Pediatric uveitis is a potentially serious condition that can increase risks for severe ocular complications leading to permanent vision loss. “Visually significant cataracts occur in more than 70% of patients with pediatric uveitis,” explains Alan Palestine, MD. “These cataracts are caused by ocular inflammation and treatment with corticosteroids for the inflammation. Cataract removal in pediatric uveitis has been a controversial subject for several decades because of data demonstrating the increased risks of complications from recurrent inflammation.”
Several recent studies have shown that perioperative control of uveitis can improve visual acuity in patients with pediatric uveitis. “However, there has been reticence among ophthalmologists on whether or not to insert an intraocular lens (IOL) in these patients,” Dr. Palestine says. “Without an IOL implant, patients need to wear contact lenses or aphasic spectacles for the rest of their lives.” Considering that pediatric uveitis can be treated by uveitis ophthalmologists or pediatric ophthalmologists, it is important to determine if there are differences in how these specialists treat uveitic pediatric cataract removal and IOL placement.
For a study published in Opthalmology and Therapy, Dr. Palestine and colleagues surveyed 62 uveitis ophthalmologists and 47 pediatric ophthalmologists using an online poll to assess the management strategies of each specialty. “We wanted to assess current attitudes towards cataract surgery in juvenile idiopathic arthritis (JIA)-associated uveitis, pars planitis, and acute anterior uveitis, especially regarding IOL insertion,” adds Dr. Palestine.
Results of the study showed that 79% of all respondents indicated that uveitis was not a contraindication for primary IOL implantation in patients with controlled intraocular inflammation (Table). “The majority of physicians in both subspecialties were willing to implant an IOL in these patients,” says Dr. Palestine. The responses were not statistically different when surveyed respondents were asked if chronic JIA-associated iridocyclitis or recurrent acute anterior uveitis was a contraindication for primary IOL implantation.
According to Dr. Palestine, there was no consensus within either specialty regarding the preferred IOL material for lens implantation. “There was a wide range of acceptable types of lens implants to be inserted,” he says. “For example, we found that uveitis specialists were more likely to use intravitreal and intravenous perioperative corticosteroids but were somewhat less likely to believe that controlled pediatric uveitis was a contraindication to surgery. Pediatric ophthalmologists were more likely to operate on patients younger than 4 years of age.”
In cataract surgery for a child with recurrent acute anterior uveitis, a higher percentage of uveitis ophthalmologists than pediatric ophthalmologists (71% vs 50%, respectively) responded that the posterior capsule should be primarily opened. A higher percentage of uveitis ophthalmologists also stated that anterior vitrectomy should be performed at the time of cataract surgery in all three uveitis types. “In general, most physicians were willing to place an IOL at the time of surgery,” adds Dr. Palestine.”
Findings from the study suggest that subspecialty management differences exist for uveitic cataracts in pediatric patients. The results help to identify current treatment decisions made by uveitis ophthalmologists and pediatric ophthalmologists for pediatric cataracts associated with uveitis. Some of these differences were statistically significant while wide variations in treatment options and decisions were also seen for both subspecialties. The data suggest it may be beneficial for these subspecialties to continue to communicate and collaborate to improve patient care.
“Once ocular inflammation can be reliably controlled, cataract surgery with an IOL implant is indicated for visual rehabilitation in these patients,” says Dr. Palestine. “This is largely due to improved surgical techniques as well as improvement in anti-inflammatory therapeutic options. In the future, prospective studies on cataract surgery in pediatric uveitis cases would provide guidance on the optimal surgical approach for these patients. It would also be beneficial to study the type of IOL and perioperative corticosteroid regimens to help both subspecialties in optimizing the management of pediatric uveitis cataracts.”
Carpentier SJ, Jung JL, Patnaik JL, Pecen PE, Palestine AG. A cross-sectional online survey identifies subspecialty differences in the management of pediatric cataracts associated with uveitis. Ophthalmol Ther. 2020;9(2):293-303. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7196112/.
Palestine AG, Singh JK, Kolfenbach JR, Ozzello DJ. Specialty practice and cost considerations in the management of uveitis associated with juvenile idiopathic arthritis. J Pediatr Ophthalmol Strabismus. 2016;53(4):246-251.
Phatak S, Lowder C, Pavesio C. Controversies in intraocular lens implantation in pediatric uveitis. J Ophthalmic Inflamm Infect. 2016;6(1):12.