Pars plana vitrectomy with intravitreal triamcinolone: effect on uveitic cystoid macular oedema and treatment limitations

Vitreoretinal Surgery in Uveitis: From Old to New Concepts - A Review

PURPOSE

The aim of this article is to do a comprehensive literature review about the current role of pars plana vitrectomy in uveitis and in its different structural complications such as cystoid macular edema, epiretinal membrane, macular hole, and retinal detachment.

METHODS

This comprehensive literature review was performed based on a search on PubMed, BioMed Central, Science Open, and CORE databases, of relevant articles abording pars plana vitrectomy in uveitis.

DISCUSSION

Uveitis is a complex disease with multiple etiologies and pathogenic mechanisms. Therapeutic pars plana vitrectomy (PPV) may aid in uveitic structural complications such as cystoid macular edema, epiretinal membranes, macular hole, and retinal detachments even though some cases may present unpredictable visual outcomes. Diagnostic PPV with appropriate ancillary testing is also a valuable tool for the assessment and diagnosis of uveitis in a large proportion of patients.

CONCLUSION

Over the years, pars plana vitrectomy has undergone significant transformations since its invention nearly 5 decades ago, however, the quality of evidence in the literature regarding its use for uveitis has not improved in the same way. Even though some structural uveitis complications (as previously mentioned) may respond well to surgery, there is still a certain unpredictability regarding its visual outcomes. On the other hand, diagnostic vitrectomy with appropriate ancillary testing is also a valuable tool for the assessment and diagnosis of uveitis in a large proportion of patients.

Mechanisms of macular edema

Macular edema is the pathological accumulation of fluid in the central retina. It is a complication of many retinal diseases, including diabetic retinopathy, retinal vascular occlusions and uveitis, among others. Macular edema causes decreased visual acuity and, when chronic or refractory, can cause severe and permanent visual impairment and blindness. In most instances, it develops due to dysregulation of the blood-retinal barrier which permits infiltration of the retinal tissue by proteins and other solutes that are normally retained in the blood. The increase in osmotic pressure in the tissue drives fluid accumulation. Current treatments include vascular endothelial growth factor blockers, corticosteroids, and non-steroidal anti-inflammatory drugs. These treatments target vasoactive and inflammatory mediators that cause disruption to the blood-retinal barrier. In this review, a clinical overview of macular edema is provided, mechanisms of disease are discussed, highlighting processes targeted by current treatments, and areas of opportunity for future research are identified.

Vitreoretinal surgery in the management of infectious and non-infectious uveitis - a narrative review

PURPOSE

This study aims to conduct a narrative review about the current role of vitreoretinal surgery in the management of infectious and non-infectious uveitis.

METHODS

This review was performed based on a search of the PubMed database or on relevant published papers according to our current knowledge.

RESULTS

A total of 91 articles were identified in the literature review. With the advance of microincision vitrectomy surgery (MIVS), pars plana vitrectomy (PPV) has gained increasing popularity in the management of infectious and non-infectious uveitis. For diagnostic purposes, larger amounts of sample can be obtained by MIVS than traditional vitreous aspiration using needles. For treatment purposes, PPV removes vitreous opacities, decreases inflammatory cytokines and mediators of inflammation, and tackles related complications, including hypotony, epiretinal membrane, macular holes, and retinal detachment. Achieving optimum control of inflammation prior to surgery is important for surgical interventions for non-emergent therapeutic indications and complications of uveitis. Peri-operative inflammation management is essential for decreasing the risk of surgical intervention. An overall complication rate of 42-54% was reported with cataract to be the leading cause of complications.

CONCLUSION

Most reports affirm the role of PPV in the management of infectious and non-infectious uveitis, although the quality of data remains limited by a lack of applying standardized reporting outcomes, limitations in study design, and a paucity of prospective data.

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.

