Effect of Adjunctive Pars Plana Vitrectomy on Focal Posterior Segment Inflammation: A Case-Control Study in Tuberculosis-Associated Uveitis

Outcomes of pars plana vitrectomy in the management and diagnosis of patients with infectious, non-infectious, and unidentified uveitis

PURPOSE

To present the outcomes of pars plana vitrectomy (PPV) in patients with infectious, non-infectious, and unidentified uveitis, focusing on visual and clinical outcomes, diagnostic yield, and surgery-related complications.

METHODS

This retrospective, single-center study included patients who underwent 23-gauge PPV for the management of uveitis and had at least 6 months of follow-up. Patients were divided into infectious, non-infectious, and unidentified uveitis groups based on definitive diagnosis after surgery. Etiologies of uveitis, indications for surgery, diagnostic yield, visual outcomes, presence of cystoid macular edema (CME), immunosuppressive drugs, intraoperative and postoperative complications, and repeated vitrectomies were reviewed.

RESULTS

This study included 62 eyes of 54 patients. Twenty eyes were diagnosed with infectious uveitis, 24 eyes with non-infectious uveitis, and 18 eyes with unidentified uveitis. The diagnostic yield of vitrectomy was 41.7%. Mean BCVA significantly improved at postoperative 1 month compared to baseline and remained stable at following time-points in all groups. The most common early postoperative complication was increased intraocular pressure (17%), and late complication was cataract (36%). Nine eyes underwent re-vitrectomy and the most common cause was retinal detachment with proliferative vitreoretinopathy (PVR).

CONCLUSION

PPV seems to be effective in diagnosing cases of unknown origin, improving visual acuity, and reducing the need for systemic immunosuppressive drugs. PVR is the most serious complication with poor prognosis that requires repeated surgery in patients with uveitis.

Therapeutic Vitrectomy in the Management of Uveitis: Opportunities and Challenges

PURPOSE

Pars plana vitrectomy (PPV) has been traditionally used for diagnostic tapping or for management of posterior segment complications, in uveitis. The anti-inflammatory potential of therapeutic PPV, independent of its role in managing uveitis complications, is yet to be realised completely. In this narrative review, we have described the indications, surgical technique, and outcomes of therapeutic PPV in the management of uveitis.

METHODS

Literature review of PubMed database for articles relating directly or indirectly, to the anti-inflammatory effect of therapeutic PPV in the management of uveitis. Of the 876 articles retrieved on initial review, only 37 articles were found to be relevant for the purpose of this review.

RESULTS

Therapeutic PPV is effective in controlling vitreous inflammation, improving visual outcomes and reducing the need for immunosuppressive medications in a wide range of infectious and non-infectious uveitis. Careful patient selection and meticulous surgical handling are mandatory. Post-operative complications include cataract progression, raised intraocular pressure, hypotony, retinal breaks, and worsening of cystoid macular edema. Despite being introduced more than 40 years ago, most data on therapeutic PPV remain retrospective. The possibility of therapeutic PPV replacing conventional medical therapy remains unknown.

CONCLUSIONS

Therapeutic PPV can control intraocular inflammation, independent of its role in managing posterior segment complications of uveitis. However, its exact place in the anti-inflammatory armamentarium against uveitis remains uncertain.

Tubercular Retinal Vasculitis: Diagnostic Dilemma and Management Strategies

Ocular tuberculosis (OTB) is a rare, extrapulmonary manifestation of systemic TB, which has been a global etiology of uveitis for centuries, though concentrated in the developing world. OTB remains difficult to diagnose clinically despite a plethora of conventional and modern investigations. Tubercular retinal vasculitis (TRV) is a common and specific presentation of OTB but is variably defined in the literature in terms of clinical profile and the investigations essential for diagnosis and treatment. Ironically, the need and duration of antitubercular treatment is uncertain for this manifestation of ocular TB. The rationale and utility for corticosteroids is similarly equivocal for TRV. This review attempts to tease out a commonsense approach from the best available evidence and consensus in the literature to suspect, investigate and diagnose TRV with reasonable certainty, and institute appropriate treatment with due ethnic and geographic considerations.

Pars plana vitrectomy in uveitis in the era of microincision vitreous surgery

Pars plana vitrectomy (PPV) in uveitis is indicated for various diagnostic and therapeutic indications. With the advent of microincision vitreous surgery (MIVS), the use of PPV in uveitis has increased with a wider spectrum of indications due to shorter surgical time, less patient discomfort, less conjunctival scarring, and a decreased rate of complications as compared to standard 20G vitrectomy. Because of faster post-operative recovery in terms of visual improvement and reduction of inflammation, and reduced duration of systemic corticosteroids, MIVS has gained popularity in uveitis as an adjunctive therapy to the standard of care medical therapy. The safety and efficacy of MIVS is related to the emerging vitrectomy techniques with better and newer cutters, illuminating probes, and accessory instruments. Because of the instrumentation and fluidics of MIVS, PPV is emerging as a safe and useful alternative for diagnostic challenges in uveitis, aiding in earlier diagnosis and better outcome of inflammatory disease, even in the presence of severe and active inflammation, which was once considered a relative contraindication for performing vitreous surgery. However, for surgical interventions for therapeutic indications and complications of uveitis, it is advisable to achieve an optimum control of inflammation for best results. The increasing reports of the use of MIVS in uveitis have led to its wider acceptance among clinicians practicing uveitis.

Recent Advances in Diagnosis and Treatment of Infectious Uveitis Prevalent in Asia-Pacific Region

ABSTRACT

The role of infections in intraocular inflammation is being increasingly recognized across the world. The Asia-Pacific region, being the single largest and most populous geographical entity on the planet, is home to a wide variety of such infections. Not surprisingly, there has been an explosion in the literature on infectious uveitis emerging from Asia-Pacific countries. In this review, we have covered recent advances in the diagnosis, treatment, and pathogenesis of common forms of infectious uveitis from the Asia-Pacific region. Much of the literature is focussed on the diagnosis of these infections by clinical criteria and laboratory investigations. There has also been an increased emphasis on the application of newer modes of ocular imaging and understanding pathomechanisms of ocular inflammation in these infections. Together this research has significantly improved our understanding of the diagnosis and management of infectious uveitis.