteria of Kimura and coauthors, 1 included small white ker­atic precipitates on the corneal endothelium, minimal

flare and cells in the anterior chamber, presence of iris atrophy or heterochromia, and absence of posterior synechias. Patients whose cataract was the result of other causes of uveitis or trauma were excluded from the study.

Preoperatively, all patients used topical antibiotics for 24 hours before surgery. None received topical or systemic steroids.

Two physicians (J.R., A.G.) performed all surgeries using a standard retrobulbar anesthesia; ECCE was done using a conventionallimbal incision and manual nucleus delivery. Methylcellulose 2% was used as viscoelastic agent. Surgeons attempted to place the IOL haptics in the capsular bag in all patients. Intra­cameral carbachol 0.01% was used to constrict the pupil after lens insertion. The incision was closed with five to seven interrupted 10-0 monofilament sutures. Methylcellulose was washed out before final closure of the wound.

A subconjunctival injection of gentamicin (20 mg) and dexamethasone ( 4 mg) was given at the end of surgery. Postoperatively, topical antibiotic and beta­methasone 0.1% eyedrops were instilled six to eight

Presented in part at the Symposium on Cataract, IOL and Refractive Surgery, Boston, April I994.

Reprint requests to Jagat Ram, M.D., Department of Ophthalmology, Postgraduate Institute of Medical Education and Research, Chandigarh I600I2, India.

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times a day for a week and tapered over the next six weeks. Intraocular pressure (lOP) was recorded 24 hours after surgery. Eyes with a postoperative inflam­matory reaction were treated with cyclopentolate 1% drops and topical steroids. Patients with severe uveitis were given additional oral prednisolone.

Mean follow-up was 2 years (range 12 months to 4 years).

RESULTS Mean age of the 24 patients (13 male) was 32 years

(range 15 to 48 years). Five patients had bilateral Fuchs' heterochromic cyclitis. Preoperative visual acuity in the affected eyes varied from light perception to 20/200. The cataract was posterior subcapsular in 17 eyes (58.6%) and soft mature in 12 (41.4%). All eyes had brown irides and a mild inflammatory reac­tion in the form of aqueous flare and small white keratic precipitates.

Intraoperative complications included hyphema in four eyes (13.8% ), smaller than 2 mm in three eyes, and a filiform hemorrhage on the iris in one eye.

Table 1 shows the postoperative complications. Ex­udates had formed in the pupillary area of the four eyes with severe uveitis in the early postoperative period. All responded to treatment except one, which developed extensive posterior synechias. Three of four eyes with recurrent uveitis showed mild inflammatory reaction; one had severe exudative uveitis (Table 1 ). Gonioscopy of the three eyes with persistent glaucoma (lOP from 22 to 30 mmHg) showed pigment depos­its in the trabecular meshwork. Intraocular pressure was controlled with timolol maleate 0.5% twice daily in all eyes. The two cases of posterior capsule opaci­fication (PCO) occurred between 18 and 24 months postoperatively.

Visual acuity at the last follow-up was 20/40 or better in 24 eyes (Figure 1). Two eyes had a visual acuity of 20/400 or less as a result of severe persistent cystoid macular edema (CME) (n = 1) or pupillary membrane formation (n = 1).

DISCUSSION Cataract formation is a common complication of

Fuchs' heterochromic cyclitis.1-

3 Conflicting reports on the outcome of surgery in these patients have made treatment decisions difficult, particularly when IOL im­plantation is done.

Mooney and O'Connor12 reported on 10 cases of ECCE with implantation of a Binkhorst iridocapsular­fixated IOL and 1 case of intracapsular cataract ex­traction (ICCE) with iris-clip IOL implantation; the IOL was well tolerated by all eyes. Mills and Rosen5

reported on 8 patients having ICCE and implantation of a Binkhorst four-loop iris-clip IOL; pupillary mem­brane formed in 4 eyes and glaucoma developed in 3. Jones4 reported the results of ECCE with and without

Table 1. Postoperative complications in patients with Fuchs' heterochromic cyclitis after ECCE with posterior chamber IOL implantation (N = 29).

Complication

Early

Uveitis

Severe

Mild

Glaucoma

Pigment deposits on anterior lens surface

Anterior vitreous opacities

Cystoid macular edema

Late

Posterior capsule opacification

Fibrotic

Pearl formation

Recurrence of uveitis

Persistent glaucoma

Number of Eyes (%)

4 (13.8)

5 (17.2)

7 (24.1)

8 (27.6)

8 (27.6)

1 (3.4)

2 (6.9)

4 (13.8)

4 (13.8)

3 (10.3)

posterior chamber IOL implantation in 29 patients with Fuchs' heterochromic cyclitis; 22 obtained 20/40 or better visual acuity. Postoperative uveitis or glau­coma developed in 13 eyes, including 11 of the 20 eyes with posterior chamber IOLs; only 2 of 10 eyes without an IOL developed uveitis or glaucoma. Jones concluded that IOL implantation significantly in­creased the risk of postoperative complications in eyes with Fuchs' heterochromic cyclitis. Gee and Tabbara1

reported on 16 patients who had ECCE; 11 of them also had posterior chamber IOL implantation. After surgery, all had 20/40 or better visual acuity; none had significant postoperative inflammation.

