Rebound Iritis following Cataract Surgery

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Rebound Iritis is described as inflammation of the anterior uveal tract and is marked by the presence of leukocytes in the anterior chamber (AC) of the eye occurring after initiation of steroid taper regimens in the post-operative period following cataract surgery. Following cataract surgery, inflammation of the surrounding structures can result from the breakdown of the blood-aqueous barrier. Inflammation can be poorly controlled or can “rebound” during the steroid taper, leading to infiltration of cells into the AC accompanied by an acute flare of anterior uveitis.

Disease Entity

“Rebound” Iritis following cataract surgery with steroid tapering regimens can be classified as a rare form of acute traumatic anterior uveitis.

Disease

Rebound Iritis is described as inflammation of the anterior uveal tract and is marked by the presence of leukocytes in the anterior chamber (AC) of the eye occurring after initiation of steroid taper regimens in the post-operative period following cataract surgery. Iritis is synonymous to anterior uveitis. Following cataract surgery, inflammation of the surrounding structures can result from the breakdown of the blood-aqueous barrier. Following breakage, white blood cells, inflammatory mediators, and/or other blood contents enter the eye and can lead to the development of an inflammatory state (5). This process typically peaks within the first week following cataract extraction and will slowly decrease back to normal levels after 2-3 weeks (1). Typically, the post-operative inflammation is well-controlled with steroid tapering regimens while the eye is still recovering. However, inflammation can be poorly controlled or can “rebound” during the steroid taper, leading to infiltration of cells into the AC accompanied by an acute flare of anterior uveitis.

Etiology

The cause of rebound iritis following cataract surgery involves improper control of a newly imposed inflammatory state in the eye following trauma from the surgery itself. Specific causes include:

• Lack of proper post-operative anti-inflammatory medication adherence

• Improper response of the eye itself to standard tapering mechanism

• Lens material lodging in the anterior angle chamber, promoting both inflammation and potentially precipitating secondary glaucoma

Epidemiology

Rebound Iritis following cataract surgery, while uncommon, is an important consideration in a country where more than 1 million cataracts are repaired annually. In one study, the overall incidence of post-operative iritis specifically was 1.20% with the exclusion of patients with prior ocular inflammation or pre-existing systemic inflammatory or autoimmune diagnosis (2). The incidence was higher in patients of African American descent (2). Other risk factors included diabetes and the use of pupil expansion device during surgery (2). Overall, the incidence of iritis is approximately 12 per 100,000 in the U.S (3). Iritis is by far the most common form of uveitis, comprising approximately 90% of all uveitis cases (4). In broad terms of uveitis, post-procedural uveitis encompasses 10% of total cases, with 48.7% of those specifically following cataract extraction and IOL implantation (15).

Primary Prevention

The promotion of inflammation following cataract surgery is a well-documented phenomenon that can lead to rebound iritis, among other more common complications including pseudophakic cystoid macular edema (PCME). Control of inflammation is largely well-controlled with topical steroid tapers and NSAIDs, with most of the inflammatory process largely resolved after 1 month (2). Several studies have been performed to assess best specific treatment modality to prevent rebound, but current literature promotes steroid regimens (prednisolone, Pred Forte, Durezol) alone or in combination with NSAIDs (Ketorolac or nepafenac commonly) as adequate measures of prophylactic inflammatory control (6-9). Other methods of inflammatory control in patients that are non-compliant or have potential loss to follow-up can include newer intracameral AC steroid and NSAID suspension delivery systems, which have been found to have similar safety and efficacy profiles when compared to standard steroid tapers while removing the burden of topical treatment options (13, 14).

Diagnosis

Acute anterior uveitis from trauma following surgery will most likely be unilateral but can also occur bilaterally (10). Patients can present with a variety of symptoms including:

• Persistent redness of eye(s), characteristically noted at the limbus (circumlimbal)

• Complaints of visual change (blurry vision)

• Eye pain, more specific to acute anterior uveitis

• Photophobia

Anterior uveitis can be confirmed via slit lamp examination in addition to DFE. SLE will reveal leukocytes in the anterior chamber (diagnostic) with or without associated flare in patients with anterior uveitis. Patients may also have miosis secondary to iris sphincter spasm and altered IOP (decreased more commonly). Assessment of proper lens placement is also an important consideration. DFE is essential to assess for findings suggestive of pan uveitis or posterior uveitis, including vitreous cell and/or chorioretinal inflammation, typically not seen in isolated anterior uveitis (11).

Management

Patients with iritis closely following cataract surgery, especially within the first few months post-operatively, are very likely suspects of rebound inflammation as the causative factor. It is imperative to get a full history and to assess patients’ understanding of current or past eye drop regimen(s) in the post-operative period. Although not always the case, it is possible that the patient has not been following regimens as initially prescribed or intended, whether that be from negligence, misunderstanding and/or improper use, lack of availability, etc. In one study assessing the proper administration of eye drops in the post-operative period following cataract extraction, up to 92.6% of 54 patients included demonstrated improper administration technique (12). If the patient has been completely compliant with medications, further probing for other potential etiologies (infectious, autoimmune, additional trauma, idiopathic, etc.) of acute anterior uveitis should be explored.

