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Postoperative Uveitis


History of Present Illness (HPI)

A 63-year-old woman underwent cataract surgery in the left eye (OS) about 3 months ago. The case was reportedly uncomplicated, and a one-piece intraocular lens (IOL) was placed in the capsular bag. Since then, she has had multiple episodes of what her cataract surgeon called “rebound iritis.” She was tapered off prednisolone acetate four times a day (QID) from postoperative week 1 to 4, promptly experienced a slight decrease in vision, and was noted to have white cells in the anterior chamber. Another week of prednisolone acetate QID was initiated, resulting in near resolution of the inflammation according to the surgeon’s notes, followed by another taper over 3 weeks. She presented postoperative week 8 with a similar presentation to week 4. Another 4 weeks of identical management with recurrent iritis again at week 12 then followed. At that point, she was referred to you on prednisolone acetate 1% twice a day (BID).

Past Ocular History

  • Keratoconjunctivitis sicca both eyes (OU), controlled with preservative-free artificial tears and topical cyclosporine 0.05% BID OU

Past Medical History

  • Gastroesophageal reflux disease

  • Osteoarthritis

  • Sjogren syndrome

Exam
OD OS
Visual acuity 20/25 20/30+
Intraocular pressure (IOP) 15 14
Sclera/conjunctiva White and quiet White and quiet
Cornea Clear A few large keratic precipitates (KPs)
Anterior chamber (AC) Deep and quiet 2+ white cells
1+ flare
Iris Unremarkable Unremarkable, no transillumination defect (TIDs)
Lens 2+ nuclear sclerosis (NS) See Fig. 13.1
Anterior vitreous clear 2+ white cells, 0 haze

Dilated Fundus Examination (DFE)
Nerve: Cup-to-disc (c/d) 0.2, pink, sharp c/d 0.2, pink, sharp
Macula: Flat Flat
Vessels: Normal caliber and course Normal caliber and course
Periphery: Unremarkable Unremarkable

Fig. 13.1, Slit lamp photograph of the left eye demonstrates a one-piece posterior chamber intraocular lens (PCIOL) with inflammatory cells/deposits on the IOL, or “lens precipitates.” The haptics are clearly within the capsular bag.

Questions to Ask

  • Acquire a copy of the operative report. Was there manipulation of uveal tissue? Was there iris prolapse out of the wound? Were hooks or a Malyugin ring used?

  • Do you have any other history of rheumatic or autoimmune disease beyond what you have told us?

  • Have you ever had any other eye problems, like inflammation in the eye or blepharitis?

There was no report of iris prolapse out of the wound. Iris hooks were used during the case. The patient was diagnosed with Sjogren syndrome two decades ago but no other autoimmune diseases. Upon prompting, she does recall that she had an episode of “iritis” in one of her eyes years ago, which resolved quickly “with just a few drops.”

Assessment

  • Anterior uveitis and intermediate uveitis OS (predominantly anterior) beginning after cataract surgery

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