If you’re living with scleroderma and have developed cataracts, you’re probably wondering how your condition might affect surgery. The truth is, scleroderma doesn’t just affect your skin and joints—it also brings a whole set of ocular surface and perioperative challenges that your surgical team needs to plan around carefully.
From tight, fibrotic eyelid skin and limited mouth opening to dry eye and poor tear film, scleroderma complicates the otherwise routine process of cataract surgery. But with the right approach and a surgeon who understands these nuances, successful outcomes are still very achievable.
Let’s take a deep dive into how cataract surgery is approached differently when scleroderma is part of the picture—and what you can expect at each stage of the journey.
Understanding Scleroderma’s Ocular and Periocular Impact
- Scleroderma isn’t just skin-deep.
While it’s best known for thickening and tightening of the skin, scleroderma can affect internal organs, blood vessels, and mucous membranes—eyes included. In fact, many patients experience significant changes in the structures around and on the surface of the eye. - Tight eyelids and limited motility.
Periocular involvement often leads to shortened, rigid eyelids. This can make it physically difficult for the surgeon to gain proper access to your eye during the procedure. Even small changes in eyelid elasticity can increase the risk of complications like incomplete lid closure after surgery, which can worsen dry eye symptoms and delay healing. - Limited facial and mouth movement.
Microstomia, or reduced mouth opening, is another concern. It complicates airway management if general anaesthesia is needed, and it can limit the use of standard equipment like retrobulbar anaesthesia cannulas. - Dry eye and conjunctival changes.
Perhaps most challenging is the ocular surface. Scleroderma patients are at high risk of developing dry eye disease due to damage to the lacrimal glands and meibomian glands. The conjunctiva may also show signs of atrophy or fibrosis, affecting tear distribution and healing.
How Cataracts Develop in Scleroderma
You might be wondering whether scleroderma itself causes cataracts. The link is more indirect. Most patients with scleroderma are on long-term corticosteroids or immunosuppressive therapy—both of which are known to accelerate cataract formation, particularly posterior subcapsular cataracts.
Other contributors include chronic inflammation and vascular dysregulation. This means cataracts may appear earlier or progress more rapidly in scleroderma patients compared to the general population.
Preoperative Assessment: What to Expect If You Have Scleroderma
Scleroderma adds several layers to the typical cataract surgery workup. You’ll undergo a comprehensive ophthalmic evaluation, but your surgeon will also ask about your systemic health and assess specific factors related to scleroderma.
- Dry eye testing is a priority.
Expect tests like tear breakup time (TBUT), Schirmer’s test, and ocular surface staining with fluorescein or lissamine green. Managing dry eye before surgery is essential—an unstable tear film can skew biometry readings and compromise visual outcomes. - Biometry and IOL planning.
Accurate intraocular lens calculations require a stable corneal surface. If your tear film is poor, these readings may fluctuate. Your surgeon might delay surgery until your ocular surface is optimised. - Eyelid and skin assessment.
The surgeon will evaluate your eyelid mobility and periocular skin elasticity to determine whether modifications to surgical technique or extra assistance will be needed to keep your eyelids open during the operation. - Anaesthesia planning.
You may not be a good candidate for certain forms of local anaesthesia, especially if microstomia or skin fibrosis limits access. Your surgical team will assess whether topical, peribulbar, or general anaesthesia is most appropriate.
Surgical Technique Modifications: Adapting to a Stiff Ocular Environment
Cataract surgery is normally a well-rehearsed routine—but with scleroderma, small changes make a big difference. The surgical plan needs to account for your unique anatomy and how your body might respond during and after the procedure.
- Speculum placement can be difficult.
Because of tight skin and eyelids, standard specula may not fit or may cause too much tension. Specialised or smaller lid specula can help. In severe cases, lateral canthotomy (a small surgical release) may be considered to allow safe access. - Irrigation and fluid management are key.
With fragile conjunctiva and dry cornea, the surgeon must be careful with irrigation. Excess fluid can exacerbate surface inflammation. Using viscoelastic agents to protect the cornea is especially important. - Shorter surgery is better.
Prolonged procedures increase the risk of surface drying, postoperative inflammation, and discomfort. Efficiency is essential, and any co-pathologies—like pseudoexfoliation or small pupils—need to be anticipated and addressed quickly. - Suture use may increase.
