Vitrectomy for Persistent Panuveitis in Behçet's Disease

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.

Fluorescein angiographic findings and Behcet's disease ocular attack score 24 (BOS24) as prognostic factors for visual outcome in patients with ocular Behcet's disease

Purpose

To determine the application of fluorescein angiographic (FA) findings and Behcet’s disease ocular attack score 24 (BOS24) scoring system in predicting poor visual outcome in patients with ocular Behcet’s disease.

Study design

Retrospective cohort study.

Methods

We included 73 eyes of 38 patients with ocular Behcet’s disease who underwent FA and reviewed FA images, anterior chamber cells, vitreous opacity, retinal and optic disc lesions, which are parameters in BOS24. The correlation between FA findings, BOS24, and visual acuity was assessed.

Results

Optic disc hyperfluoresence (74%), diffuse posterior pole leakage (52%) and diffuse peripheral leakage (52%) were the three most common findings. Common complications were peripheral capillary nonperfusion (29%), arterial narrowing (22%), and macular ischemia (19%). BOS24 scores of ≥ 6 (p < 0.0001), arterial narrowing (p < 0.0001), and severe posterior pole leakage (p = 0.004) were significantly associated with poor visual outcome. Combining significant FA findings: arterial narrowing and severe posterior pole leakage, to BOS24 ≥ 6 results in an increased relative risk of developing poor visual acuity from 7.30 to 10.43 and 1.89 to 2.02 respectively.

Conclusion

Fluorescein angiography is an important investigation for predicting poor visual outcome. BOS24 may be a useful alternative when fluorescein angiographic is unavailable.

The Effect of Perioperative Uveitis Control on the Success of Glaucoma Surgery in Uveitic Glaucoma

Purpose

To study the effects of perioperative uveitis control (PUC) on postoperative intraocular pressure (IOP) and uveitis activity in uveitic glaucoma (UG) patients who required glaucoma surgeries.

Patients and Methods

A retrospective chart review of 109 patients (120 eyes) which had glaucoma surgery for UG. A total of 66 eyes which had PUC were compared to 54 eyes which did not have. Measurements of IOP and uveitis activity were recorded preoperatively and over 2 years postoperatively. Average number of antiglaucoma medications and frequency of surgical failure were obtained in both groups.

Results

Over 2 years postoperatively, average IOP was lower in eyes which had PUC. Significant differences in IOP were found at 3 months (P = 0.004), 6 months (P = 0.001), 1 year (P < 0.001), and 2 years (P < 0.001). Lower grades of anterior chamber (AC) inflammation were found in eyes which had PUC. Significant differences were found at 1 month (P < 0.001), 3 months (P < 0.001) and 6 months (P = 0.001). Mean number of antiglaucoma medications at last visit was 0.7 ± 1.1 for eyes which had PUC and 2.6 ± 1.5 for eyes which did not have PUC (P < 0.001). Among eyes which had PUC, only two eyes required second glaucoma surgeries, while 16 eyes with no PUC required further glaucoma surgeries after 27.7 ± 12.5 months (P < 0.001).

Conclusion

Proper PUC in patients going for UG surgeries results in lower IOP levels and less AC inflammation over 2 years postoperatively. A comprehensive PUC regimen is needed for uveitic glaucoma patients going for surgeries.

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Ocular Inflammation and Choroidal Thickness after Pars Plana Vitrectomy in Chronic Recurrent Stage of Vogt-Koyanagi-Harada Disease

Purpose: To evaluate subfoveal choroidal thickness (SCT) changes and ocular inflammation after pars plana vitrectomy (PPV) in Vogt-Koyanagi-Harada (VKH) disease.Methods: We analyzed best-corrected visual acuity (BCVA), ocular inflammation, complications, and SCT in 17 eyes of 14 patients with VKH disease who underwent PPV and had ≥12-month follow-up. Main surgical indications included vitreous opacity, epiretinal membrane, and macular hole.Results: Mean BCVA showed significant improvement at all time-points after PPV. Mean SCT significantly increased up until 3 months after PPV (P = .001), but returned to baseline at 12 months and was lower than baseline at the final visit (P = .025). Mean acute uveitis relapse rate decreased after PPV (P = .008). SCT increase was greater in the nine eyes with postoperative uveitis recurrence than in those without (P = .043).Conclusion: Vision improved after PPV in patients with VKH disease. SCT increase in the early postoperative period was associated with uveitis recurrence during follow-up, suggesting that vitrectomy may induce choroiditis after PPV in VKH.

