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Ozdemir HB, Ozdal PC. Clinical characteristics and treatment of pars planitis: an adalimumab experience. Graefes Arch Clin Exp Ophthalmol 2021; 260:561-569. [PMID: 34568953 DOI: 10.1007/s00417-021-05398-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 08/03/2021] [Accepted: 08/22/2021] [Indexed: 01/01/2023] Open
Abstract
PURPOSE This study aims to investigate the clinical and demographic characteristics, treatment outcomes and complications of patients with pars planitis. METHODS This retrospective study included patients diagnosed with pars planitis between 1998 and 2019 and followed for at least 6 months. Demographics, best-corrected visual acuity (BCVA), anterior segment and fundus examination findings, intraocular pressure (IOP) values at baseline and final examination, treatments used during the follow-up, surgeries and complications were noted from medical records of the patients. The percentage of patients given adalimumab (ADA), the reasons for treatment switch and response to ADA were investigated. RESULTS One hundred fifteen eyes of 59 patients were included in the study. Forty-seven percent of patients were female. The median age of the patients was 10 (4-44) years. The median follow-up time was 33 (6-252) months. The median BCVA at admission was 0.20 (0.00-2.00) logMAR. The most common complications were cystoid macular oedema, cataract, epiretinal membrane and inferior peripheral retinoschisis. Prophylactic laser photocoagulation for peripheral retinoschisis was the most common surgical intervention, followed by cataract surgery and pars plana vitrectomy. Approximately 80% of patients received immunosuppressive and corticosteroid therapy for initial treatment. ADA was initiated in 23 patients (38.9%) due to refractory uveitis and adverse effects to the corticosteroid and helped control intraocular inflammation and decrease the use of systemic steroids/immunosuppressives in 22 of 23 (95%) of patients who received ADA. The median BCVA at final examination increased to 0.00 (0.00-2.00) logMAR. CONCLUSIONS Pars planitis is a chronic, progressive and insidious disease with several ocular complications and requires early and aggressive treatment. ADA appeared to be effective especially in patients' refractory to conventional treatment.
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Affiliation(s)
| | - Pinar Cakar Ozdal
- Department of Ophthalmology, Ulucanlar Eye Training and Research Hospital, University of Health Sciences, Ankara, Turkey
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2
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Stolowy N, Zanin E, Comet A, Jurquet AL, Benso C, Matonti F, Retornaz K, Kaplanski G, Denis D. [Immunosuppressive therapy in severe or chronic pediatric uveitis: Review of the literature]. J Fr Ophtalmol 2021; 44:252-258. [PMID: 33423814 DOI: 10.1016/j.jfo.2020.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 08/17/2020] [Accepted: 08/24/2020] [Indexed: 11/19/2022]
Abstract
Immunosuppressants are prescribed for pediatric uveitis in cases of severe involvement affecting the prognosis for vision or life, in cases of recurrent or chronic uveitis to achieve corticosteroid sparing, or in cases of corticosteroid resistance. Immunosuppressants used in children include antimetabolites (methotrexate, mycophenolate mofetil, azathioprine), cyclosporine, tacrolimus, and biologics, including infliximab, adalimumab, anakinra, canakinumab, and tocilizumab. The mechanisms of action and indications of the various immunosuppressants are described in this review.
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Affiliation(s)
- N Stolowy
- Service d'ophtalmologie, hôpital Nord, Marseille, France.
| | - E Zanin
- Service d'ophtalmologie, hôpital Nord, Marseille, France.
| | - A Comet
- Service d'ophtalmologie, hôpital Nord, Marseille, France.
| | - A-L Jurquet
- Service de pédiatrie, hôpital Nord, Marseille, France.
| | - C Benso
- Service d'ophtalmologie, hôpital Nord, Marseille, France.
| | - F Matonti
- Centre Monticelli Paradis d'Ophtalmologie, Marseille, France.
| | - K Retornaz
- Service de pédiatrie, hôpital Nord, Marseille, France.
| | - G Kaplanski
- Service de médecine interne, hôpital de la Conception, Marseille, France.
| | - D Denis
- Service d'ophtalmologie, hôpital Nord, Marseille, France.
