Performing cataract surgery in an eye with chronic uveitis presents a triple challenge: a fragile blood-aqueous barrier, dense posterior synechiae, and a fibrotic, non-dilating pupil. Success begins with ensuring the eye is “quiet” for at least a few months preoperatively. Intraoperatively, the first step is synechiolysis—using a blunt spatula or viscoelastic to gently sweep between the iris and the anterior capsule. Once the iris is freed, mechanical expansion is usually necessary. Devices like the pupil expansion rings or iris hooks can be used to provide pupil dilation, with iris hooks in a diamond configuration offering excellent ability to prevent iris prolapse through the main incision. Surgeons must also be wary of pupillary membranes, which may require micro-scissors for removal. Postoperative management is aggressive, often involving intracameral steroids or a “steroid shield” of intensive topical drops to prevent the “reigniting” of inflammation and subsequent cystoid macular edema (CME).