Pars Plana Vitrectomy for the Treatment of Uveitis

PURPOSE

To review and summarize evidence in the medical literature regarding the use of pars plana vitrectomy in the management of uveitis.

DESIGN

Systematic literature review.

METHODS

A systematic literature search was conducted for relevant articles on pars plana vitrectomy for the management of uveitis. Results from the studies were compiled and analyzed.

RESULTS

Thirty-four articles, published from 2005 through 2014, were included in the final data analysis. Thirty-two manuscripts were from retrospective case series and 2 manuscripts were from randomized pilot studies. The median Scottish Intercollegiate Guidelines Network level of evidence grade was 3 and the median Oxford Center for Evidence-based Medicine level of evidence grade was 4. Fewer than 50% of the articles in the current study applied Standardization of Uveitis Nomenclature (SUN) criteria in regard to reporting the anatomic location of uveitis, fewer than 25% of studies applied SUN criteria in regard to the reporting of anterior chamber cells before and after PPV, fewer than 10% of studies applied SUN criteria to the grading of anterior chamber flare before and after PPV, and fewer than 10% of studies applied standardized criteria to the grading of vitreous haze after PPV. Overall, 627 patients and 708 total eyes undergoing PPV for uveitis were included. The average reported age of all patients was 43.4 years. The median duration of uveitis prior to PPV reported in the studies was 36.1 months (range 4-198 months). The median follow-up after PPV reported in the studies was 18.9 months (range 2-114 months). Vision was reported for 519 eyes and was improved in 356 eyes (69%), unchanged in 95 eyes (18%), and worse in 68 eyes (13%) following PPV. Preoperatively, 157 of 300 (52%) eyes in these studies had documented cystoid macular edema compared to 112 of 300 (37%) postoperatively. Median use of oral corticosteroids improved from 48% preoperatively to 12% postoperatively among the reporting studies. Median use of other immunosuppressive medications decreased from 56% preoperatively to 36% postoperatively among the reporting studies.

CONCLUSIONS

Although nearly all studies continue to report favorable outcomes of PPV in the management of uveitis, the quality of data remains limited by a lack of application of standardized reporting outcomes, limitations in study design, and a paucity of prospective data.

Preoperative Inflammatory Control and Surgical Outcome of Vitrectomy in Intermediate Uveitis

Purpose. To demonstrate the long-term effectiveness of vitrectomy for intermediate uveitis (IU) and to determine whether complete control of inflammation before vitrectomy is necessary. Methods. This retrospective study included 66 eyes of 66 patients with IU who underwent vitrectomy for vitreoretinal complications. Eyes were followed for at least 12 months after vitrectomy. The degree of inflammation control and visual acuity were compared before and after vitrectomy. These parameters were compared according to the presence of complete inflammation control before surgery. Results. The indications of vitrectomy included epiretinal membrane (26 eyes), vitreous opacity (21 eyes), and tractional retinal detachment (12 eyes), among others. Uveitic attacks did not occur in 44 of the 66 patients after vitrectomy. The numbers of uveitis attacks, local steroid injections, and systemic medications significantly decreased, and vision meaningfully improved after vitrectomy. These parameters did not differ significantly, regardless of the presence of preoperative inflammation. Conclusions. This study showed that vitrectomy is a good modality to manage vitreoretinal complications associated with IU, even if complete control of intraocular inflammation is not achieved before vitrectomy.