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3
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Espinosa G, Herreras JM, Muñoz-Fernández S, García Ruiz de Morales JM, Cordero-Coma M. Recommendations statement on the immunosuppressive treatment of non-infectious, non-neoplastic, non-anterior uveitis. Med Clin (Barc) 2020; 155:220.e1-220.e12. [PMID: 32199631 DOI: 10.1016/j.medcli.2019.10.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 10/04/2019] [Accepted: 10/10/2019] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To generate recommendations on the use of immunomodulators in patients with non-infectious, non-neoplastic intermediate uveitis (IU), posterior uveitis (PU) and panuveitis (PanU) based on best evidence and experience. METHODS A multidisciplinary panel of 5 experts was established, who defined the scope, users, and sections of the document. A systematic literature review (SLR) was performed to assess the efficacy and safety of immunomodulatory drugs in patients with non-infectious, non-neoplastic, non-anterior uveitis. The results of the SLR were presented and discussed during an expert meeting in which 34 recommendations were generated. The level of agreement with the recommendations was also tested in 25 additional experts following a Delphi process. Recommendations were voted from 1 (total disagreement) to 10 (total agreement). We defined agreement if at least 70% of the experts voted ≥7. The level of evidence and grade or recommendation were assessed using the Oxford Centre for Evidence-based Medicine Levels of Evidence. RESULTS The SLR included 33 articles. The 34 recommendations were accepted after 2 Delphi rounds (3 of them were modified after the first round). They include specific recommendations on patients with non-infectious, non-neoplastic, PU and PanU, as well as different treatment guidelines. CONCLUSIONS In patients with non-infectious, non-neoplastic, non-anterior uveitis these recommendations might help treatment decision making, due to the lack of robust evidence or other globally accepted algorithms.
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Affiliation(s)
- Gerard Espinosa
- Servicio de Enfermedades Autoinmunes, Institut Clínic de Medicina i Dermatologia, Hospital Clínic, Barcelona, España
| | - José M Herreras
- IOBA (Instituto Universitario de Oftalmobiología), Universidad de Valladolid, Valladolid, España; Servicio de Oftalmología, Hospital Clínico Universitario de Valladolid, Valladolid, España
| | - Santiago Muñoz-Fernández
- Servicio de Reumatología, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Madrid, España; Universidad Europea, San Sebastián de los Reyes, Madrid, España
| | - José M García Ruiz de Morales
- Unidad de Uveítis, Servicio de Inmunología, Complejo Asistencial Universitario de León, León, España; Instituto de Biomedicina, Universidad de León (IBIOMED), León, España
| | - Miguel Cordero-Coma
- Instituto de Biomedicina, Universidad de León (IBIOMED), León, España; Unidad de uveítis, Servicio de Oftalmología, Complejo Asistencial Universitario de León, León, España.
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4
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Analysis of clinical features and visual outcomes of pars planitis. Int Ophthalmol 2017; 38:727-736. [PMID: 28389773 DOI: 10.1007/s10792-017-0526-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Accepted: 04/04/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE To evaluate the demographic characteristics, clinical features, treatment and outcomes of patients with pars planitis in a tertiary referral center in Turkey. METHODS Medical records of patients with pars planitis were retrospectively reviewed. The data including demographic and ocular features and treatment outcomes were recorded. The distribution of clinical findings and complications were evaluated according to age and gender groups. The changes in final BCVA compared to the initial BCVA were noted. Statistical analysis was performed using SPSS software (Version 18.0, SPSS Inc., Chicago, USA). RESULTS Twenty-seven patients (54 eyes) were included in this study. 16 patients were male (59.3%), and 11 were female (40.7%). Mean age at diagnosis was 12.84 ± 8.26 (range 4-36) years. Mean follow-up period was 61.3 ± 52.15 (range 9-172) months. Mean BCVA was 0.58 ± 0.36 (range 0.03-1.00) (0.40 ± 0.45 logMAR) at presentation, and 0.81 ± 0.28 (range 0.10-1.00) (0.14 ± 0.27 logMAR) at final visit (P = 0.001). Vitreous inflammation (100%), vitreous haze (92.6%), snowballs (74.1%), snowbanks (66.7%), anterior chamber cells (66.7%) and peripheral retinal vascular sheathing (48.1%) were the most common presentations. Ocular complications included vitreous condensation (51.9%), cystoid macular edema (22.2%), cataract (18.5%), inferior peripheral retinal detachment (11.1%), glaucoma (5.6%) and vitreous hemorrhage (3.7%). Treatments included topical, periocular, intravitreal and systemic corticosteroids, immunosuppressives, peripheral laser photocoagulation and pars plana vitrectomy when needed. CONCLUSIONS Pars planitis is an idiopathic chronic intermediate uveitis mostly affecting children and adolescents. In spite of its chronic nature with high potential of causing ocular complications, adequate treatment and close follow-up lead to favorable visual outcomes.