In some cases, the surgeon may use sutures to ensure the wound remains secure if healing is expected to be delayed due to systemic sclerosis.
Anaesthetic Considerations: Playing It Safe with a Compromised System
The type of anaesthetic used during cataract surgery can be a critical decision in patients with scleroderma. Factors like reduced skin flexibility, pulmonary involvement, and limited mouth opening come into play.
- Topical anaesthesia is often preferred.
Where possible, eye drops alone are used to numb the surface of the eye. This avoids any complications associated with needle-based anaesthesia, which can be difficult in fibrotic tissues. - Peribulbar and retrobulbar blocks are tricky.
These require careful planning, as the usual entry points may be compromised. There’s also a slightly increased risk of bleeding or bruising in patients with poor capillary resilience due to connective tissue abnormalities. - General anaesthesia: a cautious approach.
If general anaesthesia is unavoidable, airway management becomes the major concern. Microstomia and restricted neck movement may make intubation difficult, and the anaesthetist needs to be fully aware of all systemic involvements, including lung fibrosis or pulmonary hypertension.
Postoperative Recovery: Dry Eye and Healing in Scleroderma
Once the surgery is over, the healing phase becomes the next focus. In scleroderma, this phase often takes more attention than in standard cataract cases.
- Ocular surface healing is slower.
Reduced tear production and a compromised conjunctival surface can mean that epithelial healing is delayed. Your surgeon will likely prescribe preservative-free lubricating drops, gels, or even autologous serum tears if dry eye is severe. - Inflammation control is key.
Anti-inflammatory eye drops are typically used postoperatively, but in scleroderma, they may need to be given for a longer period. If you’re on systemic steroids or immunosuppressants, coordination with your rheumatologist is essential to adjust dosages appropriately. - Watch for corneal complications.
Persistent epithelial defects, punctate keratitis, or even sterile ulcers can occur if dry eye is left unmanaged. Frequent follow-ups are needed in the early weeks. - Tarsorrhaphy in severe cases.
If lid closure is impaired post-op, a temporary tarsorrhaphy (partially sewing the eyelids together) may be recommended to protect the ocular surface during healing.
Communicating with Your Rheumatology and Anaesthesia Teams
Multidisciplinary collaboration is crucial. Your ophthalmologist should be in communication with your rheumatologist, especially if you’re on disease-modifying drugs or biologics. Timing of cataract surgery might be adjusted depending on when you’re due for immunosuppressive infusions or steroid tapers.
Similarly, your anaesthesia team must be made fully aware of your systemic status—especially if lung function or cardiac output is compromised. Preoperative assessments, including pulmonary function tests or echocardiograms, may be requested to ensure you’re fit for surgery.
Long-Term Visual Prognosis: What Should You Expect?
With careful management, most patients with scleroderma do enjoy improved vision after cataract surgery. However, expectations should be realistic and tailored to each individual.
- You may not achieve “perfect” vision.
If you have longstanding dry eye, corneal scarring, or retinal changes, your vision may improve but not return to the sharpness of your youth. - Visual fluctuations can occur.
Tear film instability may continue to cause variable vision throughout the day, even after the lens is clear. Continued dry eye therapy may be necessary long-term. - Glare and halos may be more noticeable.
Due to a compromised ocular surface, some patients are more sensitive to light phenomena after surgery, especially if a multifocal lens is used. In such cases, a monofocal or toric lens may be a more comfortable option.
Frequently Asked Questions (FAQs)
1. Is cataract surgery safe if I have scleroderma?
Yes, cataract surgery can be performed safely in patients with scleroderma, but it does require more preparation and careful planning. Your surgeon will need to consider the impact of skin tightening, eyelid rigidity, and any systemic involvement, especially affecting your lungs or vascular system. The surgical approach may need to be adapted to ensure safe access to the eye and to reduce the risk of complications.
While the procedure itself remains the same in principle, the presence of fibrotic skin, dry eyes, and altered tissue response increases the chance of technical challenges both during and after surgery. That’s why many eye surgeons treating scleroderma patients will coordinate with rheumatologists and anaesthetists in advance to map out the safest strategy.
