Challenges with cataract surgery in pars planitis patients
Received: 8 May 2017 /Accepted: 17 May 2017 /Published online: 7 June 2017
The Author(s) 2017. This article is an open access publication
Children and teens with intraocular inflammation often pres-
ent with cataract. It has been predicted that the risk for cataract
development in children with anterior uveitis and juvenile
idiopathic arthritis (JIA) is 0.16 events per patient-year of
follow-up . This is likely also the case for pars planitis.
Pars planitis, which presents mainly in younger ages, is a
subset of intermediate uveitis characterized by the presence
of snowbanks at the pars plana and inflammatory cells in the
vitreous. We often realize that these patients have worse
vitritis, more severe macular edema and a guarded prognosis
when compared to our other patients with intermediate uveitis.
Indeed, cataract formation is the most frequent cause of severe
vision loss in pediatric patients suffering from pars planitis,
followed by vitreous opacification [2, 3]. The close proximity
of inflammatory changes at the pars plana to the lens with a
constant accumulation of immune mediators, as well as long
term corticosteroid treatment, predispose these eyes for cata-
ract development [4, 5].
Whereas adult uveitic cataracts are managed with
phacoemulsification with primary intraocular lens (IOL)
implantation, no standard approach exists for children. At a
time when cataract surgery is a daily routine in young patients
as well as adults, this may not appear as a major task. In the
context of uveitis, however, it remains a challenge. It requires
not only a meticulous procedure, but also critical timing of
intervention and a deeper understanding of the underlying
inflammatory mechanisms. The question of whether an IOL
can be tolerated in uveitic eyes has been disputed for decades.
It is now mainly agreed that an IOL can be safely implanted in
Fuchs uveitic and idiopathic nongranulomatous eyes, whereas
moderate success might be expected, e.g. in Behcets disease
and HLA-B27 associated uveitis, still the most critical patients
remain young children with juvenile idiopathic arthritis [6–9].
It is uncertain, however, which type of IOL provides the best
visual outcome in uveitic eyes . This issue was meticu-
lously investigated by Leung et al. in the Cochrane Database
for Systematic Reviews. Current evidence supports a superior
effect of hydrophobic acrylic lenses over silicone lenses,
specifically for posterior synechiae outcomes .
Since both cataract and vitreous haze affect vision in pars
planitis, combined procedures can be considered. The ques-
tion of simultaneous cataract extraction and vitrectomy has so
far rarely been addressed. Is this additional effort worthwhile?
Albavera-Giles et al. have addressed the question in this
issue of the journal . More than two-thirds of all their
cataract interventions were performed as combined proce-
dures including vitrectomies. Therefore, this work differs in
several points from previous observations.
Firstly, the combined procedure is a relatively Baggressive^
approach, given the relatively young age of the cohort under
investigation. It has to be stressed that these eyes often present
with a small pupil, anterior and/or posterior synechiae, cyclitic
membranes and even zonulolysis. Consequently, this may
lead to an undersized or incomplete capsulorhexis, iris pro-
lapse, increased risk of posterior capsular tear, retained nuclear
fragments and increased risk of intraoperative zonular dehis-
cence . In addition, it has to be taken in mind that in these
* Andrzej Grzybowski
Department of Ophthalmology, Poznan City Hospital, ul.
Szwajcarska 3, 61-285 Poznan, Poland
Department of Ophthalmology, University of Warmia and Mazury,
Department of Ophthalmology, Medical University of Gdańsk,
Department of Ophthalmology, Charité, University Medicine Berlin,
Campus Virchow-Klinikum, Berlin, Germany
Graefes Arch Clin Exp Ophthalmol (2017) 255:1483–1484