Dear Sir,

We would like to report an intra-operative complication of cataract surgery in a case of Takayasu arteritis. Takayasu arteritis is a rare disease with a low reported annual incidence. The incidence of the disease in Olmsted County, Minnesota, was 2.6/million/year [1]. The overall annual incidence in UK of TAK was 0.8/million [2]. Around 20 % of Takayasu arteritis cases with ocular manifestation have cataract [3]. Cataract secondary to ocular ischemia is a late complication of Takayasu arteritis. We would like to share our experience of cataract surgery and its visual outcome in this rare disease.

A 23-year-old female with Takayasu arteritis presented with gradual progressive decrease in vision and a recent development of a white reflex in the left eye (LE) .On examination, the best corrected visual acuity (BCVA) was 6/6 in the right eye (RE) and hand movements in the LE. On slit lamp examination (SLE) the LE revealed, quiet anterior chamber, with no iris neovascularisation and an intumescent total cataract. Intraocular pressure in LE was 20 mmHg. Gonioscopy revealed multiple peripheral anterior synechiae and pigments with no angle neovascularisation in LE. Ultrasound examination of the LE showed an attached retina. The patient was taken up for a cataract surgery under guarded visual prognosis explained .The intumescent cataractous lens was decompressed with aspiration of the milky cortical matter from the bag after making a small capsular opening with a cystitome. This decompression of the anterior chamber resulted in bleeding from the angles. After this, every step of the surgery was met with continuous oozing of blood from the angles. This oozing was kept in check by inflating the anterior chamber with viscoelastic at every step which controlled the bleeding by the visco-tamponade effect and by keeping the anterior chamber pressure at a higher end (Figure 1).

Figure 1: (a) Small initial capsulorrhexis made to avoid rhexis extension due to high intralenticular pressure, (b) Lens capsular bag decompressed, (c) With decompression bleeding from the angle starts [white arrow], (d) Viscoelastic injected to control bleeding, (e)Rhexis completed with forceps, (f) No bleeding during phacoemulsification when anterior chamber pressure was increased, (g) Viscoelastic injected again before removing the phacoemulsification probe to maintain chamber pressure [Note: Temporal side port used to inject viscoelastic to avoid disturbing the bleeding site at the nasal angle] (h) IOL dialled into position with difficulty due to the small rhexis while blood continues to ooze, (i) No bleeding from angle after AC formed with saline and main port secured with a suture.

Intraocular lens was placed in the bag after phacoemulsification. At 3 weeks after cataract surgery patient had a BCVA of counting fingers at 50 cm in the LE. Fundus examination of LE showed neovascularisation at disc, cystoid macular edema and epiretinal membrane. Takayasu retinopathy is classified into four stages [4]. Stage 4 is characterised by the presence of ocular complications like, cataract, rubeosis iridis. The total intumescent cataract in the left eye of our patient was secondary to ocular ischemia and fell in the Stage 4 Takayasu retinopathy spectrum.

We do not suspect the cataract in our patient to be steroid induced as it was unilateral at presentation but the contributory role of steroid cannot be completely ruled out. The visual outcome after cataract surgery in in Takayasu retinopathy stage 4 is poor. Intraoperative incalcitrant hyphaema can be encountered despite no evident iris and angle neovascularisation.

No conflicting relationship exists for any author.