Sarcoidosis is characterized by formation of non-caseating immune granulomas in various parts of
the body like the lungs,lymphatics, cardiovascular system,nervous system,eyes,kidneys,larynx
Its incidence is estimated to be around 16.5/100,000 in men and 19/100,000 in women.1
Investigations for the diagnosis of sarcoidosis:
1. Chest radiography.
2. CT scan.
3. Gallium scintigraphy.
1. Serum Angiotensin Converting Enzyme (ACE) levels.
2. Lysozyme levels.
3. Serum Calcium.
1. Bronchoscopy with bronchoalveolar lavage.
The confirmatory test is biopsy showing classic non-caseating granulomas. 2
Recently, Fluorine-18 fluorodeoxyglucose (FDG) PET-CT scan used
Ocular involvement in Sarcoidosis:
Ocular involvement is said to occur in 32% of the patients of sarcoidosis. 4
In the eyes the disease affects:
2. Lacrimal gland.
3. Ocular anterior segment.
4. Posterior segment of the eye.
In the ocular anterior segment it typically manifests as a bilateral granulomatous uveitis with large
mutton fat keratic precipitates, aqueous cells and flare, iris (Koeppes and Bussaca) nodules,
posterior synechiae, peripheral anterior synechiae and increased intraocular pressure.
Posterior segment involvement is characterized by vitritis, cystoid macular odema, vasculitis,
choroidal lesions and optic neuropathy.Sight threatening complications occur which include cystoid
macular odema in 58% of the patients and media opacities (cataract and vitreous opacities) in 25%
of the patients. 5
Cataract Surgery in Sarcoidosis:
1. Status of intraocular inflammation at time of surgery: As in any chronic uveitis surgery for visually
significant cataract is undertaken only after a period of 3 months of remission of uveal inflammation.
In sarcoidosis associated panuveitis eyes unable to undergo cataract surgery due to uncontrolled
inflammation, immunosuppression in the form of low dose Methotrexate achieves control of
inflammation. 6 Other immunosuppressive agents like Azathioprine and Chlorambucil can also be
2. Pupillary dilatation: Small pupil can be encountered due posterior synechiae.
This is dealt with either by:
a. High viscosity viscoelastic which causes manual dilatation of pupil. The amount of dilatation
achieved thus may not be adequate to complete the surgery.
b. Stretching the pupil at opposite ends with Kuglens’ hooks. This may lead to inadvertent iatrogenic
c. Keeping the pupil stretched using iris hooks. It can be cumbersome performing
phacoemulsification with 4 iris hooks in place especially for the beginner.
d. Sphinterotomies. These causes permanent lose of the pupillary shape.
3. Post operative recurrence of inflammation:
Recurrence of intraocular inflammation in the post operative inflammation can give rise to loss of
best corrected visual acuity (cystoid macular odema). Inflammatory pupillary membranes can cause
pupillary block glaucoma. To prevent this it is mandatory to perform surgical iridectomies at the end
of cataract surgery. Post operative inflammation should be anticipated in all cataract surgeries of
sarcoidosis related uveitis. Adequate peri-operative steroid and immunosuppressive cover should
be used and any increased post operative inflammation should be treated.
4. Other complications: Cataract surgery in uveitis is associated with complications intra and post
operatively. 7 These include 7
1. Corneal burns - 10%,
2. Local sphincter damage - 10%,
3. Zonular rupture - 10%,
4. Secondary cataract - 50%,
5. IOL decentration - 40%,
6. Capsular contraction - 80%,
7. Glaucoma - 10%,
8 .Recurrence of uveitis - 30%.
