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New Scoring System Predicts Risk of Cataract in Eyes with Anterior Uveitis

Key findings

  • This study examined the incidence of cataract development and associated risk factors in 3,923 anterior uveitic eyes of 2,567 patients managed at six U.S. tertiary uveitis centers
  • 13% of eyes developed cataract; risk factors included age ≥45, chronic anterior uveitis, prior incisional glaucoma surgery, band keratopathy, posterior synechiae, and anterior chamber cell grade ≥1+ or intraocular pressure ≥30 mm Hg at the prior visit
  • Topical corticosteroids were associated with increased cataract risk only at higher doses (≥2 drops/day) and when anterior chamber cells were absent or minimally present
  • A novel scoring system performed well in identifying patients with anterior uveitis who are at high risk of cataract

Uveitis is often associated with cataract development, probably because the most frequent treatment, corticosteroids, and intraocular inflammation itself can both induce clouding of the lens.

Researchers at Mass Eye and Ear determined risk factors for cataract development in a large cohort of patients with anterior uveitis at tertiary centers, and then developed a scoring system to predict cataract risk.

George N. Papaliodis, MD, director of the Ocular Immunology and Uveitis Service, John H. Kempen, MD, MPH, PhD, MHS, director of epidemiology for the Department of Ophthalmology, and colleagues report in the American Journal of Ophthalmology.


The data source was the retrospective Systemic Immunosuppressive Therapy for Eye Disease (SITE) Cohort Study, which included patients seen at six tertiary uveitis referral clinics in the U.S. between 1978 and 2010. This analysis excluded patients with infectious uveitis or HIV/AIDS and those treated with difluprednate 0.05%, the latter because of uncertainty about its equipotency with prednisolone acetate 1%.

3,643 eyes of 2,567 patients were studied: 13% with primary acute anterior uveitis (only the first episode known), 52% with recurrent acute anterior uveitis and 35% with chronic anterior uveitis.

Incidence of Cataract

507 eyes (12.9%) developed visually significant cataract during follow-up. 227 (5.8%) required cataract surgery, and 280 (7.1%) had visual acuity worse than 20/40, which is attributable to cataract.

Risk Factors

Factors significantly associated with incident cataract were:

  • Age ≥65 years—adjusted hazard ratio (aHR), 5.04
  • Age 45 to 64 years—aHR, 2.22
  • Posterior synechiae at or prior to the visit—aHR, 3.71
  • Anterior chamber cell grade ≥2 at the prior visit—aHR, 3.44
  • Anterior chamber cell grade 1 at the prior visit—aHR, 2.60
  • Intraocular pressure ≥30 mm Hg at the prior visit—aHR, 2.57
  • Band keratopathy at or prior to the visit—aHR, 2.23
  • Prior incisional glaucoma surgery—aHR, 1.86

Use of higher-dose prednisolone acetate 1%–equivalent (≥2 drops/day) was associated with >2-fold higher cataract risk in eyes with anterior chamber cell grade ≤0.5+. It was not associated with higher risk in eyes with grade ≥1+.

Patients with primary acute or recurrent acute anterior uveitis had lower cataract risk than those with chronic anterior uveitis (aHR, 0.59 and 0.74, respectively).

Risk Score

A table in the article shows a 0- to 12-point risk scoring system, not yet validated, adapted from the hazard ratios. The researchers found substantial difference in cataract risk according to total points. For example, at five years the estimated cumulative incidence of cataract was approximately 6% for a score of 0 to 2, 14% for a score of 3 to 4 and 38% for a score ≥5.

Practical Guidance for the Clinic

The researchers share clinical pearls based on these findings and their own experience:

  • For induction of quiescence of anterior chamber inflammation, topical corticosteroids of any dose level do not increase the risk of cataract and may be freely used to suppress active inflammation as quickly as possible
  • Even when using low-dose corticosteroid therapy to manage anterior uveitis, clinicians should monitor patients carefully for early signs of cataract, because non-average patients may be susceptible
  • For pseudophakic/aphakic eyes, use of suppressive topical corticosteroids could be more liberal, but eyes should be monitored for intraocular pressure elevation
  • When very low doses of topical corticosteroids are inadequate to suppress chronic anterior uveitis, supplemental systemic therapy might control uveitis without much cataract risk
  • Clinicians can reduce cataract risk by optimizing potentially modifiable risk factors (quickly controlling inflammation, preventing posterior synechiae and band keratopathy, minimizing use of topical corticosteroids when inflammation is inactive, and avoiding IOP ≥30 mm Hg and need for glaucoma surgery if possible); some of this may be achieved using systemic corticosteroids at doses ≤7.5 mg/day and immunosuppressants, for instance
  • Attention to modifiable factors is especially important for high-risk patients (e.g., age ≥65 years and after posterior synechiae and/or band keratopathy have occurred)
of eyes with anterior uveitis developed cataract

greater risk of cataract in eyes with anterior uveitis that had posterior synechiae at or prior to the visit

to 3.4x greater risk of cataract in eyes with anterior uveitis that had anterior chamber cell grade ≥1 at the prior visit

greater risk of cataract in eyes with anterior uveitis that had intraocular pressure ≥30 mm Hg at the prior visit

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In the first study of its kind, Lucia Sobrin, MD, MPH, and John H. Kempen, MD, MPH, PhD, MHS, of the Massachusetts Eye and Ear/Mass General Hospital Department of Ophthalmology, and colleagues found a low risk of noninfectious uveitis among women using hormonal contraceptives or menopausal hormone replacement therapy.


John H. Kempen, MD, MPH, PhD, MHS, director of Epidemiology in the Department of Ophthalmology, and colleagues in the Collaborative Ocular Tuberculosis Study Consensus Group led an international initiative to develop systematic recommendations about when to initiate antitubercular therapy for tubercular uveitis.