Cataract surgery with uveitis: why inflammation control matters

Why is cataract more common with uveitis?

Both repeated inflammation and the corticosteroid medicines used to control it can contribute to cataract. This does not mean the treatment was unnecessary: uncontrolled inflammation can damage the eye in other ways. Cataract surgery removes the cloudy natural lens; it does not cure the underlying uveitis.

Uveitis is a group of conditions, rather than one disease. Inflammation mainly at the front of the eye is called anterior uveitis or iritis. Other forms involve the middle or back of the eye, or several areas. The location, cause and pattern of previous flare-ups help determine the surgical plan.

The decision to operate depends on how cataract affects activities such as reading, recognising faces or driving in glare, and how much improvement is reasonably expected. If symptoms remain manageable, monitoring may be an option. The general guide to cataracts explains how a cloudy lens affects vision.

How long does the inflammation need to be quiet?

For many elective uveitic cataract operations, a commonly used starting point is at least three months of controlled inflammation. This is a planning principle, not a universal countdown. The type of uveitis, recent relapses, treatment response and urgency of surgery can change the recommendation.

Surgery itself causes an inflammatory response. Operating while uveitis is active can increase the chance of a flare or macular swelling afterwards. A period of control allows the team to assess how stable the eye is and plan preventive treatment, although it cannot remove all risk.

A comfortable eye is not necessarily a quiet eye: inflammation can remain visible on examination without much pain or redness. Being stable while taking medication does not mean that medication should be stopped. If the cataract prevents examination or treatment of the back of the eye, the balance may favour a different timetable. Tell the team about a new flare while waiting; the timing or treatment may need to change.

How much vision might improve, and what needs checking?

The key question is how much of the blur comes from the cataract. Uveitis can also affect the cornea, macula or optic nerve, and cause pressure problems. Removing a cloudy lens may improve brightness, glare or clarity, but it cannot reverse permanent retinal scarring or optic nerve damage. Your surgeon should explain both the likely benefit and what may remain limited.

The examination checks for active inflammation, adhesions that prevent the pupil opening, eye pressure and previous surgical changes. An optical coherence tomography (OCT) scan can look for macular fluid or damage when the cataract allows a useful scan. Ultrasound may help assess the back of the eye if the lens is too opaque to see through, but it cannot provide the same fine macular detail. With a very dense cataract, some uncertainty about the final vision may remain until after surgery.

Bring a list of eye drops, tablets and injections, details of previous flare-ups and any earlier eye reports. Mention previous macular swelling, glaucoma, steroid-related pressure rises and any infection linked to the uveitis. The surgeon may need to coordinate with your uveitis specialist or other treating clinicians.

What are posterior synechiae?

Posterior synechiae are adhesions in which the back of the iris (the coloured part of the eye) sticks to the front of the capsule surrounding the natural lens. They can make the pupil irregular and prevent it widening normally with dilating drops. An irregular pupil can remain after inflammation has settled; its shape alone does not tell us whether uveitis is active.

If these adhesions restrict access to the cataract, the surgeon may need to release them and use small hooks or a pupil-expansion ring to hold the pupil open. This gives access to the lens during surgery; it does not guarantee that the pupil will become perfectly round afterwards. The extra steps depend on the individual eye.

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What is cystoid macular oedema?

Cystoid macular oedema (CMO), also spelt cystoid macular edema (CME), means swelling caused by small fluid-filled spaces within the macula, the central part of the retina used for detailed vision. It can blur central vision, make straight lines look bent and make reading harder. CMO may already be present because of uveitis, or develop after cataract surgery. Removing the cataract does not, by itself, treat this retinal swelling.

Optical coherence tomography (OCT) uses light to build a cross-sectional picture of the retina. A normal macula has a gentle central dip. With CMO, OCT may show a thicker retina with dark fluid spaces within it. Comparing scans over time helps the ophthalmologist assess whether swelling is improving or returning.

Top: Normal macula
Bottom: Cystoid macular oedema (CMO)

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Treatment aims to control the inflammation and reduce the fluid. Depending on the cause, severity, previous response and eye pressure, the plan may include anti-inflammatory drops, treatment by injection or changes to longer-term uveitis treatment. Vision can improve as swelling settles, but recovery varies and longstanding damage may limit it.

CMO can appear after an initially encouraging recovery. If vision becomes blurrier or distorted, contact your treating team promptly rather than waiting for the next routine appointment. Other problems can cause similar symptoms and may need urgent treatment. The guide to blurred vision after cataract surgery explains other possible causes.

Will I need extra treatment before and after surgery?

Often, yes. Extra anti-inflammatory treatment may be needed even when your usual medicines have kept the eye quiet. Treatment around surgery may include more intensive drops, tablets or an injection, depending on the location and severity of the uveitis and your previous response. There is no single regimen suitable for every eye.

