The effect of pars plana vitrectomy in the management of Fuchs heterochromic cyclitis

Monoclonal immunoglobulin heavy chain gene rearrangement in Fuchs' uveitis

Background

Fuchs’ uveitis (FU) is occasionarlly complicated with heavy vitreous opacity. We have performed vitrectomy procedures to remove vitreous opacity in affected patients as part of differential diagnosis for primary vitreoretinal lymphoma (PVRL).

Case presentation

We retrospectively reviewed the clinical records of five patients who first visited the Uveitis Clinic of the University of Tokyo Hospital between 2009 and 2013, were diagnosed with FU and underwent a vitrectomy for removal of dense vitreous opacity. All were diagnosed as FU by ocular findings and elevation of Goldmann-Witmer coefficient (GWC) value for the rubella virus (RV) antibody. In examinations of the vitreous body, cytological diagnosis, elevation of IL-10/IL-6 ratio, and the kappa/lambda ratio in flow cytometry findings were negative in all cases, whereas monoclonal immunoglobulin heavy chain (IgH) gene rearrangement was positive in 4 cases and negative in 1 case.

Conclusions

Although monoclonal IgH gene rearrangement is thought to be a reliable biomarker for PVRL, a high percentage of vitreous specimens from our FU patients showed pseudo-positive results. Ophthalmologists must take care regarding possible pseudo-positive findings when performing differential diagnosis between FU and PVRL. Combinations of results of cytological diagnosis, IL-10/IL-6 ratio, kappa/lambda ratio, and IgH gene rearrangement may be necessary for a definitive diagnosis of PVRL and differentiation from FU.

Phacoemulsification and Core Vitrectomy in Fuchs' Heterochromic Uveitis

OBJECTIVE

To evaluate the efficacy of phacoemulsification combined with posterior capsulorhexis, core vitrectomy and ciliary sulcus intraocular lens (IOL) implantation in patients with Fuchs' heterochromic uveitis (FHU).

MATERIALS AND METHODS

A total of 18 eyes of 18 patients with FHU underwent cataract surgery were included in the study. 18 eyes with FHU underwent posterior capsulorhexis, core vitrectomy and poly (methyl methacrylate) (PMMA) IOL implantation in the ciliary sulcus. Subjects were chosen for this procedure based on an intraoperative vitreous haziness assessment, performed by indirect ophthalmoscopy. Patients with +2 or more vitreous haziness qualified for this procedure.

RESULTS

Of the 83 eyes with FHU that underwent cataract surgery, 18 eyes (21.6%) of 18 patients were employed in the study. There were 11 (61.1%) men and 7 (38.9%) women in the study; ages ranged from 23 to 47, with a mean of 32.06 years. Follow-up ranged from 8 months to 49 months. There were no intraoperative complications except for peripheral iris bleeding in 7 eyes. There was no severe intraocular inflammation in any patient postoperatively. All patients had 0.05 or better logMAR visual acuity after corneal suture removal. Glaucoma developed in 2 patients. For the short term period, the main vision threatening problem was suture-induced astigmatism.

CONCLUSION

Cataract surgery combined with posterior capsulorhexis, core vitrectomy and IOL implantation in the ciliary sulcus is safe and leads to good visual outcome due to the removal of the hazy vitreous in patients with FHU.

A review of pediatric uveitis: part II. Autoimmune diseases and treatment modalities

Uveitis is a manifestation of complex processes that can represent an infectious process or a dysfunction of the immune system that may have grave effects on the eye. Although infectious causes, once properly identified, may be successfully treated by addressing the inciting organism with recognized interventions, the immune-modulated chronic forms of uveitis often provide more complex challenges in management. Recent strides in understanding the inflammatory pathway and better bioengineering capabilities have resulted in some new modalities of treatment.

Fuchs' heterochromic uveitis: a longitudinal clinical study

PURPOSE

To carry out a longitudinal study of patients with Fuchs' heterochromic uveitis (FHU) in western Sweden and to establish the factors responsible for diagnostic delay.

METHODS

A sample of 54 patients, 51 with monocular and three with binocular FHU, were followed for periods ranging from 8 months to 15 years. Firm diagnostic criteria were set. A detailed anamnesis regarding ocular and extraocular symptoms was taken. The eyes were repeatedly examined. Toxoplasma serology was analysed. Complications were noted.

RESULTS

The delay between the first visit to an ophthalmologist and diagnosis was 0-26 years. The most common first symptom was floaters. Iris heterochromia was absent in 11 patients and discrete in 26. Iris atrophy (a diagnostic criterion) was easy to miss. Chorioretinal scars were found in six patients. Toxoplasma serology was positive in 18 (35%) patients. The only serious complication was glaucoma.

CONCLUSIONS

The most important reason for delay in diagnosis of FHU is, in our opinion, failure to consider the disease as a diagnosis. This failure may occur because heterochromia is often missing or discrete, iris atrophy is easily overlooked, and vitreous opacities are common, often cause early symptoms and can explain prolonged workup and therapy. A connection with toxoplasmosis in individual cases cannot be excluded but toxoplasmosis cannot be considered a major aetiological factor. If detailed anamnesis is negative and diagnostic criteria are fulfilled, no further workup is required.

Update on Fuchs' uveitis syndrome

PURPOSE OF REVIEW

This update aims to summarize the current knowledge on Fuchs' uveitis syndrome and review publications in the last 10 years. Theories on the pathogenesis and etiology of Fuchs' uveitis syndrome are revisited and the management of cataract and glaucoma is updated to reflect recent surgical change.

