Pars Plana Vitrectomy for Vitreoretinal Complications of Behçet 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.

Treatment outcomes of macular holes in the setting of uveitis: a scoping review

OBJECTIVE

We conducted a systematic review to evaluate the outcome of macular hole (MH) treatment in eyes with uveitis.

DATA SOURCE

We searched PubMed and Embase databases from inception through August 15, 2021.

STUDY SELECTION

We included eyes with MHs secondary to uveitis that were managed medically or underwent pars plana vitrectomy (PPV). We excluded eyes with idiopathic MH and those secondary to causes other than uveitis.

RESULTS

Of 27 articles, we identified 86 eyes with MH secondary to uveitis that received either conservative medical treatment alone or PPV with adequate follow-up. The mean (± SD) age of patients included in this review was 46.6 (± 16.8) years; 60.5% were males. The most common etiology of uveitis was Behçet's disease (34.6%) and toxoplasmosis (19.7%). The most common anatomical location of uveitis was posterior (59.3%) followed by panuveitis (35.2%). The mean (± SD) baseline LogMAR vision was 1.1 (± 0.5). Conservative medical treatment was employed in 34.9%, while PPV was performed in 65.1% of eyes. Overall, the mean (SD) LogMAR vision improved from 1.1 (± 0.5) at baseline to 0.7 (± 0.5) after treatment. Inflammation-related MHs were closed in 40% of eyes after conservative therapy and in 87.5% of eyes after PPV. Visual improvement occurred in most eyes (83.9%) that had successful closure of their MH.

CONCLUSIONS

Visual improvement occurs in most eyes that had successful closure of their inflammation-related MH. Conservative medical control of uveitis may lead to closure of inflammation-related MHs and is an important step prior to surgery, if required. Surgical intervention for inflammation-related MHs is associated with good functional and anatomical results.

Successful repair of combined tractional and rhegmatogenous retinal detachment with pars plana vitrectomy without scleral buckle in severe Behçet’s disease

Behçet’s disease (BD) is a multisystemic, immune-mediated occlusive vasculitis of unknown etiology with a chronic, relapsing remitting course. Ocular involvement is characterized by recurrent nongranulomatous uveitis with necrotizing obliterative vasculitis affecting both the anterior and posterior segments of the eye and often leads to blindness.

We describe successful surgical management of a rare case of combined rhegmatogenous retinal detachment (RRD) and tractional retinal detachment (TRD) in a patient with Behçet’s disease.

A 28-year-old Hispanic women with known Behcet’s disease presented with loss of vision of both eyes. She was found to have extensive bilateral necrotizing vasculitis with severe ischemia. Despite aggressive antivascular endothelial growth factor (VEGF) therapy and pan retinal photocoagulation, patient progressed to total blindness from development of combined rhegmatogenous and tractional funnel retinal detachment. Small gauge pars plana vitrectomy (PPV) with silicone oil tamponade was performed for retinal detachment repair (without scleral buckle).

Combined RRD and TRD was successfully treated with standard PPV with silicone oil placement without use of scleral buckle. Visual acuity 1 year postoperatively improved from ability to perceive light to 20/400.

Combined forms of retinal detachment, a rare development in Behçet’s disease may be effectively treated with PPV (without scleral buckling) with favorable visual and anatomic outcomes.

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.

The Effectiveness of Pre- and Postoperative Infliximab in Controlling Behçet's Disease Posterior Uveitis in Patients Undergoing Vitrectomy: A Preliminary Study

Purpose. To evaluate the short-term effectiveness of infliximab in controlling ocular manifestations in Behçet's Disease (BD) patients candidate for pars plana vitrectomy, if given in a regimen before and after the planned procedure. Patients and Methods. 30 eyes of 27 adult male BD patients with a mean age of 35.56 yrs presented with refractory posterior uveitis not responding to immunosuppressive drugs and candidate for vitrectomy were included. Infliximab was given in a dose of 5 mg/kg intravenous infusion once every two weeks for 3 treatment sessions before the intended vitrectomy followed by 3 treatment sessions at two-week intervals, after vitrectomy. Results. Improvement of ocular manifestations was noted in all eyes, with complete resolution in 26 eyes (87%). Visual acuity improved from 0.23 ± 0.11 to 0.38 ± 0.17 (p ≤ 0.2), ESR decreased from 65.92 mm/hr ± 17.32 SD to 24.93 mm/hr ± 5.28 SD at the last treatment cycle (p ≤ 0.1). The mean daily dose of systemic corticosteroids was tapered from 44.54 mg/d ± 2.89 to 8.48 mg/d ± 6.38 (p ≤ 0.2), and no relapses were noted during the follow-up period. Conclusion. Infliximab may be safe and effective in controlling posterior uveitis and inducing remissions if given in a regimen before and after vitrecomy in BD patients.