Journal Reading

Cataract Surgery Outcomes in Uveitis The

Multicenter Uveitis Steroid Treatment Trial

Presentan:
Yohanes Firmansyah (406162018)
Pembimbing:
Dr. Lenggo Geni Oetama, Sp. M

Kepaniteraan Klinik Ilmu Penyakit Mata

RS SumberWaras Jakarta
Fakultas Kedokteran Universitas Tarumanagara
Periode 23 April – 26 Mei 2018
Introduction
Introduction (1)
 Cataract is a common complication of uveitis.
 Inflammation as part of the disease process or from the
corticosteroids used to treat the inflammation.
 Cataract surgery in the setting of uveitis differs from senile
cataract
 The outcomes of cataract surgery in uveitic eyes are not as
well studied as those in nonuveitic eyes, most studies suggest
poorer visual outcomes and more postoperative
complications among patients with uveitis.
Introduction (2)
 Preoperative control of inflammation is crucial for cataract
surgery in uveitic eyes.
 A prospective study showed that eyes with active
inflammation within 3 months before cataract surgery were
more likely to have postoperative macular edema and that a
short perioperative course of oral corticosteroids, started 2
days before surgery, significantly reduced the incidence of
postoperative macular edema.
 Preoperative addition or increase in systemic therapy, mainly
corticosteroids, has become a standard approach in cataract
surgery for uveitic eyes.
Introduction (3)
 An alternative approach to systemic therapy for treating
intermediate uveitis, posterior uveitis, and panuveitis is the
fluocinolone acetonide implant
 Both the implant and systemic therapy controlled the
inflammation in the large majority of patients.
 Nevertheless, implant therapy resulted in inactive
inflammation in a greater proportion of eyes than did
systemic therapy.
 Cataracts occurred in both treatment groups  Reason of
Research
 Methods - Eligibility
MUST Trial, a randomized,
comparative effectiveness
clinical trial comparing the
fluocinolone acetonide
intraocular implant s standard
systemic therapy 
noninfectious, recently active
intermediate uveitis, posterior
uveitis, or panuveitis
Methods- Outcome
 The primary outcome of the current study was best-
corrected visual acuity
 Secondary outcomes included bi-nary categorizations of
visual acuity patterns.
 The change from the preoperative to the first available
postoperative visit was defined in 2 ways.
 We first calculated the proportion of eyes with an
improvement based on the number of letters (5 or 10 letters
of improvement), and then the proportion of eyes that
improved to 20/40 or better at the first postoperative visit
was analyzed.
Methods- Statistical
 The Kruskal-Wallis rank-sum test and the Fisher exact test
were used to compare patient-level characteristics of the 2
therapies for eligible patients at the pre-operative visit.
 A linear logistic (binary attribute) or multinomial
(multicategory attribute) mixed-effects model with a patient-
level random effect to adjust for between-eye correlation was
used to compare preoperative eye-level characteristics
between therapies.
 Secondary outcomes were modeled by logistic regression
estimated via generalized estimating equations that account
for the between-eye correlation for individuals with bilateral
cataract surgery.
Results
Table 1. Characteristics of Patients and Eyes Undergoing Cataract Surgery in the Multicenter
Uveitis Steroid Treatment Trial
Figure 2. Mean visual acuity over time for eyes with cataract surgery during the Multicenter
Steroid Treatment Trial stratified by treatment (implant [grey] vs. systemic [black] therapy). The
95% confidence intervals are included for each treatment group at each interval.
Table 2. Adjusted* Risk Factors Affecting Visual Acuity at the Preoperative Visit and Affecting the
Preoperative to Postoperative Visit Change in Visual Acuity in the Multicenter Uveitis Steroid
Treatment Trial
Table 3. Risk Factors for Visual Acuity Improvement in Eyes Undergoing Cataract Surgery in the
Multicenter Uveitis Steroid Treatment Trial
 Overall, visual acuity
improved by 23 letters
 The visual acuity was stable
thereafter with an additional
2 letters at 6 months
 This pattern of
improvement at 3 months
that remained stable
 systemic therapy (29 letters;
95% CI, 17e43 letters; P <
0.001) vs implant therapy
(21 letters; 95% CI, 16e27
letters; P < 0.001).
 However, the difference
between the groups in visual
improvement was not
statistically significant
(mean, 9 letters for implant
vs. systemic therapy; 95%
CI, 23 to 6 letters; P ¼
0.24).
Discussion
Discussion (1)
 Cataract is among the most common structural complications of
uveitis and its treatment with corticosteroids, and cataract surgery
is among the most common surgical procedures performed on
patients with uveitis.
 Although cataract is a well-recognized occurrence with the
fluocinolone acetonide implant and cataract surgery is needed in
more than 90% of eyes by 3 years after
 The current study showed statistically significant, clinically
meaningful, and sustained (for up to 9 months after surgery)
improvement in visual acuity of similar magnitude after cataract
surgery in both eyes treated with systemic therapy and those
treated with the fluocinolone acetonide implant.
Discussion (2)
 In a meta-analysis of the outcomes of cataract surgery, Mehta et al3
estimated that the overall percent of eyes with uveitis achieving
20/40 or better postoperative visual acuity was 68%
 Anterior approaches, intraocular lens placement, nonsilicone
lenses, and operating on eyes with inactive uveitis were associated
with better outcomes.
 Uveitis class was not evaluated systematically, but Fuchs
heterochromic uveitis seemed to respond better than other types
of uveitis; intermediate uveitis seemed to have a similar success
rate to the overall rate; and the one panuveitis evaluated, Behçet’s
disease, had worse outcomes.
 In this regard, there was a suggestion from our data that posterior
uveitis and panuveitis may show a worse response than
intermediate uveitis.
Discussion (3)
 The level of vision before cataract surgery differed between the 2
treatment groups  in the systemic group had worse cataracts at
the time of surgery.  systemic therapy (< preoperative visual
acuity worse than 20/100 )  Reason UNKNOWN