The team also considers treatment side effects. Steroids can raise eye pressure; tablets can have wider effects, including on blood glucose. Tell the team if this has happened before. If an infection caused your uveitis, a separate plan to prevent or treat infection may be needed alongside inflammation control.

Ask for a written schedule covering what to continue, what starts before surgery and how treatment will be reduced afterwards. Do not stop your immunosuppressive medicines (which reduce immune activity), increase steroids or restart old drops yourself. A taper means reducing treatment in planned steps, guided by examination. Feeling better is not a reliable reason to stop early. Have conflicting instructions from different teams reconciled before surgery.

Which lens implant is suitable if I have uveitis?

Lens choice depends on the health of the whole eye and your visual priorities. A monofocal lens focuses mainly at one chosen distance. If it is set for distance vision, reading glasses are usually needed; glasses may still be needed for other tasks. Discuss the intended focus before surgery rather than assuming the operation will remove the need for glasses.

Multifocal lenses split light between different focal distances and can cause halos or reduce contrast, making objects harder to distinguish from their background. Those trade-offs may be more troublesome if uveitis has already affected the macula or optic nerve. A lens offering greater freedom from glasses may therefore be unsuitable for a particular eye. A toric lens, which corrects corneal astigmatism, is a separate consideration and may be an option when the measurements and lens support are suitable. Ask why the proposed lens fits your eye.

Lens material is a separate choice from its focusing design. Your surgeon may favour a hydrophobic acrylic lens if you have uveitis. Older evidence suggests more inflammation and new iris adhesions with silicone than hydrophobic acrylic lenses, but comparative evidence is limited. Hydrophilic acrylic lenses are another option: a small 2025 trial found no clear difference in inflammation between the two acrylic lenses it tested over six months. Neither material suits every eye.

Hydrophilic acrylic contains more water than hydrophobic acrylic. Some hydrophilic lenses can develop calcium deposits and become cloudy, particularly after surgery involving air or gas inside the eye. This matters if future retinal or corneal surgery may be needed. The individual lens model also matters. My guide to hydrophobic versus hydrophilic acrylic lenses explains the material trade-offs in more detail.

Inflammation and adhesion concerns may favour choosing an acrylic lens over silicone, particularly if future retinal treatment could be needed. Silicone oil, sometimes used inside the eye to support a detached retina, can stick particularly strongly to silicone implants and interfere with optical clarity or the view of the retina. A silicone lens and silicone oil are different things; other lens materials are not completely immune to oil adhesion. Ask how your inflammation history and retinal health affect the proposed implant.

Can surgery trigger a flare or other problems?

The basic operation removes the cloudy lens and replaces it with an artificial lens implant. A small pupil, adhesions or changes from previous inflammation can make the procedure more involved. Additional pupil-opening techniques or changes to the lens-support plan may be needed. The complex cataract surgery page explains why some eyes need extra steps.

After surgery, inflammation may flare and cystoid macular oedema may develop, even when the lens implant is clear and correctly positioned. Eye pressure may also rise because of inflammation, treatment or the operation. Preventive treatment and follow-up reduce avoidable risk but cannot guarantee an uncomplicated recovery.

The usual cataract surgery risks still apply, including infection inside the eye, damage to the lens capsule, retinal detachment and the possibility of further surgery or worse vision. The relevance of each risk varies with the eye. Ask which risks are increased in your case and how the team plans to manage them.

What should I expect during recovery and later on?

Vision may improve over the first days and weeks, but an eye with uveitis may need longer to settle. More frequent visits, repeat OCT scans or a longer course of drops may be appropriate. Pressure checks remain important even if the eye feels comfortable. A slow recovery needs assessment rather than an assumption that the cataract operation has failed.

Before surgery, arrange transport home and help with drops if you need it. Make sure you can attend the planned reviews and know whom to contact between appointments. Ask when you can return to work, exercise, swimming and driving; this depends on the operation, your vision and the inflammation. Drive only once your vision meets the relevant requirements and your treating team advises it is appropriate. The cataract recovery guide gives general advice; your individual uveitis plan takes priority.

Months or years later, the thin capsule left behind the implant can become cloudy. This is posterior capsule opacification (PCO), rather than the cataract growing back. A YAG laser procedure can open the cloudy capsule when appropriate. With uveitis, the ophthalmologist also checks whether inflammation or macular swelling is contributing to the blur and considers the timing and anti-inflammatory plan for laser treatment. Cataract surgery does not end the need for ongoing uveitis care.

Which questions should I ask before I decide?

Ask: What improvement is realistic for my eye? Is the inflammation sufficiently controlled? Could macular swelling or permanent damage limit the result? Why is this lens implant suitable? What is my medicine and pressure-monitoring plan? If the eye flares, who will manage it? Ask for the next review date and an urgent contact number before going home.

After surgery, worsening vision, increasing pain or redness, marked light sensitivity, or new flashes, floaters or a curtain over vision need urgent advice. Contact your ophthalmologist urgently, or attend an emergency department. Do not assume these symptoms are an expected uveitis flare.