If you’ve been diagnosed with sarcoidosis and now find yourself facing cataract surgery, you’re probably wondering—how will this affect my procedure and recovery? The short answer is: it adds some complexity, but with the right care, you can still achieve excellent outcomes. In this article, we’re going to walk you through everything you need to know about how sarcoidosis—especially when it involves the eyes—can influence cataract surgery. From granulomatous uveitis to chronic steroid use, and the impact of systemic inflammation, we’ll cover it all.
Understanding Sarcoidosis and Its Impact on the Eyes
Sarcoidosis is a chronic, inflammatory disease characterised by the formation of non-caseating granulomas—clumps of inflammatory cells—in various organs. While the lungs and lymph nodes are most commonly affected, up to 50–60% of people with sarcoidosis will develop ocular manifestations at some point.
The most significant eye-related complication is uveitis, specifically granulomatous anterior uveitis. This condition can lead to a host of problems, including cataracts. Why? Because both the inflammation itself and the long-term use of corticosteroids (often necessary to control the disease) can accelerate lens opacification.
When the eye is inflamed, the intraocular environment becomes unstable. The normal balance of aqueous humour flow, lens nutrition, and immune privilege is disrupted. Add in a history of steroid drops, oral steroids, or even systemic immunosuppressants, and you’ve got an eye that doesn’t behave like the “average” eye during surgery or recovery.
Granulomatous Uveitis: A Complicating Factor in Cataract Formation
One of the major concerns with sarcoidosis-related cataracts is the role of granulomatous uveitis. This form of inflammation is distinct due to the presence of mutton-fat keratic precipitates, iris nodules, and posterior synechiae (adhesions between the iris and lens).
These features not only increase the likelihood of cataract development but also complicate surgical planning:
- Posterior synechiae can make pupil dilation difficult, limiting the surgeon’s view and access.
- Chronic inflammation increases the risk of cystoid macular oedema (CMO) after surgery.
- Fragile iris tissue and angle abnormalities raise the chance of intraoperative complications.
Before proceeding with surgery, your ophthalmologist will usually aim to ensure the eye is “quiet”—free of active inflammation—for at least three months. This often involves adjusting immunosuppressive medications or topical steroid regimens, which must be done in coordination with your respiratory or rheumatology team.
Cataract Types in Sarcoidosis: More Than Just a Cloudy Lens
In patients with sarcoidosis, cataracts can present in a variety of forms. The most common types include:
- Posterior subcapsular cataracts (PSC): Often associated with steroid use and inflammation.
- Nuclear sclerotic cataracts: Develop over time as part of the ageing process, but may be accelerated in sarcoidosis.
- Complicated cataracts: Result from chronic uveitis and present with irregular opacities or associated structural changes in the anterior segment.
PSC cataracts tend to cause the most noticeable vision changes—especially with reading or bright light—and progress rapidly. They are also more likely to return if postoperative inflammation isn’t tightly controlled, making postoperative management a key part of the strategy.
Chronic Steroid Use: Friend and Foe in Surgical Planning
Let’s talk steroids. If you’ve had sarcoidosis for some time, chances are you’ve been on systemic or topical corticosteroids. These medications are essential for controlling granulomatous inflammation, but they’re also known to increase the risk of cataract formation and glaucoma.
From a surgical perspective, steroids present several challenges:
- Steroid-induced cataracts are usually dense and fast-growing, requiring earlier intervention.
- Elevated intraocular pressure (IOP)—sometimes due to steroid use—can worsen after surgery.
- Steroid tapering must be managed carefully to prevent rebound inflammation, but under-treatment can jeopardise healing.
To balance these risks, your ophthalmologist may consult your broader care team to temporarily increase steroid cover before surgery and taper cautiously afterward, sometimes even adding topical NSAIDs or other adjuncts to support healing.
Preoperative Evaluation: What Your Surgeon Will Be Looking For
Pre-op assessments in sarcoidosis patients go beyond the typical eye exam. Your team will likely look at:
- Level of current inflammation using slit lamp and fundus examination.
- OCT scans to check for macular oedema or epiretinal membranes.
- Visual field testing to assess optic nerve health (especially if glaucoma is suspected).
- Systemic disease activity, often requiring communication with your respiratory or rheumatology team.
Importantly, blood tests or imaging (such as a chest X-ray or HRCT scan) may be required to evaluate systemic sarcoidosis activity if not done recently. An active flare—even outside the eyes—can increase surgical risks, particularly from anaesthesia or healing delays.
