DED Increases Post-op Cataract Complications for Rheumatoid Arthritis, Sjögren’s Patients

Careful preoperative assessment and close postoperative monitoring following cataract surgery are recommended in patients with rheumatoid arthritis, Sjögren’s syndrome and dry eye to help avoid complications such as vision loss. Photo: Suzanne Sherman, OD. Click image to enlarge. Patients with rheumatoid arthritis and/or Sjögren’s syndrome often have ocular complications and need to be treated with steroid or NSAID eye drops, which can threaten vision and also complicate ocular procedures, such as cataract surgery. In a recent study, researchers sought to determine the frequency and types of post-op complications following cataract surgery in such patients. The findings were reported in Clinical Ophthalmology.A total of 100 eyes from 75 patients with rheumatoid arthritis and/or Sjögren’s syndrome who underwent cataract surgery between 2006 and 2018 were included: rheumatoid arthritis (n=81), Sjögren’s (n=11) and both rheumatoid arthritis and Sjögren’s (n=8). Twenty-nine eyes had preoperative keratoconjunctivitis sicca.Postoperatively, 4% of eyes showed reduced best-corrected visual acuity (BCVA).Cystoid macular edema developed in 6% of eyes. One potential explanation for this is a higher propensity to inflammation in patients with rheumatoid arthritis and/or Sjögren’s, as these are chronic inflammatory conditions. “In particular, eyes with prior ocular inflammation such as uveitis or scleritis from any cause are known to be associated with increased postoperative inflammation and cystoid macular edema,” the authors explained in their paper.Prolonger anterior chamber inflammation was found in 3% of patients.One Sjögren’s patient developed a paracentral corneal melt without perforation, leading to significant vision loss. While this is a rare complication, the patient was not on immunosuppression and had severe dry eye. Corneal ulcerations have also been found in previous studies in patients with rheumatoid arthritis and Sjögren’s syndrome. The authors suggest that dry eye disease (DED) is a potential contributing factor in the development of complications in these patients as it is a common manifestation of rheumatoid arthritis and Sjögren’s syndrome.“Other proposed mechanisms mediating corneal thinning include: the presence of corneal collagenase as a result of the inflammatory cascade triggered by autoantibodies, deficiency in α2- macroglobulin (an inhibitor of collagenase) and surgical interruption of conjunctival and episcleral vasculature, resulting in ischemia aggravating the pathophysiological process associated with rheumatoid arthritis and Sjögren’s syndrome,” they suggested in their paper.Patients with preoperative dry eye had worse postoperative visual acuity (median 20/30) compared to those without it (median 20/25). Four out of 29 eyes (13.8%) with pre-op dry eye had worse post-op BCVA than those without dry eye. Previous studies explain the possible reasoning behind these numbers, the researchers noted.One study that examined complications of cataract surgery in 21 eyes with marked DED identified more complications and worse visual outcomes in those patients with an underlying connective tissue disease as the cause of dry eye, underscoring the worse prognosis in this subpopulation.Another study also identified that prophylactic ocular surface optimization before surgery may reduce the likelihood of severe complications. “In particular, aggressive dry eye management may be warranted in patients with rheumatoid arthritis/Sjögren’s syndrome, including the use of preservative-free lubricants, punctal occlusion (plugs or cautery), autologous serum tears and topical anti-inflammatory therapy where appropriate,” the authors wrote in their paper.One patient with Sjögren’s developed postoperative endophthalmitis resulting in complete vision loss. Because they were not on any immunosuppressive medications, any increased propensity to infection should be presumed to be due to Sjögren’s syndrome or the associated ocular surface disease, the authors noted.The authors recommend careful preoperative assessment and close post-op monitoring, particularly aggressive dry eye management for this population.“Furthermore, given that both cases of the most vision-threatening complications in our series (corneal melt and endophthalmitis) occurred in Sjögren’s syndrome patients, separate and more detailed counseling is recommended for this subgroup to ensure patients are informed of their elevated risk profile,” the authors concluded in their paper.Click here for the journal source. Sadeghi S, Yu T-Y, Choi D, Meyer JJ. Post-operative complications after cataract surgery in patients with rheumatoid arthritis and/or Sjögren syndrome. Clin Ophthalmol. October 22, 2025. [Epub ahead of print.] This article was developed by the editorial staff in conjunction with experts in the field. In the process, AI may have been among the editorial tools used to meet the goals of human editors, who approved all content.