Ocular Manifestations, Conventional Fundus Fluorescein Angiographic Findings, and Relationship Between Angiographic Findings and Visual Acuity in Behçet's Disease

PURPOSE

Evaluating the ocular manifestation and fundus fluorescein angiography (FA) findings of patients with Behçet's disease as well as the relationship between visual acuity and angiographic findings.

METHODS

Retrospective chart review of patients with Behçet's disease seen at the Farabi Eye Hospital.

RESULTS

Forty-six patients (92 eyes) with mean age of 33.41 ± 10.67 were included. The most frequent presenting symptom and sign were reduced vision (76%) and uveitis (87%), respectively. Panuveitis was the most frequent type of uveitis (76%). Among patients with FA, vasculitis was the most common finding (87%) and it was significantly more severe among patients with visual acuity less than 20/200. Macular leakage (P = 0.001), arterial narrowing (P = 0.000), and posterior retinal vasculitis (P = 0.002) on FA were all associated with worsening final visual acuity.

CONCLUSION

The most common ocular findings in Behçet's disease were panuveitis and vasculitis. Location of vasculitis, arterial narrowing, and macular leakage on initial FA may predict visual prognosis.

Remission of Intermediate Uveitis: Incidence and Predictive Factors

PURPOSE

To evaluate the incidence of remission among patients with intermediate uveitis; to identify factors potentially predictive of remission.

DESIGN

Retrospective cohort study.

METHODS

Involved eyes of patients with primary noninfectious intermediate uveitis at 4 academic ocular inflammation subspecialty practices, followed sufficiently long to meet the remission outcome definition, were studied retrospectively by standardized chart review data. Remission of intermediate uveitis was defined as a lack of inflammatory activity at ≥2 visits spanning ≥90 days in the absence of any corticosteroid or immunosuppressant medications. Factors potentially predictive of intermediate uveitis remission were evaluated using survival analysis.

RESULTS

Among 849 eyes (of 510 patients) with intermediate uveitis followed over 1934 eye-years, the incidence of intermediate uveitis remission was 8.6/100 eye-years (95% confidence interval [CI], 7.4-10.1). Factors predictive of disease remission included prior pars plana vitrectomy (PPV) (hazard ratio [HR] [vs no PPV] = 2.39; 95% CI, 1.42-4.00), diagnosis of intermediate uveitis within the last year (HR [vs diagnosis >5 years ago] =3.82; 95% CI, 1.91-7.63), age ≥45 years (HR [vs age <45 years] = 1.79; 95% CI, 1.03-3.11), female sex (HR = 1.61; 95% CI, 1.04-2.49), and Hispanic race/ethnicity (HR [vs white race] = 2.81; 95% CI, 1.23-6.41). Presence/absence of a systemic inflammatory disease, laterality of uveitis, and smoking status were not associated with differential incidence.

CONCLUSIONS

Our results suggest that intermediate uveitis is a chronic disease with an overall low rate of remission. Recently diagnosed patients and older, female, and Hispanic patients were more likely to remit. With regard to management, pars plana vitrectomy was associated with increased probability of remission.

Risk of reactivation of toxoplasmic retinitis following intraocular procedures without the use of prophylactic therapy

BACKGROUND/AIMS

Toxoplasmic retinochoroiditis is the commonest known cause of posterior uveitis worldwide and reactivation is unpredictable. Based on results from one study, the authors proposed that antitoxoplasmic therapy should be initiated as prophylaxis for intraocular surgery in patients with toxoplasmic scars. The aim of this study is to analyse the risk of toxoplasmic retinochoroiditis reactivation following intraocular procedures.

METHODS

Retrospective analysis of the medical records of a total of 69 patients who underwent intraocular surgery and presented with toxoplasmic retinochoroiditis scars.

RESULTS

No patient received prophylactic antitoxoplasmic therapy. Reactivation following the surgical procedure occurred in four cases, with one at 3 months and the others respectively at 13, 14 and 17 months.

