Postsurgical Uveitis

Intraocular inflammation can occur after any ocular surgical procedure. It is especially important in the postoperative patient to differentiate infectious causes of uveitis from other causes of intraocular inflammation because bacterial and fungal endophthalmitis require prompt treatment with specific antimicrobial therapy. The major causes of postsurgical uveitis are listed in Box 19.1 .

Patients with a pre-existing uveitis often experience exacerbation of intraocular inflammation after surgery. The flare-up usually occurs 3 days to a week postoperatively in patients who receive subconjunctival corticosteroids at the end of the surgical procedure. In patients who do not receive steroids, the inflammation may occur earlier. Patients with a history of uveitis undergoing retinal detachment repair develop more proliferative vitreoretinopathy (PVR) compared with other patients but have an overall similar prognosis. Occasionally, uveitis occurring after cataract surgery can be severe enough to be confused with infectious endophthalmitis, although hypopyon and severe pain are rare in patients with noninfectious postsurgical uveitis. In contrast, low-grade intraocular inflammation is common after many ocular procedures, especially after cataract extraction. This inflammation appears to be mediated by prostaglandins and can be inhibited by prostaglandin inhibitors. In contrast, a rat model of bacterial endophthalmitis showed that a wide range of proinflammatory cytokines are released, including tumor necrosis factor (TNF)-α, interleukin (IL)-1β, and the rat equivalent of IL-8. A better idea that is emerging is that of host/pathogen interactions during these severe infections ; the eye upregulates αB crystallin in an attempt to prevent apoptosis of the retinal cells. However, some infectious agents, such as Propionibacterium acnes, may produce low-grade postsurgical endophthalmitis, which may take months to develop.

There are many options for the management of patients with uveitis undergoing ocular surgery. A common paradigm is for the eye to be quiet for 3 months before surgery. However, the perioperative corticosteroid regimen varies among surgeons, with preoperative topical, periocular, and systemic drugs being used from a few days to 2 weeks before surgery. After surgery, tapering can be tailored to the inflammatory response. It is unclear whether patients with a distant history of uveitis require prophylactic preoperative corticosteroids, and there are no clear guidelines as to the risk of uveitis recurrence in patients whose condition has been controlled with long-term systemic immunosuppressive therapy. Likewise, we do not have strong data regarding the risk of posterior uveitic recurrence after ocular surgery, although patients with anterior or intermediate uveitis appear to be at the highest risk for postsurgical complications. A patient with active uveitis with a dense cataract and iris bombé, similar to the one shown in Fig. 19.1 , would need several months of therapy before cataract surgery. However, if urgent surgery for glaucoma or retinal detachment is needed, an intensive course of oral, periocular, intraocular, and systemic corticosteroid therapy would be needed and surgery cannot be delayed for the customary 3 months of quiescence.

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Active granulomatous uveitis with keratic precipitates, posterior synechia, iris bombé, and a dense cataract.