With these tailored adjustments in place, most people with scleroderma can undergo cataract surgery without major issues. Outcomes are usually positive—just expect a little more time and attention before and after your operation to ensure everything heals as it should.
2. Should I stop my immunosuppressants before surgery?
Not automatically. Many people with scleroderma are on systemic immunosuppressive therapies to manage their disease, and abruptly stopping these medications can trigger a flare. That said, your surgical and rheumatology teams will assess the type of drug, your dosing schedule, and your immune status to decide what’s best in your case.
Some medications, like methotrexate or biologics, may slightly increase your infection risk, but cataract surgery is typically a clean and low-risk procedure. In most cases, the benefits of staying stable on your medications outweigh the risks of holding them. However, timing the surgery so that it doesn’t immediately coincide with an infusion or high-dose steroid treatment is often advisable.
It’s essential to have an open conversation with both your eye surgeon and rheumatologist before surgery. They can coordinate a plan that balances inflammation control with immune safety, tailored to your individual needs and scleroderma severity.
3. Will my dry eye get worse after surgery?
There’s a good chance that your dry eye symptoms may intensify in the short term following cataract surgery. The procedure itself can disrupt the ocular surface, and since scleroderma already compromises tear production and eyelid function, this can lead to more noticeable discomfort, blurry vision, and sensitivity to light.
You’ll likely be given lubricating eye drops before and after the procedure to keep the eye protected and promote healing. In some cases, preservative-free artificial tears or even autologous serum drops may be prescribed if the dryness is severe. You might also be advised to avoid medications or environments that exacerbate dryness.
The good news is that with consistent management, most patients find that their eye surface recovers over time. It may require a few weeks or even months of supportive care, but the increased dryness is usually temporary—especially when it’s addressed proactively.
4. Can I choose a multifocal IOL?
Technically, you can request a multifocal intraocular lens (IOL), but your eye surgeon will need to evaluate whether it’s the right option for you. Multifocal lenses work by splitting light to help you see at different distances, but they’re very sensitive to optical imperfections on the eye’s surface. If you have dry eye, corneal irregularities, or poor tear film—as is often the case with scleroderma—these lenses may cause more glare and reduce your overall quality of vision.
Your surgeon will likely assess your corneal surface stability and tear film quality using imaging and dry eye tests. If the results show fluctuating or patchy tear coverage, a monofocal lens may be the safer and more reliable choice. These lenses offer crisp vision at one distance with fewer side effects, and glasses can help fill in for the other distances.
Ultimately, the goal is to maximise your clarity and comfort. A multifocal IOL might sound appealing, but it’s only beneficial if your eye surface can support it. Your surgeon will walk you through the pros and cons so you can make an informed decision together.
5. Will I need general anaesthesia?
In most cataract surgeries, general anaesthesia isn’t required—topical or local anaesthesia is usually sufficient. However, for patients with scleroderma, things get more complicated if you have very tight facial skin, reduced eyelid mobility, or limited mouth opening (microstomia). These issues can make it harder to safely administer local anaesthetic or maintain patient comfort.
If general anaesthesia is deemed necessary, your anaesthetic team will carry out a thorough pre-op evaluation. Special attention will be given to how well your lungs are functioning (especially if you have pulmonary fibrosis) and whether your airway can be safely managed. You may need additional imaging or lung function tests in advance.
That said, many surgeons can still perform cataract surgery under eye-drop anaesthesia, particularly if the procedure is expected to be quick and straightforward. So while general anaesthesia is a possibility, it’s not a given—and your surgical team will choose the least risky option for your specific condition.
6. How long will recovery take?
Recovery from cataract surgery in scleroderma patients often takes a bit longer than in the general population. While most people start seeing improvements within a few days, you may need several weeks for your eye to fully stabilise. Healing can be slower due to reduced blood flow, dryness, and tissue fragility associated with your condition.
Postoperative inflammation may also take longer to settle. Your surgeon might prescribe anti-inflammatory eye drops for an extended period and will monitor your progress more closely. Regular follow-up appointments help catch any complications early, such as delayed epithelial healing or persistent dryness.
By about 4 to 6 weeks post-op, many patients start enjoying improved vision, but complete recovery can extend to 8 weeks or more, depending on how your eye responds. Be patient and stick to your eye care regimen—it’ll pay off in the end.
