Posttransplant cataract: Lessons from kidney-pancreas transplantation

Introduction. Cataract is a major cause of visual disturbance after transpl antation. Although corticosteroid therapy has been linked with posterior su bcapsular cataract, its natural history in the cyclosporine era is not well understood. Methods, Baseline and regular postoperative slit-lamp biomicroscopy and oph thalmic examinations (n=432) were performed in 108 eyes of simultaneous kid ney/pancreas (SPK) recipients (n=54) for up to 10 years after transplantati on. Triple therapy immunosuppression of cyclosporine, azathioprine, and pre dnisolone was used, Results. Cataract was present in 40% of eyes at simultaneous kidney/pancrea s associated with duration of diabetes, lower insulin dose, and the use of pretransplant hemodialysis (P<0.05-0.01). Cataract became increasing more c ommon 2 years after simultaneous kidney/pancreas, and lens abnormalities we re virtually universal at 6-10 years by slit lamp biomicrosopy, The instant aneous hazard rate for new cataract formation was highest within the first 2 years and remained abnormal for the study duration. Nuclear and posterior subcapsular cataract increased significantly after transplantation (P<0.05 ) and were the predominant types of cataract presenting late. Risk factors for posttransplant cataract formation included older age and high-dose puls e methylprednisolone dose. Visual acuity was reduced by severity of catarac t grade, presence of combined nuclear and subcapsular cataract, retinal hem orrhage and underlying diabetic retinopathy (P<0.05-0.001). Cataract format ion imposed significant additional impairment of visual acuity above that o f diabetic retinopathy, Cataract surgery was undertaken in 14% of eyes, imp roving visual acuity from mean decimalized score of 0.28 to 0.43, P<0.01 bu t did not normalize it to the noncataract level of 0.72. Conclusion. Transplantation substantially increases all types of cataract, and is highly prevalent by slit lamp examination. High-risk patients are ol der and diabetic, and received hemodialysis and pulse corticosteroid therap y. In contrast to older studies using high-dose corticosteroid and azathiop rine, the pattern of cataract in the cyclosporine era is different with bro ader cataract types, a weaker association with corticosteroids and a progre ssive course. Regular screening of visual acuity and appropriate surgery fo r posterior subcapsular or severe cataract are recommended.