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Smith WM. Cyclosporine: A Historical Perspective on Its Role in the Treatment of Noninfectious Uveitis. J Ocul Pharmacol Ther 2017; 33:247-262. [PMID: 28287852 DOI: 10.1089/jop.2016.0155] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
The history of cyclosporine and uveitis is intertwined with the development of experimental autoimmune uveitis (EAU) animal models and the understanding that T lymphocytes play a major role in the pathogenesis of uveitis. The early studies of CsA in uveitis also demonstrated the power of collaborative efforts in translational research. Dr. Robert Nussenblatt and his colleagues were the first to show that CsA can inhibit EAU. Over many years after the initial CsA experiments, Dr. Nussenblatt's group as well as others continued to study CsA under experimental conditions as well as in clinical trials with human patients. The data and observations from these studies significantly advanced our knowledge of uveitis pathophysiology and demonstrated the value of well-designed masked, controlled treatment trials in uveitis. Dr. Nussenblatt and his collaborators delved into the most significant adverse effect of CsA, renal toxicity, and helped elucidate the pathophysiology of renal injury. They explored adjunctive treatments to improve the efficacy and decrease the toxicity of CsA and also studied other members of the cyclosporine family. Among the immunosuppressives used to treat ocular inflammation, CsA was the first, and remains the only medication comprehensively studied under both experimental and clinical conditions.
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Dry eye disease and uveitis: A closer look at immune mechanisms in animal models of two ocular autoimmune diseases. Autoimmun Rev 2016; 15:1181-1192. [DOI: 10.1016/j.autrev.2016.09.001] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2016] [Accepted: 07/08/2016] [Indexed: 12/13/2022]
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Ozdal PC, Berker N, Tugal-Tutkun I. Pars Planitis: Epidemiology, Clinical Characteristics, Management and Visual Prognosis. J Ophthalmic Vis Res 2016; 10:469-80. [PMID: 27051493 PMCID: PMC4795398 DOI: 10.4103/2008-322x.176897] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Pars planitis is an idiopathic chronic intermediate uveitis which predominantly affects children and adolescents, and accounts for 5-26.7% of pediatric uveitis. Although an autoimmune process with a genetic predisposition has been suggested, its etiology still remains unknown. The most common presenting symptoms are floaters and blurred vision. Diffuse vitreous cells, haze, snowballs and snowbanks are typical findings of pars planitis. Peripheral retinal vasculitis, optic disc edema and anterior segment inflammation are other well-known findings. Although pars planitis is known to be a benign form of uveitis in most cases, it may become a potentially blinding disease due to complications including cataract, cystoid macular edema, vitreous opacities and optic disc edema. Cystoid macular edema is the most common cause of visual morbidity. Band keratopathy, epiretinal membrane formation, vitreous condensation, neovascularizations, vitreous hemorrhage, retinal detachment, cyclitic membranes, glaucoma and amblyopia may develop as a consequence of the chronic course of the disease. Exclusion of infectious and non-infectious causes which may present with intermediate uveitis is of utmost importance before starting treatment. Treatment of pars planitis has been a controversial issue. There is no consensus specifically for treatment of cases with minimal inflammation and relatively good visual acuity. However, current experience shows that pars planitis may cause severe inflammation and needs an aggressive treatment. A stepladder approach including corticosteroids, immunosupressive agents, anti-tumor necrosis factor-alpha and pars plana vitrectomy and/or laser photocoagulation is the most commonly used method for treatment of pars planitis. Adequate control of inflammation and prompt detection of associated complications are crucial in order to improve the overall prognosis of the disease.