CONCLUSIONS

Our study shows that intraocular surgery did not result in a significant reactivation rate of toxoplasmic retinochoroiditis in the absence of preoperative prophylactic antitoxoplasmic therapy.

Outcome of surgical management for rhegmatogenous retinal detachment in Behçet's disease

BACKGROUND

The purpose of the current study is to evaluate the surgical outcome for rhegmatogenous retinal detachment (RD) associated with Behçet's disease (BD).

METHODS

The current retrospective study included all patients operated for rhegmatogenous RD associated with BD in our institution from June 2007 to June 2012. Surgical repair was done either by scleral buckling (SB) or pars plana vitrectomy (PPV) according to the topography and clinical criteria of the detachment.

RESULTS

The current study included 7 eyes of 7 patients (6 males and one female). The mean age was 34.3 ± 4.9 years and all patients showed systemic features of BD. In 3 eyes, intravitreal triamcinolone acetonide (IVTA) was injected within 8 weeks prior to the occurrence of rhegmatogenous RD. Five eyes were treated with SB (segmental buckle in 4 cases and encircling buckle in one case) and 2 cases were treated by PPV. One case was initially treated by SB but showed recurrence of RD which was surgically repaired by PPV with successful closure of the retinal break. The retina was successfully reattached in all cases at the end of follow up period (22.0 ± 6.7 months).

CONCLUSIONS

Rhegmatogenous RD in BD can be effectively treated by scleral buckling in selected cases and PPV in more complex cases. Intravitreal injections may be a precipitating factor for rhegmatogenous RD.

Evidence-based practice in Behçet's disease: identifying areas of unmet need for 2014

BACKGROUND

Behçet's Disease (BD) is characterized by a relapsing-remitting course, with symptoms of varying severity across almost all organ systems. There is a diverse array of therapeutic options with no universally accepted treatment regime, and it is thus important that clinical practice is evidence-based. We reviewed all currently available literature describing management of BD, and investigated whether evidence-based practice is possible for all disease manifestations, and assessed the range of therapeutic options tested.

METHODS

We conducted an internet search of all literature describing management of BD up to August 2013, including pharmacological and non-pharmacological interventions. We recorded treatment options investigated and disease manifestations reported as primary and secondary study outcomes. Quality of data was assessed according to the Scottish Intercollegiate Guideline Network (SIGN) hierarchy of evidence.

RESULTS

Whilst there is much literature describing treatment of ocular and mucocutaneous disease, there is little to guide management of rheumatoid, cardiovascular and neurological disease. This broadly reflects the prevalence of disease manifestations of BD, but not the severity. Biologic therapies are the most commonly investigated intervention. The proportion of SIGN-1 graded studies is declining, and there are no SIGN-1 graded studies investigating neurological or gastrointestinal manifestations of BD.

CONCLUSIONS

This is the first study to investigate trends in published literature for management of BD over time. It identifies neurological, cardiovascular and gastro-intestinal disease as particular areas of unmet need and suggests that overall quality of evidence is declining. Future research should be designed to address these areas of insufficiency to facilitate evidence-based practice in BD.

Current approach in the diagnosis and management of panuveitis

Panuveitis is a generalized inflammation of not only the whole of the uveal tract but also involves the retina and vitreous humor. It differs from other anatomical sites of inflammation in terms of causes as well as distribution. The common causes of panuveitis in our population are tuberculosis, Vogt-Koyanagi-Harada syndrome, sympathetic ophthalmia, Behcet's disease and sarcoidosis. A large number of cases still remain idiopathic. A stepwise approach is essential while evaluating these patients to be able to identify and treat the disease timely and correctly. Ancillary tests can be appropriately applied once the anatomic site of inflammation is identified. An exhaustive approach comprising a full battery of tests is obsolete. Only specific tailored investigations are ordered as suggested by the preliminary clinical and ocular examination. The mainstay of the treatment of uveitis is corticosteroids. Immunosuppressive agents are administered if the inflammation is not adequately controlled with corticosteroids. One of the recent breakthroughs in the treatment of refractory uveitis includes the introduction of immunomodulating drugs: Tumor necrosis factor-alpha antagonist and Interferon-alpha. Vitrectomy has been used in uveitis for over a few decades for diagnostic and therapeutic purposes. When compared to other anatomical sites of inflammation, panuveitis has poor visual outcome due to more widespread inflammation. The side-effects of the chronic treatment that these patients receive cannot be overlooked and should be specifically monitored under the supervision of an internist with special interest in inflammatory diseases.