Outcomes of Primary 27-Gauge Vitrectomy for 73 Consecutive Cases With Uveitis-Associated Vitreoretinal Disorders

Background: Since the advent of 27-gauge microincision vitrectomy system a decade ago, evidence regarding the feasibility, safety, and effectiveness of 27-gauge pars plana vitrectomy (PPV) has increased. Aim: To assess the effectiveness and safety profile of 27-gauge PPV for various vitreoretinal conditions associated with uveitis. Methods: We retrospectively investigated 73 consecutive cases that underwent primary 27-gauge PPV for uveitis-related ocular disorders between October 2014 and April 2021. The primary outcome measures were mean change in logMAR best-corrected decimal visual acuity (BCVA) pre-operatively to 3 months post-operatively, the proportion of BCVA improvement category defined as the degree of logMAR BCVA difference ("improved" [≤-0.3], "unchanged" [-0.3 to 0.3], and "worsened" [≥0.3]) pre-operatively to 3 months post-operatively, the mean change in intraocular inflammation scores pre-operatively to 3 months post-operatively; and intraoperative and post-operative complications. Results: The mean logMAR BCVA significantly improved from 0.69 pre-operatively to 0.42 at 3 months post-operatively (P = 0.017). The percentages of eyes with "improved," "unchanged," and "worsened" BCVA at 3 months post-operatively were 37, 50, and 13%, respectively. The mean anterior chamber cell score was 0.6 pre-operatively and 0.2 at 3 months post-operatively (P = 0.001), the mean anterior chamber flare score was 0.4 pre-operatively and 0.1 at 3 months post-operatively (P = 0.004), and the mean vitreous haze score was 1.9 pre-operatively and 0.1 at 3 months post-operatively (P < 0.001). Surgery-related complications occurred in 35 (48%) eyes, 68% of which were related to intraocular pressure and transient. Conclusions: Given its risk-benefit profile, 27-gauge PPV is a promising option for the treatment of vitreoretinal disorders in uveitis.

Surgical Therapy for Macular Edema: What We Have Learned through the Decades

Macular edema is a leading cause of functional visual loss in retinal vascular or ocular inflammatory diseases. Because persistent macular edema can lead to irreversible retinal damage, multi-approached treatment should be considered to achieve complete resolution of macular edema. With an enhanced understanding of its pathophysiology, numerous therapeutic options have been developed for the management of macular edema over the decades. Although medical therapies account for the mainstay of treatment, surgical approaches with vitrectomy can play an important role in the management of macular edema, depending on its mechanism of fluid accumulation. The index review focuses on the efficacy of surgical therapy for macular edema secondary to various ocular diseases including diabetic retinopathy, uveitis, and retinal vein occlusion, and consequently provides the evidences that may expand the knowledge and support the employment of surgical options.

Update in treatment of uveitic macular edema

Macular edema (ME) represents the most common cause for visual loss among uveitis patients. The management of uveitic macular edema (UME) may be challenging, due to its often recalcitrant nature. Corticosteroids remain the mainstay of treatment, through their capability of effectively controlling inflammation and the associated ME. Topical steroids may be effective in milder cases of UME, particularly in edema associated with anterior uveitis. Posterior sub-Tenon and orbital floor steroids, as well as intravitreal steroids often induce rapid regression of UME, although this may be followed by recurrence of the pathology. Intra-vitreal corticosteroid implants provide sustained release of steroids facilitating regression of ME with less frequent injections. Topical nonsteroidal anti-inflammatory drugs may provide a safe alternative or adjuvant therapy to topical steroids in mild UME, predominantly in cases with underlying anterior uveitis. Immunomodulators including methotrexate, mycophenolate mofetil, tacrolimus, azathioprine, and cyclosporine, as well as biologic agents, notably the anti-tumor necrosis factor-α monoclonal antibodies adalimumab and infliximab, may accomplish the control of inflammation and associated ME in refractory cases, or enable the tapering of steroids. Newer biotherapies have demonstrated promising outcomes and may be considered in persisting cases of UME.

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.

Uveitic Macular Edema: Treatment Update

The aim of this review is to summarize recent developments in the treatment of uveitic macular edema (ME). ME represent a major cause of visual loss in uveitis and adequate management is crucial for the maintenance of useful vision in patients with chronic uveitis.

