Letters to the Editor Intraocular Lens Implants in Patients with Uveitis
Dear Editor: In an article by Foster et al entitled, "Cataract Surgery and Intraocular Lens Implantation in Patients with Uveitis" (Ophthalmology 1989: 96:281-7), good results are described with the use of posterior chamber implants in patients with uveitis; however, the final data concerning plastic intraocular lens (IOL) implants in these patients are uncertain. Patients must be carefully selected if they are to receive implants and if they have chronic iridocyclitis. The basic question is whether, in patients already predisposed to cystoid macular edema (CME), placing a plastic lens in the eye will aggravate this condition. We have been conducting a double-masked prospective study on the use of implants in patients with chronic iridocyclitis. A recent case may be illustrative. A patient was randomized to no IOL in his study eye. He did well, and 1 year later his visual acuity was 20/20 with a contact lens. He complained about the contact lens and desired an implant in his second eye. The study protocol allows only one eye to be randomized, thus the patient is given the choice of procedure in the second eye. This patient received an IOL in his fellow eye, and 5 months postoperatively his visual acuity was 20/200 in this eye because of severe CME. Before surgery, both eyes had equal amounts of inflammation. We hope that our study will answer the question as to whether CME is aggravated by the presence of an IOL in patients with uveitis. Until this question is answered, in a study such as ours, we think we should reserve judgment whether implants are the treatment of choice in patients with chronic iridocyclitis. HOWARD H. TESSLER, MD MARILYN D. FARBER, DrPH Chicago, Illinois Author's reply
Dear Editor: I appreciate the opportunity to respond to the letter by Drs. Tessler and Farber regarding cataract surgery and intraocular lens (IOL) implantation in patients with uveitis. We agree with Drs. Tessler and Farber that the final data concerning plastic lens implants in these patients are uncertain, though we now have follow-up on some of our patients extending to 6 years, and these patients continue to do very well. We also agree with Tessler and Farber's comment that, "Patients must be carefully selected if they are to receive implants." Indeed, this was one of the major points of emphasis of our article. Weare pleased that Drs.
Tessler and Farber are pursuing a double-masked prospective trial on the use of implants in patients with chronic iridocyclitis, and note that for their study, "the basic question is whether, in patients already predisposed to cystoid macular edema, placing a plastic lens in the eye will aggravate this condition." A case they describe in their letter is indeed interesting. We note with interest that they state that, "Before surgery, both eyes had equal amounts of inflammation." One of the major points of emphasis in our article was that cataract surgery in patients with uveitis should not be performed for at least 3 months after all uveitic inflammatory activity has been abolished. We believe that this recommended guideline is especially important in any patient who might receive an IOL implant. We also believe that certain diagnostic groups of patients are poor candidates for lens implantation (e.g., patients with juvenile rheumatoid arthritis). We, and others,I-3 have shown, however, that selected correctly and treated before, during, and after surgery correctly, certain patients with a history of uveitis are well rehabilitated visually with an IOL implant at the time of cataract removal. We would predict that the study of Drs. Tessler and Farber will show that cystoid macular edema is indeed aggravated by the presence of an IOL in patients with uveitis. We find no evidence, however, that recurrence of uveitis or development of macular edema is provoked by the presence of the implant in patients whose uveitis has been abolished through appropriate drug therapy. C. STEPHEN FOSTER, MD Boston, Massachusetts References 1. Foster CS, Fong LP, Singh G. Cataract surgery and intraocular lens implantation in patients with uveitis. Ophthalmology 1989; 96:281-8. 2. Mills KB, Rosen ES. Intraocular lens implantation following cataract extraction in Fuchs' heterochromic uveitis. Ophthalmic Surgery 1982;
13:467-9. 3. Kaplan HJ, 287-8. Discussion of Foster CS, Fong LP, Singh G. Cataract surgery and intraocular lens implantation in patients with uveitis. Ophthalmology 1989; 96:281-8.
