Optimising outcomes for cataract surgery in ocular mucous membrane pemphigoid

Abstract

Purpose : Mucous membrane pemphigoid (MMP) is a heterogenous group of immunobullous disorders affecting the orifical mucous membranes including the ocular (OcMMP), oral and aerodigestive regions. MMP is associated with significant ocular morbidity due to conjunctival shrinkage where visual loss is secondary to ocular surface failure, secondary glaucoma and complex cataract. Cataract surgery is challenging due to difficult access, poor visualisation and risk of postoperative epithelial breakdown and disease progression. We describe an ocular surface optimising protocol that aims to minimise post-operative complications and improve patient outcomes.

Methods : Cataract surgery was performed on 73 consecutive eyes (47 OcMMP patients, aged (50-87) years, 25 (53%) Female, 35 (74.5%) biopsy-positive) presenting to a regional tertiary centre between 2005 and 2019. Optimisation was achieved by ensuring all patients were free of inflammation for a minimum of 3 months prior to surgery, followed by preconditioning of the ocular surface with topical non-preserved dexamethasone eyedrops for 2 weeks, intravenous methylprednisolone on the day of surgery, intra-operative hydroxypropylmethylcellulose corneal protection, amniotic membrane to the corneal surface, and post-operative topical non-preserved dexamethasone, chloramphenicol, and lubricants. Six-month outcomes are reported using generalised linear models adjusted for longitudinal and inter-eye correlations

Results : Of the 47 patients, 34 (72.3%) required systemic immunosuppression. At the time of surgery, >50% forniceal foreshortening was observed in 44 (60%) eyes with 35 (74%) eyes requiring intraoperative lid sutures. There was significant improvement in visual acuity by >0.7 LogMar (P=0.000). While there were no statistically significant differences between pre- and postoperative inflammation, scarring, morbidity and dryness scores (all p>0.05), one patient demonstrated progressive scarring at 6-months follow-up and 14(19%) eyes required serum eyedrops for increased ocular surface staining. No cases of corneal perforation, microbial keratitis or endophthalmitis were recorded.

Conclusions : Cataract surgery can be safely performed in OcMMP patients with advanced conjunctival scarring but requires careful preoperative optimisation and post-operative ocular surface management for good patient outcomes. Good vision may be temporary due to the progressive nature of the underlying disease.

This is a 2021 ARVO Annual Meeting abstract.