Comparison between Outcomes of Vitrectomy in Granulomatous and Nongranulomatous Uveitis

Purpose: The aim of this study was to compare the outcomes of vitrectomy in granulomatous uveitis and nongranulomatous uveitis insufficiently managed by immunosuppressive therapy. Methods: Thirty-eight eyes with granulomatous uveitis and 17 eyes with nongranulomatous uveitis that underwent vitrectomy for ocular complications between July 2006 and August 2012 were reviewed retrospectively. Visual acuity and ocular inflammation scores before and 6 months after surgery were compared. Patients treated with vitrectomy alone and those in whom vitrectomy was combined with phacoemulsification were analyzed separately. Results: The mean visual acuity improved significantly both in granulomatous and nongranulomatous uveitis. In granulomatous uveitis, the mean inflammation scores decreased significantly both in the anterior segment and in the posterior segment. In nongranulomatous uveitis, the mean inflammation score in the posterior segment decreased significantly, although it did not change in the anterior segment. Conclusion: Vitrectomy was effective for treating ocular complications both in granulomatous uveitis and nongranulomatous uveitis, with favorable outcomes of improved visual acuity and decreased uveitis activity.

Interventions for the treatment of uveitic macular edema: a systematic review and meta-analysis

Background

Uveitic macular edema is the major cause of reduced vision in eyes with uveitis.

Objectives

To assess the effectiveness of interventions in the treatment of uveitic macular edema.

Search strategy

Cochrane Central Register of Controlled Trials, Medline, and Embase. There were no language or data restrictions in the search for trials. The databases were last searched on December 1, 2011. Reference lists of included trials were searched. Archives of Ophthalmology, Ophthalmology, Retina, the British Journal of Ophthalmology, and the New England Journal of Medicine were searched for clinical trials and reviews.

Selection criteria

Participants of any age and sex with any type of uveitic macular edema were included. Early, chronic, refractory, or secondary uveitic macular edema were included. We included trials that compared any interventions of any dose and duration, including comparison with another treatment, sham treatment, or no treatment.

Data collection and analysis

Best-corrected visual acuity and central macular thickness were the primary outcome measures. Secondary outcome data including adverse effects were collected.

Conclusion

More results from randomized controlled trials with long follow-up periods are needed for interventions for uveitic macular edema to assist in determining the overall long-term benefit of different treatments. The only intervention with sufficiently robust randomized controlled trials for a meta-analysis was acetazolamide, which was shown to be ineffective in improving vision in eyes with uveitic macular edema, and is clinically now rarely used. Interventions showing promise in this disease include dexamethasone implants, immunomodulatory drugs and anti-vascular endothelial growth-factor agents. When macular edema has become refractory after multiple interventions, pars plana vitrectomy could be considered. The disease pathophysiology is uncertain and the course of disease unpredictable. As there are no clear guidelines from the literature, interventions should be tailored to the individual patient.

Everolimus for the treatment of uveitis refractory to cyclosporine A: a pilot study

BACKGROUND

This study investigated the efficacy of everolimus, a potent inhibitor of T lymphocyte proliferation, for treating noninfectious uveitis. The study design was an open-label prospective trial.

METHODS

Twelve patients with severe chronic uveitis (anterior and intermediate n = 9, panuveitis n = 3) refractive to cyclosporine A (CsA) received additional everolimus.

MAIN OUTCOME MEASURE

the primary outcome measure was uveitis inactivity at 3 months. Secondary outcome measures were uveitis recurrence, visual acuity (BCVA), laser flare photometry values, cystoid macular edema, and tapering of concomitant corticosteroids and/or immunosuppressive drugs in 12 months with the addition of everolimus and after withdrawing everolimus. Percentages of peripheral blood CD3(+)CD4(+)CD25(+)Foxp3(+) cells were studied.

RESULTS

At month 3 with everolimus, uveitis was inactive in all patients. By 12 months, uveitis had recurred in four patients after tapering (n = 2) or withdrawing (n = 2) CsA. BCVA remained stable in all patients, mean foveal thickness (OCT) was slightly reduced from 308 μm at baseline to 255 μm (p = 0.1), and mean flare values were slightly reduced from 27.8 to 19.3 photons/msec (p = 0.1). It was possible to achieve a 50 % dose reduction of systemic prednisone (n = 8) or CsA (n = 8). After withdrawing everolimus, uveitis recurred in 50 % within 1 month; by 6 months, BCVA dropped ≥2 lines in five patients, and prednisone use increased ≥50 % in four patients. The percentage of peripheral blood CD3(+)CD4(+)CD25(+)FoxP3(+) T cells increased during the everolimus treatment, and dropped after withdrawal.