 Sheppard et al17 evaluated cataract outcomes in uveitic eyes that

received the fluocinolone acetonide implant and compared them
with those of fellow, nonimplanted eyes. They reported that eyes
undergoing cataract surgery after the implantation had a better
visual acuity gain and less postoperative inflammation than the
fellow eyes, which were untreated or managed with regional
corticosteroid injections.
Discussion (4)
 The risk factors that were associated with lower preoperative
visual acuity (black race, disease duration, hypotony) are
known risk factors for poorer visual acuity in eyes with
uveitis.
 Although these factors were associated with poorer overall
vision, none of them had an impact on improvement in visual
acuity after surgery (P > 0.05, test of interaction).
 The only characteristic associated with better gains in vision
after surgery was ungradable vitreous haze before surgery.
Discussion (5)
 A systematic review and meta-analysis of the literature found
that active uveitis at the time of cataract surgery was
associated with poorer outcome  worse outcomes and
evidenced by more macular edema.
 Unfortunately, the follow-up schedule and visit windows in
this study precluded the evaluation of the effect of inactive
uveitis in the 3 months before surgery. Similarly, the surgical
data collection did not include information on the use of
perioperative oral corticosteroids.
Discussion (6)
 Our study is limited by the relatively small number of eyes in the
systemic treatment group. We were unable to measure the severity of
cataract directly and instead used a surrogate (inability to grade vitreous
haze) to attempt to account for the impact of severity. The large majority
of eyes showed an improvement in visual acuity, which limited our
ability to perform multivariate analyses of risk factors related to visual
acuity threshold. Nearly all eyes had placement of an intraocular lens,
limiting any power to evaluate the effect of aphakia. Finally, the small
number of eyes with a decline made it impossible to evaluate for risk
factors related to decline. Nevertheless, our study suggested that
patients with intermediate uveitis, posterior uveitis, or anuveitis show
similar improvements in visual acuity after cataract surgery, regardless
whether the uveitis was treated with the fluocinolone acetonide implant
or with systemic therapy with oral corticosteroids and
immunosuppression.
References