Intraoperative Considerations: Adjusting Technique for Inflammation
Cataract surgery in patients with sarcoidosis must be approached with care and flexibility. Surgeons often need to modify their approach based on preoperative findings.
Key adjustments might include:
- Use of iris hooks or pupil expansion rings if the pupil won’t dilate adequately due to synechiae.
- Capsular tension rings (CTR) in cases where zonular weakness is suspected.
- Minimising phaco energy to reduce inflammation.
- Intracameral steroids at the end of surgery to prevent flare-ups.
Even the choice of intraocular lens (IOL) is considered carefully. Most surgeons prefer acrylic, hydrophobic lenses as they are associated with a lower rate of posterior capsule opacification (PCO) and have good biocompatibility.
Postoperative Management: Staying Ahead of Inflammation
Recovery after cataract surgery can be longer and more complicated in sarcoidosis patients. The main concern? Postoperative inflammation flaring up, which can lead to:
- Cystoid macular oedema (CMO)
- Persistent anterior chamber reaction
- Posterior synechiae recurrence
- Secondary glaucoma
To stay ahead of these issues, your treatment plan may involve:
- High-frequency topical steroids, such as prednisolone acetate, often tapered slowly over weeks.
- Topical NSAIDs to reduce the risk of CMO.
- Systemic immunosuppression, continued or modified depending on your rheumatologist’s guidance.
- Frequent follow-ups, especially in the first 4–6 weeks after surgery.
Some surgeons also recommend preemptive oral steroids starting a day before surgery to blunt any inflammatory response—a decision made on a case-by-case basis.
Managing Systemic Disease in Tandem with Ocular Care
Here’s where things get a bit more collaborative. Sarcoidosis isn’t just an eye disease—it affects your whole body. So it’s crucial that your eye care team works closely with your respiratory or immunology specialists.
This coordination helps to:
- Avoid systemic flares post-surgery.
- Maintain adequate immunosuppressive cover during recovery.
- Tailor anaesthetic and perioperative management, especially if you’ve got lung involvement.
You might also need to avoid general anaesthesia if your lungs are compromised, favouring local or topical options instead. Your anaesthetist will likely want up-to-date imaging and pulmonary function testing before making that call.
What to Expect Long-Term: Visual Prognosis and Recurrence
The good news? Most patients with sarcoidosis-related cataracts do well if inflammation is well-controlled before and after surgery. In fact, many regain significant visual function, particularly if there’s no lasting macular damage or optic nerve involvement.
That said, long-term risks remain:
- CMO recurrence even months after surgery.
- Posterior capsule opacification (PCO), requiring a YAG laser capsulotomy.
- Ongoing steroid dependence, which can bring additional complications like glaucoma.
Regular monitoring—both for visual acuity and systemic sarcoid activity—remains key even after the cataract is gone.
Lifestyle and Support Considerations
Having sarcoidosis and facing eye surgery can feel overwhelming. That’s why emotional and lifestyle support is just as important as medical treatment. If you’re managing fatigue, systemic symptoms, or work challenges, discuss these openly with your care team.
Also, don’t underestimate the importance of dry eye management, as many sarcoidosis patients—especially those with lacrimal gland involvement—have reduced tear production. Lubricating eye drops and punctal plugs can support comfort and visual recovery post-surgery.
Frequently Asked Questions (FAQs)
- Can I have cataract surgery if my sarcoidosis is still active?
It’s not ideal to undergo cataract surgery while your sarcoidosis is active, especially if the eye is inflamed. Most eye surgeons prefer that the eye be quiet—meaning no signs of active uveitis—for at least three months before proceeding. Surgery during an active phase carries higher risks of complications, including prolonged inflammation and delayed healing. - What makes cataract surgery more complicated in sarcoidosis patients?
The main challenges are inflammation, fragile eye structures, and poor pupil dilation due to synechiae. Chronic steroid use can also thin tissues and affect intraocular pressure. These factors can make both the surgical technique and the recovery process more delicate, requiring close monitoring and custom treatment plans. - Do I need to stop my immunosuppressive medications before surgery?
Usually, no. Most patients are advised to stay on their immunosuppressive treatment to help maintain immune control during and after surgery. However, this decision must be made collaboratively between your eye surgeon and the doctor managing your systemic sarcoidosis, such as a rheumatologist or respiratory specialist. - Will I need more eye drops than usual after surgery?