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Affiliation(s)
- Pinar Cakar Ozdal
- Service of Uveitis and Retinal Diseases, Ankara Ulucanlar Eye Research Hospital, Ankara, Turkey
| | - Nilufer Berker
- Service of Uveitis and Retinal Diseases, Ankara Ulucanlar Eye Research Hospital, Ankara, Turkey
| | - Ilknur Tugal-Tutkun
- Department of Ophthalmology, Istanbul University Faculty of Medicine, Istanbul, Turkey
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8
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Clinical characteristics of intermediate uveitis in Tunisian patients. Int Ophthalmol 2010; 30:531-7. [DOI: 10.1007/s10792-010-9352-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2009] [Accepted: 02/07/2010] [Indexed: 01/13/2023]
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9
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Kansupada KB, Whitcup SM. Intermediate Uveitis. Semin Ophthalmol 2009. [DOI: 10.3109/08820539609067462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Dev S, Mieler WF, Pulido JS, Mittra RA. Visual outcomes after pars plana vitrectomy for epiretinal membranes associated with pars planitis. Ophthalmology 1999; 106:1086-90. [PMID: 10366075 DOI: 10.1016/s0161-6420(99)90247-6] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
OBJECTIVE To evaluate the results of pars plana vitrectomy and membrane stripping for visually significant macular epiretinal membranes associated with chronic idiopathic pars planitis. DESIGN Consecutive noncomparative case series. PARTICIPANTS AND METHODS The records of all patients who underwent pars plana vitrectomy for pars planitis from 1988 through 1997 were retrospectively reviewed. Seven eyes of five patients who were diagnosed with visually significant epiretinal membranes associated with pars planitis and who underwent vitrectomy and membrane stripping were analyzed. Patients were diagnosed with pars planitis based on characteristic clinical signs and pertinent negative laboratory test results. INTERVENTION Pars plana vitrectomy and epiretinal membrane stripping. MAIN OUTCOME MEASURES Visual acuity and inflammatory grade were compared between the last preoperative visit and the most recent follow-up visit. Intraoperative and postoperative complications were also analyzed. RESULTS The mean patient age was 31 years (range, 6 to 45 years). The mean duration of uveitis was 6.4 years (range, 6 months to 13 years). All patients were treated with combinations of periocular, topical, and oral corticosteroids before surgery. Five eyes had laser retinopexy, and two eyes had cryopexy to the inferior retina at the time of surgery. Five eyes had at least 3 Snellen lines of visual acuity improvement, and visual acuity in one eye worsened by 2 lines. Mean preoperative visual acuity was 20/73 (range, 20/50 to 20/300), and mean final visual acuity was 20/37 (range, 20/25 to 20/70). Five eyes had a final visual acuity of 20/40. Vitritis improved in all cases. Mean follow-up was 23 months (range, 3 to 54 months). Six of seven eyes had progressive cataract development, four of which underwent cataract extraction. No other intraoperative or postoperative complications occurred. CONCLUSIONS Removal of epiretinal membranes associated with pars planitis can be safely performed and may result in improved visual acuity. Patients often require subsequent cataract extraction to obtain the best long-term final acuity.
