Vitrectomy in the management of uveitis

OBJECTIVE: To review the indications for vitrectomy in uveitis cases. PATIENTS AND METHODS: Charts of patients seen at the uveitis clinic of the Jules Gonin Eye Hospital from January 1993 to August 1998 and who had undergone vitrectomy were reviewed. Patients with infectious uveitis occurring within three months after intraocular cataract surgery were excluded. The types of uveitis were recorded and indications for vitrectomy were analyzed. RESULTS: A total of 630 patients were examined at the uveitis clinic. Fifty-one of these patients (51 eyes, 8.1%) were referred for vitrectomy and were included in this study. Vitrectomy was performed for three reasons: 1) to treat the complications of uveitis (90%), including vitreous opacification in 35 eyes (69%), retinal detachment in seven eyes (14%), epimacular membrane in seven eyes (14%), and dense opacification of the posterior capsule after cataract surgery in six eyes (12%)(the mean delay between uveitis and vitrectomy in this group was 8.4 years); 2) for diagnostic purposes in 19 eyes (37%); and 3) to remove confined infectious foci in 16 eyes (31%) and allow a thorough intraocular distribution of antibiotics. Visual acuity improved in 41 patients (80.4%), remained unchanged in three (5.8%), and decreased in seven (13.7%) because of secondary or persistent retinal detachment or cystoid macular edema. CONCLUSION: Vitrectomy was indicated to treat the complications of uveitis, to provide vitreous for diagnostic purposes, and to allow a better diffusion of intraocular antibiotics. Long-standing uveitis did not seem to be influenced by vitrectomy.     

Vitrectomy in uveitis

Between January 1976 and December 1983, at the First University Eye Clinic in Vienna, 568 vitrectomies and 287 lensectomies were carried out; in 69 of these interventions (20 lensectomies and 49 vitrectomies) the diagnosis was uveitis. In 24 cases the indication for vitrectomy was an intermediary uveitis, a post-traumatic uveitis in 4 and a sympathetic uveitis in 6 cases as well as suppurative endophthalmitis in 7 patients. Indications for surgical removal of pathological tissue from the anterior chamber by the use of vitrectomy instrumentation were, in 4 cases each, hypopioniritis and a hemorrhagic uveitis, and in 12 cases a phacogenic uveitis. In about two thirds of this very heterogeneous patient material, employing vitrectomy made it possible to achieve regression of uveitis. In the remaining third of the patients, at least a stationary state of the disease was achieved and a reduction of corticosteroid and immunosuppressive therapy were made possible. The best functional results were achieved in all surgical interventions in the anterior ocular segment and in vitrectomies for intermediary uveitis. In suppurative endophthalmitis, however, these results were unfavorable.     

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.     

Vitrectomy in uveitis associated with ankylosing spondylitis

Chronic recurrent iridocyclitis in three eyes of two patients with ankylosing spondylitis was associated with posterior spillover of inflammatory cells into the vitreous cavity. Continued inflammation resulted in significant vitreous opacification in all three eyes. After pars plana vitrectomy (two eyes) and cataract extraction with subtotal vitrectomy (one eye), visual acuity improved and stabilized in all three instances. Ocular inflammation was not appreciably exacerbated by surgical intervention. Vitreous opacification did not recur after vitrectomy, but visual improvement was limited because of chronic cystoid macular edema.     

Cryopexy of the vitreous base in the management of peripheral uveitis

We reviewed 27 consecutive eyes with peripheral uveitis and vitreous base neovascularization that had been treated with cryopexy and followed up for a median of 4.5 years. During the follow-up period, 21 eyes (78%) remained quiescent, whereas five eyes (18%) demonstrated intermittent inflammation, although only one of these eyes progressed to a traction retinal detachment. One eye (4%) eventually atrophied; however, this was believed to be a result of the ongoing uveitis rather than the cryopexy. The treated eyes had an average improvement of three lines in Snellen visual acuity. We found that corticosteroid therapy remains the primary treatment modality for active inflammation, and vitreous base cryopexy should be reserved for those cases which are resistant to corticosteroids, and which demonstrate active neovascularization.     

慢性葡萄膜炎黄斑病变的玻璃体手术治疗

目的探讨玻璃体手术对慢性葡萄膜炎合并黄斑病变的治疗价值.方法16例（16眼）反复发作6月以上的慢性迁延性葡萄膜炎,其中合并囊样黄斑水肿6眼,黄斑前膜5眼,玻璃体黄斑牵引综合症4眼,黄斑孔性视网膜脱离1眼,采用玻璃体切除联合人工玻璃体后脱离,内界膜剥离等.术后随访12～30月.结果12眼（75.00%）术后视力明显提高,视力不变或下降4眼为囊样黄斑水肿;视网膜脱离复位;16例术后全身用药减少,炎症得到控制.结论玻璃体手术是治疗慢性葡萄膜炎黄斑病变的有效手段,可以明显提高患者视力,减少全身用药量.     