Intravitreal triamcinolone reduces the morphologic changes of ciliary body after pars plana vitrectomy for retinal vascular diseases

PURPOSE

To investigate the early postoperative changes in ciliary body after pars plana vitrectomy (PPV) for retinal vascular disease and to determine whether intravitreal triamcinolone acetonide (IVTA) affects postvitrectomy changes of the ciliary body.

DESIGN

Prospective interventional case-control study.

METHODS

We recruited 46 patients who underwent uncomplicated PPV for retinal vascular disease (35 with proliferative diabetic retinopathy (PDR) and 11 with branch retinal vein occlusion) and divided the patients into two groups according to the use of IVTA at the end of the PPV. The morphologic changes of the anterior segments were measured by ultrasound biomicroscopy (UBM) one day before and one day, two days, three days, five days, two weeks, one month, and two months after the PPV. The main outcome measures were the thickness and area of the ciliary body, the frequency of supraciliary effusions (SEs), angle-opening, and anterior chamber depth (ACD). We compared the UBM parameters between the two groups.

RESULTS

The thickness and area of the ciliary body significantly increased from day 1 to day 5 postoperatively. Nineteen of 46 eyes had SEs that were frequently associated with divergent alterations of postoperative intraocular pressure (IOP). The angle-opening and ACD were significantly decreased and dependent upon the findings of ciliary body thickness and SEs. The degree of the morphologic changes of the ciliary body and the frequency of SEs were significantly lower and of shorter duration in the IVTA group compared to the non-IVTA group.

CONCLUSIONS

The PPV for retinal vascular disease induces the morphologic changes of the ciliary body associated with postoperative abnormalities in IOP during the early postoperative period. Administration of IVTA at the end of the PPV effectively reduces or shortens the duration of the postvitrectomy changes of the ciliary body.

Phacotrabeculectomy with mitomycin C in patients with uveitis

PURPOSE

To evaluate the safety and efficacy of combined phacoemulsification, intraocular lens implantation, and trabeculectomy with mitomycin C for the management of uveitic complications.

DESIGN

Retrospective case-control study.

METHODS

We conducted a retrospective review of the records of 23 consecutive eyes with chronic noninfectious uveitis (uveitic group) and 43 nonuveitic eyes (control group) that had received primary phacotrabeculectomy. Mitomycin C was used in all the uveitic eyes. Considering the high preoperative intraocular pressure (IOP) of the uveitic group, nonuveitic eyes that had a preoperative IOP of >or=20 mm Hg or that had been given two or more medications were included in the control group. All patients were followed for at least one year. The main outcome measures were postoperative vision, IOP control, complications, and acute uveitis relapse rates.

RESULTS

Visual outcome of the uveitic group was similar to the control group. In the uveitic group, the success rate of IOP control (91.3% at one year, 84.8% at two years) was favorable but was significantly lower than in the control group (P = .0423). Complications were comparable between the groups. Primary surgical failure in the uveitic group was associated with the postoperative acute uveitis attack. In the uveitic group, the acute uveitis attack rate showed no change after surgery (P = .283).

CONCLUSION

With adequate inflammation suppression, phacotrabeculectomy with mitomycin C is an effective and safe therapeutic option for the management of secondary cataract and glaucoma in uveitic eyes. A lower surgical success rate of the uveitic group might be attributable to the postoperative inflammation recurrence.