CONCLUSIONS

Uveitis inactivity was achieved with the addition of everolimus in patients with chronic, CsA-refractive anterior and intermediate uveitis, or panuveitis.

Transconjunctival 25-gauge pars plana vitrectomy and internal limiting membrane peeling for chronic macular edema

BACKGROUND

The purpose of this study was to investigate the visual and anatomic outcomes in patients with chronic macular edema who underwent 25-gauge pars plana vitrectomy with internal limiting membrane peeling.

METHODS

This study was a retrospective chart review of 24 eyes from 21 patients who underwent 25-gauge pars plana vitrectomy and indocyanine green-assisted internal limiting membrane peeling for chronic macular edema. Preoperative and postoperative spectral-domain optical coherence tomography (OCT) was examined for macular thickness and macular volume. Outcomes and variables were analyzed using the two-tailed t-test and Spearman's rank correlation coefficient.

RESULTS

Twenty-four eyes from 11 men and 10 women of mean age 69 (range 55-84) years were included. Four patients (17%) had chronic macular edema from uveitis, four (17%) from retinal vein occlusion, and 16 (67%) from diabetes. Mean visual acuity was 20/103 preoperatively and 20/87 postoperatively (P = 0.55). Sixty-three percent of the eyes had improved vision (47% better than 20/40), 21% maintained the same vision, and 17% had worse vision. Forty-seven percent of improved eyes and 30% of total eyes gained more than two lines of visual acuity (range -9 to +7 lines). Mean macular thickness was 455 μm preoperatively and 396 μm postoperatively (P = 0.29). Mean macular volume was 7.9 mm(3) preoperatively and 7.5 mm(3) postoperatively (P = 0.51). The strongest predictor of postoperative visual acuity was initial visual acuity (r = 0.673, P = 0.0003).

CONCLUSION

Even though a majority of patients had improved vision and decreased macular thickening after 25-gauge pars plana vitrectomy with internal limiting membrane peeling for chronic macular edema of various etiologies, the difference in visual acuity or macular thickening did not reach statistical significance.

Periocular triamcinolone acetonide injections for cystoid macular edema complicating noninfectious uveitis

PURPOSE

To describe the effectiveness of periocular corticosteroid injections in the treatment of cystoid macular edema (CME) complicating noninfectious uveitis.

DESIGN

Retrospective cohort study.

METHODS

A total of 126 patients (156 eyes) were evaluated for presence of CME, visual acuity, intraocular pressure, degree of intraocular inflammation, and the presence of ocular complications. Main outcome measures included resolution of CME and visual acuity at the 1- and 3-month visits, failure of periocular injection therapy, and side effects.

RESULTS

Twenty-eight percent of the 156 eyes had anterior uveitis, 22% intermediate uveitis, and 31% panuveitis. Of these eyes, 53% demonstrated clinical resolution of CME at 1 month and 57% at 3 months after a single periocular corticosteroid injection. Forty eyes were treated with >1 periocular injection because the CME persisted 1 month after the first injection (1 additional injection in 21 eyes; 2 additional injections in 14 eyes; >2 additional injections in 5 eyes). For the 21 eyes treated with a second periocular corticosteroid injection, 81% had no CME 1 month after the second injection and 48% had no CME 3 months after the second injection. Twenty-three eyes (15%) failed periocular corticosteroid therapy. Of eyes initially responding to periocular injection, CME recurred in 53% (median time to recurrence = 20.2 weeks). A halving of the visual angle was observed in 52% and 57% at the 1- and 3-month visits after injection, respectively.

CONCLUSIONS

Fifty-three percent of eyes treated with a single periocular corticosteroid injection had clinical resolution of CME 1 month after the injection.

Ranibizumab for refractory uveitis-related macular edema

PURPOSE

To evaluate the effect of intravitreal ranibizumab injections (Lucentis; Genentech Inc, South San Francisco, California, USA) on refractory cystoid macular edema (CME) in patients with controlled uveitis who have failed oral and regional corticosteroid treatment, the mainstays of current medical therapy.

DESIGN

Prospective, noncomparative, interventional case series.