Bolster Material for Suture Tarsorrhaphy
Dear Editor: An effective, inexpensive bolster for use during the placement of a suture tarsorrhaphy can be made from the foam backing found in most double-armed suture packs. We use Davis & Geck Ophthalon suture with a D-l needle, but most of the other double-armed packs use a foam
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Dear Editor: In an article by Foster et al entitled, "Cataract Surgery and Intraocular Lens Implantation in Patients with Uveitis" (Ophthalmology 1989: 96:281-7), good results are described with the use of posterior chamber implants in patients with uveitis; however, the final data concerning plastic intraocular lens (IOL) implants in these patients are uncertain. Patients must be carefully selected if they are to receive implants and if they have chronic iridocyclitis. The basic question is whether, in patients already predisposed to cystoid macular edema (CME), placing a plastic lens in the eye will aggravate this condition. We have been conducting a double-masked prospective study on the use of implants in patients with chronic iridocyclitis. A recent case may be illustrative. A patient was randomized to no IOL in his study eye. He did well, and 1 year later his visual acuity was 20/20 with a contact lens. He complained about the contact lens and desired an implant in his second eye. The study protocol allows only one eye to be randomized, thus the patient is given the choice of procedure in the second eye. This patient received an IOL in his fellow eye, and 5 months postoperatively his visual acuity was 20/200 in this eye because of severe CME. Before surgery, both eyes had equal amounts of inflammation. We hope that our study will answer the question as to whether CME is aggravated by the presence of an IOL in patients with uveitis. Until this question is answered, in a study such as ours, we think we should reserve judgment whether implants are the treatment of choice in patients with chronic iridocyclitis. HOWARD H. TESSLER, MD MARILYN D. FARBER, DrPH Chicago, Illinois Author's reply
Dear Editor: I appreciate the opportunity to respond to the letter by Drs. Tessler and Farber regarding cataract surgery and intraocular lens (IOL) implantation in patients with uveitis. We agree with Drs. Tessler and Farber that the final data concerning plastic lens implants in these patients are uncertain, though we now have follow-up on some of our patients extending to 6 years, and these patients continue to do very well. We also agree with Tessler and Farber's comment that, "Patients must be carefully selected if they are to receive implants." Indeed, this was one of the major points of emphasis of our article. Weare pleased that Drs.
Tessler and Farber are pursuing a double-masked prospective trial on the use of implants in patients with chronic iridocyclitis, and note that for their study, "the basic question is whether, in patients already predisposed to cystoid macular edema, placing a plastic lens in the eye will aggravate this condition." A case they describe in their letter is indeed interesting. We note with interest that they state that, "Before surgery, both eyes had equal amounts of inflammation." One of the major points of emphasis in our article was that cataract surgery in patients with uveitis should not be performed for at least 3 months after all uveitic inflammatory activity has been abolished. We believe that this recommended guideline is especially important in any patient who might receive an IOL implant. We also believe that certain diagnostic groups of patients are poor candidates for lens implantation (e.g., patients with juvenile rheumatoid arthritis). We, and others,I-3 have shown, however, that selected correctly and treated before, during, and after surgery correctly, certain patients with a history of uveitis are well rehabilitated visually with an IOL implant at the time of cataract removal. We would predict that the study of Drs. Tessler and Farber will show that cystoid macular edema is indeed aggravated by the presence of an IOL in patients with uveitis. We find no evidence, however, that recurrence of uveitis or development of macular edema is provoked by the presence of the implant in patients whose uveitis has been abolished through appropriate drug therapy. C. STEPHEN FOSTER, MD Boston, Massachusetts References 1. Foster CS, Fong LP, Singh G. Cataract surgery and intraocular lens implantation in patients with uveitis. Ophthalmology 1989; 96:281-8. 2. Mills KB, Rosen ES. Intraocular lens implantation following cataract extraction in Fuchs' heterochromic uveitis. Ophthalmic Surgery 1982;
13:467-9. 3. Kaplan HJ, 287-8. Discussion of Foster CS, Fong LP, Singh G. Cataract surgery and intraocular lens implantation in patients with uveitis. Ophthalmology 1989; 96:281-8.
Bolster Material for Suture Tarsorrhaphy
Dear Editor: An effective, inexpensive bolster for use during the placement of a suture tarsorrhaphy can be made from the foam backing found in most double-armed suture packs. We use Davis & Geck Ophthalon suture with a D-l needle, but most of the other double-armed packs use a foam
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