玻璃体手术治疗中间葡萄膜炎玻璃体视网膜并发症的临床效果

目的 探讨玻璃体手术治疗中间葡萄膜炎玻璃体视网膜并发症的临床效果.方法 为系列病例研究.选择16例(16只眼)并发玻璃体视网膜疾病的中间葡萄膜炎患者进行玻璃体手术治疗.术后随访5～32个月,平均(14.25±7.90)个月.随访期间观察患者视力、术后并发症及中间葡萄膜炎的复发情况.结果 16例(16只眼)患者中,有4例分别患有肺结核、多发性硬化、Beheet综合征及风湿性关节炎等全身性疾病,其余12例无系统性疾病.术前所有患者均有糖皮质激素治疗史,使用时间为6～16个月,平均(9.94±2.67)个月.玻璃体视网膜并发症包括重度玻璃体混浊伴机化5只眼,牵引性视网膜脱离6只眼,孔源性视网膜脱离1只眼,玻璃体积血2只眼,黄斑前膜伴玻璃体机化2只眼,所有患眼均出现周边部视网膜新生血管.术后并发白内障3只眼,牵引性视网膜脱离1只眼.术后4例患者需长期服用糖皮质激素或联合免疫抑制剂治疗.术后视力提高或保持不变14只眼,视力下降2只眼,与术前视力比较差异有统计学意义(x2=4.923,P＜0.05).术后未见中间葡萄膜炎复发者.结论 对严重或药物控制不佳而出现玻璃体视网膜并发症的中间葡萄膜炎患者采用经平坦部的玻璃体手术治疗,可以明显改善患者视力,减少长期使用免疫抑制剂治疗的不良反应.     

玻璃体切割治疗结核性葡萄膜炎1例

患者,女,17岁,因左眼视力下降8个多月于2 0 0 2年12月2日入院。8个月前因“高烧、盗汗、咳嗽2 0余天”被当地医院拟以“血型播散性肺结核”收住入院。入院后第三天双眼视力骤降至视物不见,当地医院诊断为“急性虹膜炎”。予以结膜下注射和眼药水治疗(具体不详) ,视力稍有好转但仍然视物不清,后多次就诊外院,予以结膜下注射和眼药水及口服药物治疗,右眼视力恢复,左眼无明显好转。有低热及咳嗽史,无卡介苗接种史。其家族有结核病史。现“肺结核”已痊愈。查体:心、肺、腹部检查未见明显异常。专科检查:视力,右眼0 .15 ,矫正0 .8;左眼0 .0 2 ,…     

Experience in the treatment of peripheral uveitis

The paper analyses results of conservative and surgical treatment of 65 patients (83 eyes) with peripheral uveitis. For treatment complex therapy was used, including corticosteroids, agents of desensitizing action, antibiotics, enzymes. In a severe course of the process, suprachoroidal irrigations were made by means of corticosteroids, antibiotics, cytostatics. In recurrent peripheral uveitis, for the purpose to block the process, aimed and limiting argon laser coagulation of peripheral foci was used and in case of neovascularization--aimed coagulation of the new-formed vessels. Total stoppage of the inflammatory process with the absence of recurrences within 3 years was achieved in 45 eyes (54.2%). Visible clinical improvement with suppression of inflammation, reduction of the sizes of exudative depositions and active inflammatory foci, tendency to their cicatrization were recorded in 31 eyes (37.4%). In 7 eyes (8.4%) the therapeutic effect was absent.     

玻璃体切除治疗外伤性青光眼

用玻璃体切除术治疗31例外伤性青光眼,术后眼压控制在2.93kPa(1kPa=7.5mmHg)以下22例(71%),视力提高和不变26例(83.9%).此法的主要优点是:(1)解除眼压升高的原因;(2)防治增殖性视网膜病变的发生;(3)除去浑浊的屈光间质,提高视力.主要并发症是眼内出血和低眼压.     

Antituberculosis therapy in the treatment of peripheral uveitis

Tuberculous uveitis usually appears as chronic anterior uveitis or disseminated choroiditis. From 1982 to 1989, we conducted a retrospective study of 23 patients with presumed tuberculous uveitis. All patients had a positive tuberculin purified protein derivative skin test. The diagnosis was based on history, positive skin test, and physical examination. We excluded other conditions that could induce uveitis, based on the absence of signs, symptoms, or laboratory results suggesting any other diagnosis. Tuberculous uveitis was also considered in the differential diagnosis when progressive ocular inflammation was resistant to corticosteroid therapy. The patients received the following treatment: (1) isoniazid (300mg/day) and rifampin (600mg/day) for nine to 12 months, (2) ethambutol (1200mg/day) in some cases for two to three months, and (3) corticosteroids orally where indicated. In cases with anterior uveitis, we added local instillation of mydriatics and corticosteroids. There was no regression, nor were there any side effects of antituberculosis therapy in all 23 patients. We noted clinical improvement in 78% of cases. Five patients had other conditions (cataract or retinal detachment) that worsened their vision.     

Vitrectomy for juvenile uveitis: prognostic factors for the long-term functional outcome

PURPOSE: This study evaluated the long-term effect of pars plana vitrectomy (PPV) in children and adolescents with chronic uveitis on visual function, anatomical outcome, and the requirement of systemic treatment. Further, predictive preoperative factors associated with a beneficial visual outcome were assessed. METHODS: Retrospective review of 29 eyes of 23 consecutive paediatric and juvenile patients below 20 years of age with chronic uveitis who underwent a PPV for visually significant opacities in 25 eyes, vitreous haemorrhage in three eyes, and retinal detachment in one eye. The clinical diagnosis was chronic intermediate uveitis in 22 eyes and retinal vasculitis of different origin in seven eyes. RESULTS: LogMAR visual acuity improved from an average of 0.91 to 0.33 (P<0.001). Cystoid macular oedema (CME) was significantly reduced in eight of 10 eyes postoperatively (P=0.021). In the multiple regression analysis, a low preoperative logMAR visual acuity and the presence of a CME had a negative influence on the final logMAR visual acuity. Furthermore, the appearance of chronic uveitis relapses was significantly reduced from 15 eyes before to seven eyes after surgery (P=0.042). CONCLUSIONS: PPV has a beneficial effect on the course and the complications of chronic uveitis in paediatric and juvenile patients with respect to the anatomical and visual outcome. Preoperative logMAR visual acuity and clinically significant CME were the most accurate predictors for the functional outcome.