Fig. 1. (Ram) Visual outcome after ECCE with posterior chamber IOL implantation in patients with Fuchs' heterochromic cyclitis.

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Table 2. Complications in reported series of Fuchs' heterochromic cyclitis having cataract surgery with and without IOL implantation.

Number of Eyes

Procedure Intraoperative and Postoperative Complications

ECCE ICCE ± +PC PC Pupil VA

Series Year IOL ECCE IOL Rupture PCO Uveitis Glaucoma Membrane ~20/100

Mills & Rosen5 1982 8 0 0 NK NK NK 4 2 1

Jain and coauthors9 1983 1 20 0 1 NK 2 1 1 1

Chung & coauthors10 1987 0 0 13 NK 2 0 NK NK 0

Pignalosa & coauthors16 1988 0 0 12 0 1 3 0 NK 0

Gee & Tabbara1 1989 0 5 10 NK NK 2 0 0 0

Jones4 1990 0 10 20 2 NK 5 10 0 3

Razzak & AI Samarrai18 1990 0 0 9 0 1 0 0 0 0

Jakeman & coauthors17 1990 0 0 20 0 3 4 4 2 1

Baarsma & coauthors19 1991 0 0 22 1 4 1 2 NK 1

Present study 1995 0 0 29 0 6 9 7 4 2

ICCE ± IOL = intracapsular cataract extraction with or without IOL implantation; ECCE = extracapsular cataract extraction; ECCE + PC IOL = extracapsular cataract extraction with posterior chamber IOL implantation; PC = posterior capsule; PCO = posterior capsule opacification; VA = visual acuity; NK = not known

In our study, most patients had a good visual out­come; 24 eyes (82.8%) achieved a visual acuity of 20/40 or better. Thirty-one percent had uveitis in the early postoperative period; 13.7% had late recurrence of uveitis. Because the cause of uveitis in eyes with Fuchs' heterochromic cyclitis is not known, Apple et al. 13·14 recommend in-the-bag IOL placement to min­imize IOL-uveal tissue contact.

Incidence of glaucoma after cataract surgery in pa­tients with Fuchs' heterochromic cyclitis varies from 3% to 35%.15 In our study, 24.1% of eyes had high lOP in the early postoperative period; 10.3% had per­sistent lOP elevation that required prolonged antiglau­coma medication.

Twenty-seven percent of eyes had pigment deposits on the lens surface, and a similar percentage had opacities in the anterior vitreous. Vitreous opacities, reported in 12% to 50% of the eyes having cataract extraction in patients with Fuchs' heterochromic cy­clitis,4·5 may occur in a natural course of the disease. In our study, however, because of the presence of advanced cataract at presentation, the opacities were detected after surgery.

Pignalosa and coauthors16 studied 12 eyes having ECCE with posterior chamber IOL implantation and found postoperative uveitis, corneal edema, and pig­ment deposits on the lens in several patients. In a study by Jakeman and coauthors, 17 five of 20 eyes having ECCE and posterior chamber IOL implantation had severe postoperative uveitis; two of them had pupillary membrane formation and posterior synechias. Twenty­five percent of eyes had glaucoma. Razzak and AI

Samarrai18 also observed pigment deposition on the lens surface in nine eyes after ECCE with posterior chamber IOL implantation.

Posterior capsule opacification has been reported in 8% to 20% of eyes after ECCE with posterior chamber IOL implantation.16- 19 Six eyes (20.7%) in our study developed PCO, requiring a neodymium:YAG (Nd: YAG) laser posterior capsulotomy between 1.5 and 3.0 years postoperatively. Five of the six eyes had a visual acuity of 20/40 or better after the Nd:YAG laser capsulotomy. One eye developed CME, which subse­quently resolved; final visual acuity was 20/60.

A recent review concluded that in general, response to cataract surgery in eyes with Fuchs' heterochromic cyclitis is good,20 but there are no long-term follow-up data available on posterior chamber IOL implantation in these eyes. In these patients, ECCE with posterior chamber IOL implantation is the procedure of choice if microsurgical techniques are used and the IOL hap­tics are placed in the capsular bag after adequate removal of lens material. 21 Postoperatively, topical steroids are indicated for six to eight weeks to mini­mize uveitis.

Table 2 summarizes the outcome of cataract surgery in reported series of patients with Fuchs' heterochro­mic cyclitis. In our study, patients had good visual recovery after posterior chamber IOL implantation; however, we recommend long-term follow-up for early detection and treatment of postoperative re­current uveitis and persistent glaucoma in these patients.

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