METHODS

Seven consecutive patients with controlled uveitis and refractory CME who had failed corticosteroid treatment were studied. One eligible patient chose not to participate and another did not complete follow-up for nonmedical reasons. Intravitreal ranibizumab injections (0.5 mg) were given monthly for 3 months, followed by reinjection as needed. The primary outcome was the mean change in best spectacle-corrected visual acuity (VA) from baseline to 3 months, and the secondary objective was the mean change in central retinal thickness (CRT) on ocular coherence tomography. Six-month outcomes were also assessed.

RESULTS

At 3 months, the mean increase in acuity for the 6 patients who completed follow-up was 13 letters (2.5 lines), and the mean decrease in CRT was 357 mum. Both VA and CRT improved significantly between baseline and 3 months (P = .03 for each). Although most patients required reinjection, this benefit was maintained at 6 months. There were no significant ocular or systemic adverse effects.

CONCLUSIONS

Intravitreal ranibizumab led to an increase in VA and regression of uveitis-associated CME in patients refractory to or intolerant of standard corticosteroid therapy. Further studies of this promising treatment are warranted.

Inflammatory cystoid macular edema

PURPOSE OF REVIEW

The aim of this article is to update our current understanding and management of inflammatory cystoid macular edema.

RECENT FINDINGS

Cystoid macular edema is a common cause of visual loss in uveitis, which occurs predominantly in older patients with chronic uveitis forms and might be heralded by subclinical changes on optic coherence tomography. Cystoid macular edema is emerging as a major cause of visual loss in HIV-infected patients with immune recovery uveitis. Elevated levels of proinflammatory cytokines and vascular endothelial growth factor were found in all types of cystoid macular edema. Treatment with anti-inflammatory and anti-vascular endothelial growth factor drugs is widely applied for all forms of cystoid macular edema and usually has a beneficial, but temporary effect. So far, there are no clear guidelines for the treatment of subclinical cystoid macular edema in uveitis. The effect of vitrectomy in inflammatory cystoid macular edema is not yet clear and might become more important in the future. Recent advances in management include intravitreal drug delivery systems of cystoid macular edema-modifying drugs.

SUMMARY

This review summarizes current thoughts on inflammatory cystoid macular edema focusing on the new, clinically relevant findings. Upcoming data on aqueous constituents in cystoid macular edema and imaging with the new generation of optic coherence tomography offer the hope that a better treatment strategy will soon be established.

Anatomy and function of the macula after surgery for retinal detachment complicated by proliferative vitreoretinopathy

PURPOSE

To investigate the macular changes following silicone oil removal after surgery for complicated retinal detachment (RD) with proliferative vitreoretinopathy (PVR).

DESIGN

Retrospective interventional case series.

METHODS

setting: Vienna, Austria. study population: Thirty-nine patients with attached retina after silicone oil removal following previous vitrectomy and silicone oil tamponade for complicated RD and PVR grade C3 and worse. observation procedures: Examination of macular anatomy with biomicroscopy, optical coherence tomography (OCT), and fluorescein angiography (FA). Macular function was tested by assessing logMAR distance visual acuity (VA) using Early Treatment Diabetic Retinopathy Study (ETDRS) charts and reading acuity and reading speed using a standardized test (Radner charts). main outcome measures: Macular anatomy, VA, reading acuity, and reading speed.

RESULTS

The macula was clinically normal in five patients (12.8%). Retinal pigment epithelium (RPE) irregularities were found in nine patients (23.1%). Eight patients (20.5%) had macular pucker, seven (18.0%) had cystoid macular edema (CME), and 10 (25.6%) had subretinal fibrosis. The mean VA of all patients was logMAR 0.67 +/- 0.68 (range, -0.1 to 3.0). Six eyes did not achieve reading acuity. The distance VA of the remaining 33 eyes was logMAR 0.44 +/- 0.29 and their mean reading acuity was logRAD 0.62 +/- 0.35, with a reading speed ranging from 55 to 240 words per minute.

CONCLUSIONS

We found macular changes in 87% of the patients, one-third thereof being eligible for further treatment (macular pucker or CME). Thus, the majority of these patients do not seem to be eligible for a further improvement of anatomic or functional outcome.