Ocular cicatricial pemphigoid is a limited form of mucous membrane pemphigoid which affects only ocular surface. It is often overlooked until the later stages of the disease. If left untreated, it can lead to blindness. Additionally, any procedure—including cataract surgery—performed on these eyes may cause the disease to become more aggressive. Early diagnosis through conjunctival biopsy, along with appropriate immunomodulatory therapy, plays a key role in the management of patients with ocular cicatricial pemphigoid. However, many patients with OCP receive corticosteroid therapy through various routes of administration, which can lead to cataract formation and glaucoma over time.
The questions are how safe it is to perform cataract surgery on these patients and when it should be done?
We reported the results of our experience with cataract surgery in 20 patients (26 eyes) with biopsy proven ocular cicatricial pemphigoid. All patients were on systemic immunomodulatory therapy at the time of surgery (dapsone, azathioprine, cyclophosphamide, or combinational therapies) and were treated with peri-operative topical and oral corticosteroids. Patients were evaluated pre- and postoperatively for conjunctival inflammation, conjunctival cicatrization, degree of keratopathy, and disease stage. No patient progressed in disease stage. In this study, the average level of vision improvement in vision was 3.5 lines on the Snellen Acuity Chart (Range: -3 to +8). Worse outcome was associated with chemotherapy intolerance or the presence of any preoperative conjunctival inflammation. Thirteen patients remained on immunosuppressives for the entire study. Corneal ulcers developed postoperatively in three patients in whom continued immunosuppression was not tolerated. Results indicate that after successful abolition of all conjunctival inflammation through chemotherapy, cataract surgery may be safely performed in patients with cicatricial pemphigoid.
This study demonstrated that eyes with OCP in which the disease is well controlled with immunomodulatory therapy can safely undergo routine cataract surgery and intraocular lens implantation. However, minimizing intraoperative manipulation is critical for a successful outcome. Additionally, it is recommended that surgery be performed while the patient remains on immunomodulatory therapy, rather than during tapering or after discontinuation, as surgical stress may reactivate the disease. Our findings have been corroborated by other studies as well.
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