With phacoemulsification these complications (esp. recurrences of uveitis, cystoid macular odema,
epiretinal membrane formation and posterior synechiae) are lesser than that seen after
extracapsular cataract extraction. 8
IOL placement after cataract surgery in Sarcoidosis:There is deposition of inflammatory cells and
debris on the IOL surface and inflammatory membrane formation. 9 Recent studies have suggested
that the rate of post operative complications is lesser in patients having acrylic intraocular lens
implantation as compared to other materials. 10
Centripetal membranous proliferation from the posterior capsular edge on to the posterior surface of
biconvex polymethylmethacrylate (PMMA) intraocular lens 3-6 months after Nd-YAG LASER
posterior capsulotomy requiring repeat capsulotomy has been reported. 11
Visual Outcome:In a cohort study of sarcoid associated uveitis patients, posterior chamber
intraocular lens was implanted in 90.5% of patients undergoing cataract surgery with an average
final visual acuity of 20/51 with 61% achieving a stable visual acuity of 20/40 or better. 12 Visual
acuity < 20/40 was due to sequelae of chronic posterior uveitis including cystoid macular odema,
epiretinal membrane formation and glaucomatous optic nerve damage. Pars plana vitrectomy has
proven to be beneficial in the presences of vitreous opacities 13, epiretinal membranes 14, and
cystoid macular odema 15. Some authors have suggested total removal of cataract plus anterior
vitrectomy and scleral fixation of PCIOL for exudative uveitis. 16
Visual outcome after cataract surgery in sarcoidosis associated uveitis is good if adequate control of
intraocular inflammation is achieved pre-operatively, appropriate surgical technique is used with
minimum manipulation of the iris, with surgical peripheral iridectomies and appropriate post operative
control of inflammation.
1. Nunes H, Bouvry D, Soler P, Valeyre D. Sarcoidosis.Orphanet J Rare Dis. 2007 Nov 19;2:46.
2. Bonfioli AA, Orefice F. Sarcoidosis. Semin Ophthalmol. 2005 Jul-Sep;20(3):177-82.
3. Tannen BL, Ghesani NV, Frohman L, Eichler JD, Maldjian PD, Chu DS.Use of whole-body FDG
PET-CT to aid in the diagnosis of occult sarcoidosis.
Ocul Immunol Inflamm. 2008 Jan-Feb;16(1):25-7.
4. Constantino T, Digre K, Zimmerman P. Neuro-ophthalmic complications of sarcoidosis.
Semin Neurol. 2000;20(1):123-37.
5. Dana MR, Merayo-Lloves J, Schaumberg DA, Foster CS.Prognosticators for visual outcome in
sarcoid uveitis.Ophthalmology. 1996 Nov;103(11):1846-53.
6. Dev S, McCallum RM, Jaffe GJ. Methotrexate treatment for sarcoid-associated panuveitis.
Ophthalmology. 1999 Jan;106(1):111-8.
7. Jurowski P, Goś R, Kaszuba-Bartkowiak K, Zeman-Miecznik A. Comparative analysis of the eye
function and complications after removal of complicated cataract due to uveitis and senile cataract.
Klin Oczna. 2005;107(7-9):421-5.
8. Estafanous MF, Lowder CY, Meisler DM, Chauhan R.. Phacoemulsification cataract extraction and
posterior chamber lens implantation in patients with uveitis.Am J Ophthalmol. 2001 May;131(5):620-5
9. Harper SL, Foster CS. Intraocular lens explantation in uveitis.Int Ophthalmol Clin. 2000 Winter;40
10. Van Gelder RN, Leveque TK. Cataract surgery in the setting of uveitis.Curr Opin Ophthalmol.
11. Konno K, Nagamoto T. Membranous proliferation on the posterior surface of an intraocular lens
after Nd:YAG laser capsulotomy.Jpn J Ophthalmol. 2005 Mar-Apr;49(2):173-5.
12. Akova YA, Foster CS. Cataract surgery in patients with sarcoidosis-associated uveitis.
Ophthalmology. 1994 Mar;101(3):473-9.
13. Ieki Y, Kiryu J, Kita M, Tanabe T, Tsujikawa A, Yamashiro K, Miyamoto N, Miura S, Honda Y .
Pars plana vitrectomy for vitreous opacity associated with ocular sarcoidosis resistant to medical
treatment.Ocul Immunol Inflamm. 2004 Mar;12(1):35-43.
14. Kiryu J, Kita M, Tanabe T, Yamashiro K, Ieki Y, Miura S, Miyahara S, Tamura H, Honda Y. Pars
plana vitrectomy for epiretinal membrane associated with sarcoidosis.
Jpn J Ophthalmol. 2003 Sep-Oct;47(5):479-83.
15. Kiryu J, Kita M, Tanabe T, Yamashiro K, Miyamoto N, Ieki Y. Pars plana vitrectomy for cystoid
macular edema secondary to sarcoid uveitis.Ophthalmology. 2001 Jun;108(6):1140-4.
16. Secchi AG. Cataract surgery in exudative uveitis: effectiveness of total lens removal, anterior
vitrectomy, and scleral fixation of PC IOLs.
Eur J Ophthalmol. 2008 Mar-Apr;18(2):220-5.
Cataract in Sarcoidosis