Medical therapy

Medical therapy for rebound iritis follows the same standard therapy for other cases of acute anterior uveitis, including:

• Topical corticosteroids, commonly prednisolone acetate 1% followed by dexamethasone 0.1% and prednisolone sodium phosphate 1% are prescribed via a tapering regimen to decrease inflammation (11).

• Cycloplegics (Homatropine 5%) are prescribed until there are fewer than 5 cells/HOF in the AC. Dilation of the pupil prevents synechiae development and decreases ciliary body spasm to help with pain management (11).

Medical follow up

Patient follow-up should be scheduled 7 days after the initial diagnosis is made. If anterior chamber cell has decreased appropriately (ideally considered a reduction by at least 50% of the original number of cells) and the patient has no pain or discomfort, cycloplegics can be discontinued at this time. The patient should be followed weekly until less than 5 cells per HPF are detected in the AC. With proper improvement via strict monitoring and adherence to medications, drop frequency can be decreased and follow-up times can be extended slowly (11). Rebound iritis typically lasts 5-6 months, consequentially patients will need long-term monitoring, strict adherence to medications, and accessibility to an Ophthalmology clinic during an extended period (2).

References

(1) Al-Mezaine HS, Kangave D, Al-Assiri A, Al-Rajhi AA. Acute-onset nosocomial endophthalmitis after cataract surgery: incidence, clinical features, causative organisms, and visual outcomes. J Cataract Refract Surg 2009; 35:643–649.

(2) Neatrour, K., McAlpine, A., Owens, T.B. et al. Evaluation of the etiology of persistent iritis after cataract surgery. J Ophthal Inflamm Infect 9, 4 (2019). https://doi.org/10.1186/s12348-019-0170-2

(3) Alexander KL, Dul MW, Lalle PA, Magnus DE. Onofrey B. Optometric Clinical Practice Guideline: Care of the Patient with Anterior Uveitis. St. Louis, MO: American Optometric Association; 1994:3-29.

(4) Gutteridge IF, Hall AJ. Acute anterior uveitis in primary care. Clinical and Experimental Optometry. 2007. 90(2):70-82.

(5) Reidy JJ. Section 08: External Disease and Cornea. Basic and Clinical Science Course. San Francisco, CA: American Academy of Ophthalmology; 2012: 363.

(6) Malik A, Sadafale A, Gupta YK, Gupta A. A comparative study of various topical nonsteroidal anti-inflammatory drugs to steroid drops for control of post cataract surgery inflammation. Oman J Ophthalmol. 2016;9(3):150-156. doi:10.4103/0974-620X.192268

(7) Kessel L, Tendal B, Jørgensen KJ, et al. Post-cataract prevention of inflammation and macular edema by steroid and nonsteroidal anti-inflammatory eye drops: a systematic review. Ophthalmology. 2014;121(10):1915-1924. doi:10.1016/j.ophtha.2014.04.035

(8) Juthani VV, Clearfield E, Chuck RS. Non-steroidal anti-inflammatory drugs versus corticosteroids for controlling inflammation after uncomplicated cataract surgery. Cochrane Eyes and Vision Group, ed. Cochrane Database Syst Rev. Published online July 3, 2017. doi:10.1002/14651858.CD010516.pub2

(9) Ylinen P, Holmström E, Laine I, Lindholm J-M, Tuuminen R. Anti-inflammatory medication following cataract surgery: a randomized trial between preservative-free dexamethasone, diclofenac and their combination. Acta Ophthalmol (Copenh). 2018;96(5):486-493. doi:10.1111/aos.13670

(10) Whitley W, Sheppard J. The basics of uveitis. Rev Optom. 2011 Available at: http://www.reviewofoptometry.com/continuing_education/tabviewtest/lessonid/107773. [Google Scholar]

(11) Harthan, J. S., Opitz, D. L., Fromstein, S. R., & Morettin, C. E. (2016). Diagnosis and treatment of anterior uveitis: optometric management. Clinical optometry, 8, 23–35. https://doi.org/10.2147/OPTO.S72079

(12) An JA, Kasner O, Samek DA, Lévesque V. Evaluation of eyedrop administration by inexperienced patients after cataract surgery. J Cataract Refract Surg. 2014 Nov;40(11):1857-61. doi: 10.1016/j.jcrs.2014.02.037. Epub 2014 Sep 22. PMID: 25248295.

(13) Donnenfeld ED, Solomon KD, Matossian C. Safety of IBI-10090 for inflammation associated with cataract surgery: Phase 3 multicenter study. J Cataract Refract Surg. 2018 Oct;44(10):1236-1246. doi: 10.1016/j.jcrs.2018.07.015. Epub 2018 Aug 20. PMID: 30139638.

(14) Visco DM, Bedi R. Effect of intracameral phenylephrine/ketorolac 1.0%/0.3% on postoperative cystoid macular edema, iritis, pain, and photophobia following cataract surgery. J Cataract Refract Surg. 2020 Mar 26. doi: 10.1097/j.jcrs.0000000000000193. Epub ahead of print. PMID: 32221152.

(15) Bajwa A, Osmanzada D, Osmanzada S, Khan I, Patrie J, Xin W et al (2015) Epidemiology of uveitis in the mid-Atlantic United States. Clin Ophthalmol (Auckland, NZ) 9:889–901