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Affiliation(s)
- S Dev
- Medical College of Wisconsin Eye Institute, Vitreoretinal Section, Milwaukee 53226, USA
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11
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Vitale AT, Rodriguez A, Foster CS. Low-dose cyclosporin A therapy in treating chronic, noninfectious uveitis. Ophthalmology 1996; 103:365-73; discussion 373-4. [PMID: 8600411 DOI: 10.1016/s0161-6420(96)30683-0] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
PURPOSE To describe the authors' approach to the management of patients with recalcitrant, chronic, endogenous uveitis using low-dose Cyclosporin A (CSA) alone or in combination with other immunosuppressive agents with attention to the anti-inflammatory efficacy, visual outcome, and side effects of therapy. METHODS The authors reviewed the records of 50 patients (92 eyes) with uveitis of various etiologies who had been treated with low-dose CSA (2.5-5.0 mg/kg daily) alone or in combination with prednisone and/or azathioprine (1.5-2.0 mg/kg daily). The median follow-up on low-dose CSA was 16 months (range, 6-64 months). RESULTS Inflammatory control was achieved in 68 (73.9%) eyes, while persistent inflammatory activity was observed in 14 (15.2%). Thirty-eight (41%) eyes improved two Snellen lines or more, 43 (47.0%) stabilized, and 11 (12.0%) lost two lines or more. The CSA was discontinued because of nephrotoxicity in three patients and in each of two with systemic hypertension and constitutional intolerance to the drug, respectively. Thirteen patients enjoy inflammatory remission with this regimen. CONCLUSION Low-dose CSA used alone or in combination with other immunosuppressive agents is effective in achieving inflammatory control with a favorable visual outcome and provides a useful steroid-sparing strategy in the management of chronic endogenous uveitis. The CSA-associated toxicity may be reduced by initiating therapy at very low initial doses, with incremental dosage escalation to the desired target range.
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Affiliation(s)
- A T Vitale
- Immunology and Uveitis Service, Massachusetts Eye and Ear Infirmary, Harvard University Medical School, Boston, 02114, USA
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Ortega-Larrocea G, Arellanes-Garcia L. Pars planitis: epidemiology and clinical outcome in a large community hospital in Mexico City. Int Ophthalmol 1995; 19:117-20. [PMID: 8586494 DOI: 10.1007/bf00133182] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Medical records of 51 patients with a diagnosis of pars planitis (97 eyes) were reviewed. Based upon the severity of vitreous inflammation, in 34 eyes (35%) the condition was classified as mild, in 38 (39%) as moderate, and in 25 eyes (26%) as severe. Vascular sheathing was present in 51 eyes (53%), snowballs in 42 (43%), snowbanks in 29 (30%), cataract in 19 (20%), cystoid macular edema in 26 (27%), retinal detachment in 4 (4%) and glaucoma in 3 (3%) eyes. Treatment consisted of prednisone and periocular injections of deposteroids or immunosuppressive agents; 13 patients required surgery for retinal repair, glaucoma, vitreous opacities or cataract. After treatment the visual acuity improved in 58% of the eyes, did not change in 33%, and worsened in 9%.
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Affiliation(s)
- G Ortega-Larrocea
- Department of Uveitis, Asociación para evitar la ceguera en México, Luis Sanchez Bulnes Hospital, Mexico City, Mexico
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Dugel PU, Rao NA, Ozler S, Liggett PE, Smith RE. Pars plana vitrectomy for intraocular inflammation-related cystoid macular edema unresponsive to corticosteroids. A preliminary study. Ophthalmology 1992; 99:1535-41. [PMID: 1454319 DOI: 10.1016/s0161-6420(92)31769-5] [Citation(s) in RCA: 66] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
PURPOSE To determine the role of pars plana vitrectomy in patients with intraocular inflammation-related cystoid macular edema that is unresponsive to corticosteroids. METHODS Eleven eyes of nine patients underwent a standard three-port pars plana vitrectomy. The primary indication was intraocular inflammation-related cystoid macular edema that was unresponsive to oral, sub-Tenon's, and topical corticosteroids. Preoperative follow-up ranged from 20 months to 144 months (average, 70 months). Postoperative follow-up ranged from 3 months to 108 months (average, 21 months). RESULTS Seven eyes (64%) improved 4 or more lines of Snellen visual acuity within 4 weeks. Two eyes (18%) remained unchanged and 2 eyes (18%) worsened. Cystoid macular edema improved by clinical examination and fluorescein angiography in 9 eyes (82%) and by clinical examination alone in 2 eyes (18%). No intraoperative complications were noted. Postoperative complications consisted of cataract formation in 1 eye (9%), glaucoma in 2 eyes (18%), and epiretinal membrane formation in 1 eye (9%). CONCLUSION Pars plana vitrectomy may have a role in the treatment of intraocular inflammation-related cystoid macular edema that fails to respond to corticosteroids. The subgroup of patients who benefit most remains to be identified.
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Affiliation(s)
- P U Dugel
- Doheny Eye Institute, Los Angeles 90033
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