RECENT FINDINGS

Retrospective reviews have highlighted that patients with Fuchs' uveitis syndrome are often initially misdiagnosed. Studies comparing local inflammatory mediators and cell types have found differences in Fuchs' uveitis syndrome, but the differences in steroid response and degree of inflammation remain poorly understood. Local production of antibodies to rubella has been recently reported in the aqueous of all patients with Fuchs' uveitis syndrome and no controls. Excellent visual outcomes from phacoemulsification have been reported with reduced complications compared with extracapsular cataract extraction.

SUMMARY

Although a single etiological agent and a sensitive laboratory test for the diagnosis of Fuchs' uveitis syndrome is alluring, the diagnosis of Fuchs' uveitis syndrome remains clinical, at least for now. Phacoemulsification has increased the safety of cataract extraction, and the use of intraocular lens is generally safe. The ideal lens material and design are not yet known, but silicone lenses may be best avoided. Glaucoma is often resistant to treatment and should actively be screened for in patients with Fuchs' uveitis syndrome. Medical and surgical treatment for reducing intraocular pressure should be especially aggressive in these patients. Vitrectomy appears to be safe in patients with visually significant vitreous opacification.

Vitrectomy in the treatment of uveitis

PURPOSE

To assess the evidence that pars plana vitrectomy (PPV) is useful in improving vision, reducing disease activity, or ameliorating cystoid macular edema (CME) in patients with uveitis.

DESIGN

Review of the literature.

METHODS

A Medline search was conducted for relevant articles published in English, German, or French. Articles were analyzed for content and evidence level.

RESULTS

A total of 44 interventional case series published between 1981 and 2005 were identified that included 1575 patients (1762 eyes). Evidence level was grade CII-3 indicating possibly improved clinical outcomes with fair or poor evidence. The average age of patients was 36 years with a median duration of uveitis before surgery of 48 months and a median follow-up of 1.9 years. Intermediate uveitis was present in 841 eyes. Cystoid macular edema and cataract were common co-morbidities, and there were large numbers of additional surgical procedures. Visual outcomes in 39 articles were stated as improved in 708 eyes (68%), unchanged in 202 eyes (20%), and worsened in 124 eyes (12%). Reduction in systemic medication following PPV was reported in 25 studies. The median reported percentage of patients per study with CME was 36% preoperatively and 18% postoperatively.

CONCLUSIONS

Based on the evidence in the literature, PPV is possibly relevant to the outcomes of improving vision and reducing inflammation and CME. Randomized, controlled, collaborative trials or hypothesis-based case series with precise outcome measures that incorporate control groups would improve the quality of evidence supporting PPV as an adjunct to the medical treatment of uveitis.

Das Fuchs’sche Uveitis Syndrom — die Heterochromie ist keine Conditio sine qua non

Fuchs uveitis syndrome (FUS) is typically a unilateral, chronic, low-grade inflammation of the anterior segment which manifests in young adulthood. It is underdiagnosed because of its variable clinical spectrum. Although it can mimic various forms of anterior uveitis, it is important to make the correct diagnosis, based on clinical grounds, because both the management and prognosis differ from those of other uveitides. While its etiology remains unknown, it is possible that the disease has multiple causes that lead through different pathogenic mechanisms to the same clinical entity. Although many patients do not require treatment, it is not a benign condition, as often perceived. The high incidence of glaucoma makes it mandatory that all patients with FUS should be screened at regular intervals, even if they are not being actively treated and are relatively asymptomatic.

Outcomes of phacoemulsification and in-the-bag intraocular lens implantation in Fuchs' heterochromic iridocyclitis

PURPOSE

To evaluate the visual outcomes and complications of phacoemulsification (PE) and posterior chamber intraocular lens implantation, (PC IOL) in patients with Fuchs heterochromic iridocyclitis (FHIC).

SETTING

Private clinic and an academic hospital.

METHODS

In this noncomparative interventional case series, existing data for 41 eyes of 40 consecutive patients clinically diagnosed with FHIC and cataract were studied retrospectively. Scleral tunnel PE and in-the-bag IOL implantation were performed in all cases. Preoperative and postoperative visual acuities and intraoperative and postoperative complications were evaluated.

RESULTS

Twenty-four male and 16 female patients aged 12 years to 70 (SD) (mean 35 +/- 12 years) were operated on and followed for 17.8 +/- 8.7 months. Preoperatively, best corrected visual acuity (BCVA) was less than 20/40 in all patients, which improved to 20/40 or better after surgery. Twenty-two eyes (53.6%) achieved BCVA of 20/20. The major cause of postoperative visual acuity less than 20/20 was vitreous haze. There were no major intraoperative complications. Postoperatively, mild anterior chamber fibrin reaction occurred in 4 patients (9.7%), IOL deposits occurred in 11 eyes (26.8%), and decentration was observed in 1 eye. During follow-up, 6 eyes (14.6%) developed posterior capsule opacification requiring a neodymium:YAG (Nd:YAG) laser capsulotomy. There was 1 case of clinical cystoid macular edema that resolved with medication. There were no cases of posterior synechias, postoperative glaucoma, or retinal detachment.

CONCLUSION

Phacoemulsification with PC IOL implantation is a safe procedure with good visual outcomes in patients with FHIC and cataract.