7. Is there a higher chance of infection?
Scleroderma itself doesn’t dramatically increase your infection risk during cataract surgery, but if you’re on immunosuppressive medication, your ability to fight off infections may be reduced. This is why your surgical team will take extra precautions to ensure a sterile environment and might adjust your medications as needed around the time of surgery.
Another potential concern is delayed wound healing due to reduced vascularity in scleroderma. If healing is slower, the window for infection risk may be slightly longer, which means careful hygiene and regular monitoring are even more important in your case.
Fortunately, eye infections after cataract surgery are rare, especially when preventive antibiotics and sterile protocols are followed. If any redness, pain, or discharge occurs after surgery, you should seek immediate medical attention to rule out an early infection.
8. Will my eyelids go back to normal after surgery?
Cataract surgery itself doesn’t usually affect eyelid function directly, but if you already have tight or shortened eyelids due to scleroderma, that won’t automatically change. In fact, you may notice a temporary increase in stiffness or difficulty blinking after surgery because of postoperative swelling or dryness.
The surgical team may need to use special tools or techniques to keep your eyelids open during the procedure, and in rare cases, this can leave you with mild eyelid bruising or inflammation. If lid closure becomes compromised, you might need temporary measures like taping the eyelids closed at night or using ointments to prevent dryness.
For severe eyelid involvement that interferes with blinking or eye surface protection, eyelid surgery (such as canthoplasty or skin grafts) may be considered in the future. That said, this is very rare and usually only required in advanced scleroderma cases.
9. Can cataracts come back?
Once your cataract is removed, it doesn’t come back. The cloudy natural lens is taken out and replaced with a clear artificial one, which doesn’t degrade in the same way. However, something called a “secondary cataract” or posterior capsule opacification (PCO) can develop in the months or years after surgery.
PCO occurs when the thin membrane that holds the lens implant becomes cloudy, causing vision to blur again. This is more likely in patients with inflammation-prone eyes, which can include those with scleroderma. Fortunately, PCO is easily treated with a painless laser procedure called YAG capsulotomy, which takes just a few minutes and is done in the clinic.
So while you won’t grow another cataract, it’s worth knowing that some people need this quick follow-up laser treatment to restore clarity after cataract surgery.
10. What should I tell my surgical team before the operation?
Be open and thorough about your scleroderma diagnosis—don’t assume they already know the full picture. Make sure your surgeon knows about any issues with your skin, eyelids, joints, mouth opening, or breathing. Also, let them know about medications you’re taking, particularly immunosuppressants or steroids, and whether you’ve had lung or heart involvement.
Your anaesthesia team needs to understand any limitations with your airway or neck mobility, especially if there’s a possibility of general anaesthesia. Providing a letter or recent report from your rheumatologist can help the surgical team prepare properly.
By sharing all relevant medical details upfront, you allow the entire team to customise the surgical plan for your needs—making the procedure safer and your recovery smoother.
Final Thoughts
Cataract surgery in patients with scleroderma is definitely more complex—but it’s far from impossible. With the right team, good communication between specialties, and tailored pre- and post-op care, you can look forward to safer surgery and a clearer world ahead.
At the London Cataract Centre, we’re used to managing cases that need a bit more time, thought, and finesse. If you’re living with scleroderma and are considering cataract surgery, we’d be happy to walk you through your personalised options and help you make the most informed and confident decision.
References
- Paschides, C.A., Stefaniotou, M., Vasilopoulos, D., Koutsandrea, C. and Skoutakis, G., 1998. Ocular manifestations of progressive systemic sclerosis. International Ophthalmology, 22(6), pp.345–349.
Available at: https://pubmed.ncbi.nlm.nih.gov/11200230/ - Jordan, D.R., Dutton, J.J. and Anderson, R.L., 1990. Scleroderma and periocular fibrosis: a surgical dilemma. Archives of Ophthalmology, 108(9), pp.1271–1274.
Available at: https://jamanetwork.com/journals/jamaophthalmology/fullarticle/635443 - Smith, V., Van Praet, J., Herrick, A.L. and Distler, O., 2016. Scleroderma and the eye: a review of the literature. Eye, 30(4), pp.514–521.
Available at: https://www.nature.com/articles/eye2015275