RULE OF THE IRIS: IRIS SYNECHIAE AND CATARACTS IN UVEITIS

To report a case of bilateral uveitic cataract in Vogt Koyanagi Harada Disease

San Carlos Eye Center in San Carlos City, Philippines

Case report and literature review

This is a case of a 36-year-old Filipino male who presented with bilateral uveitic cataract from longstanding panuveitis. Patient was referred to our clinic for persistent eye inflammation despite treatment with oral steroids given by different ophthalmologists for 6 months. Upon first presentation at Uveitis clinic, his ocular examination shows visual acuity of 20/70 on the right eye and 20/40 on the left eye, intraocular pressures of 37mmhg on the right eye and 32mmHg on the left eye, bilateral non-pigmented keratic precipitates, bilateral +2-3 cells/flare,  extensive posterior synechiae in occlusion configuration, bilateral uveitic cataracts,  bilateral vitritis, and diffuse sunset-glow fundus which corresponds to bilateral chorioretinal thickening on Macular OCT. He was also noted to have intermittent headaches and hearing loss in the early stage of his disease. He was treated as a case of Chronic Panuveitis of Vogt Koyanagi Harada Disease.

Uveitis workups shows normochromic CBC, normal urinalysis, chest xray, blood sugar, liver function test, and kidney function test. Infectious etiology was also ruled out after a non-reactive tests for TB Quantiferon, Syphilis, HIV. ESR was mildly elevated to 22.

Immunotherapy was started with Mycophenolate mofetil 1000mg BID and oral Prednisone 50mg OD. Topical steroids, antiglaucoma, and cycloplegics was continued. His inflammation responded well immunosuppression and was relatively quiet after 3 months.

Cataracts are complications of uveitis or steroid induced.  In our case, it is a combination of both, the posterior synechiae fibrin formation block the pupil, increasing intraocular pressure.

Patient was scheduled for bilateral cataract surgery with hydrophobic intraocular lens implantation. 1 week prior to surgery, oral steroids were increased to 50mg/day as pre-operative medication while continuing Mycophenolate.

Intraoperatively, we release the fibrin formation and posterior synechiae and inserted a pupillary expansion device, irrigation and aspiration (Centurion Vision Systems) and implantation of hydrophobic IOLs (SA60AT) in the capsular bag.

Postoperatively, his vision gradually improved from 20/70 to 20/20 on the right eye, and 20/40 to 20/20 on the left eye, initially anterior chamber has +2-3 cells/ flare which responded well to topical steroids. He recovered with a bilateral round pupil after removal of pupillary fibrin formation and release of posterior synechiae.

In Uveitic cataracts, etiology determination is critical in treating eye inflammation and careful surgical techniques are critical to improve visual outcome in these patients. This case shows a good functional outcome postoperatively in a patients with uveitic cataracts from Chronic Panuveitis of Vogt Koyaganagi Harada disease.