Yes, most likely. Patients with sarcoidosis often require more intensive anti-inflammatory treatment after cataract surgery. This may involve using steroid drops more frequently or for a longer duration than someone without systemic inflammation. Sometimes, additional medications like NSAID drops or even oral steroids are prescribed. - Are my chances of regaining clear vision lower because of sarcoidosis?
If the inflammation is well-controlled and there’s no permanent damage to the retina or optic nerve, your chances of visual improvement are still good. However, if sarcoidosis has caused scarring, macular oedema, or optic neuropathy, full visual recovery might be limited. That’s why early management of ocular sarcoid is so important. - Is there a higher risk of glaucoma after cataract surgery with sarcoidosis?
Yes, you may be at a slightly higher risk. Long-term steroid use and chronic uveitis both increase the chance of developing glaucoma. Cataract surgery itself can cause pressure fluctuations, so your eye pressure will be closely monitored during follow-up visits. In some cases, glaucoma medications may be required before or after surgery. - Can sarcoidosis come back in the eye after surgery?
It can. Any surgical procedure involving the eye can potentially trigger a flare-up, especially in inflammatory conditions like sarcoidosis. That’s why anti-inflammatory prophylaxis—such as steroid drops or systemic cover—is used to reduce this risk. Regular follow-ups are key to catching any signs of recurrence early. - How long will it take to recover after cataract surgery if I have sarcoidosis?
Recovery may take slightly longer than usual. While most people see improvement in vision within a few days, those with sarcoidosis often need an extended tapering schedule for their eye drops, and more frequent check-ups. It’s not uncommon for the healing process to stretch over several weeks or even months. - What happens if I have cataracts in both eyes? Can I have surgery on both?
Yes, but usually one eye is operated on first to assess how your inflammation responds. If the outcome is stable, surgery on the second eye can be planned, often within a few weeks. In special cases where both eyes are severely affected, simultaneous bilateral surgery may be considered, but only under tightly controlled circumstances. - Can I have a multifocal intraocular lens if I have sarcoidosis?
Multifocal lenses are generally not recommended in patients with any history of ocular inflammation, including sarcoidosis. These lenses require perfect clarity of the retina and macula to function well. If there’s a history of macular oedema or ongoing inflammation, a monofocal lens is usually the safer and more predictable choice. - Will my steroid treatment cause the cataract to return after surgery?
Once the natural lens is removed during cataract surgery, it cannot become cloudy again. However, posterior capsule opacification (PCO)—sometimes called a “secondary cataract”—can develop, especially in patients with inflammation. This can be corrected with a painless laser procedure (YAG capsulotomy) if needed. - Should I do anything differently to prepare for surgery because of my sarcoidosis?
Yes, preparation often involves more than just standard pre-op instructions. You may need additional blood tests, chest imaging, or pulmonary function assessments to ensure you’re fit for surgery. Your ophthalmologist may also ask your sarcoidosis specialist to adjust or review your medications. Staying hydrated, well-rested, and in communication with your full care team is especially important.
Final Thoughts: Collaboration and Customisation Make All the Difference
If you’re living with sarcoidosis, cataract surgery isn’t off the table—it just requires a bit more planning, teamwork, and personalisation. The key is to approach it with a well-coordinated team that understands the systemic nature of your condition, manages inflammation proactively, and closely monitors your progress during recovery.
At the London Cataract Centre, we regularly work with patients who have complex systemic and ocular conditions, including sarcoidosis. From preoperative assessment to postoperative care, our consultants ensure every detail is tailored to your unique needs. If you’re considering cataract surgery and have sarcoidosis, we’d be happy to guide you through the safest and most effective path forward.
References
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- Rothova, A., 2000. Ocular involvement in sarcoidosis. British Journal of Ophthalmology, 84(1), pp.110–116. Available at: https://bjo.bmj.com/content/84/1/110
- Acharya, N.R., Browne, E.N., Rao, N. and Mochizuki, M., 2009. Distinguishing Features of Ocular Sarcoidosis in an International Cohort of Uveitis Patients. Ophthalmology, 116(9), pp.1478–1483.e1.
- Kijlstra, A. and Rothova, A., 2007. The Role of Autoimmunity in Uveitis. Archives of Ophthalmology, 125(3), pp.371–375. Available at: https://jamanetwork.com/journals/jamaophthalmology/fullarticle/419157
- Bajwa, A., Lee, C.S. and Foster, C.S., 2012. The role of systemic immunomodulatory therapy in uveitis: current concepts and future directions. Eye, 26(3), pp.291–301. Available at: https://doi.org/10.1038/eye.2011.320