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

Pediatric Pars Planitis: A Review

PURPOSE

To provide an overview of pediatric pars planitis.

METHODS

Narrative literature review.

RESULTS

Pars planitis refers to the idiopathic subset of intermediate uveitis in which there is vitritis along with snowball or snowbank formation occurring in the absence of an associated infection or systemic disease. It is thought to be a T-cell mediated disease with a genetic predisposition. Pars planitis accounts for 5-26.7% of pediatric uveitis cases. Presentation is commonly bilateral but asymmetric, often with insidious onset of floaters and blurred vision. Although pars planitis is known to be a benign form of uveitis in most cases, severe complications secondary to chronic inflammation may arise, with cystoid macular edema being the most common cause of visual morbidity. Mild vitritis in the absence of symptoms, vision loss, or macular edema may be observed. Patients with severe vitritis and/or associated vision-threatening complications require prompt aggressive treatment. A stepladder approach including corticosteroids, immunosuppressive 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.

CONCLUSION

Timely diagnosis and adequate treatment of pediatric pars planitis and associated complications are crucial in order to improve visual outcomes.

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.

Combined Phacoemulsification and Pars Plana Vitrectomy for the Treatment of Cataract in Patients With Noninfectious Uveitis

Purpose:

This work evaluates the role of combined phacoemulsification and vitrectomy surgery in the management of cataract associated with noninfectious uveitis.

Methods:

A retrospective chart review was conducted of all patients aged 7 years or older who underwent a combined surgical approach from 2005 to 2018.

Results:

Eighty-five eyes of 67 patients were included in the study; 10.7% of eyes had a best-corrected visual acuity (BCVA) of 20/40 or better at time of surgery. At 1-year follow-up, 63.4% of eyes had a BCVA 20/40 or better and 7.6% had a BCVA of 20/200 or worse. There was an overall decrease in cystoid macular edema after surgery compared with preoperatively (47.6% vs 34.5% presurgery and postsurgery, respectively). Complete inflammatory disease remission off immunomodulatory therapy and systemic steroids was achieved in 21.1% of patients.

Conclusions:

A combined surgical approach is effective in visual rehabilitation in patients with uveitic cataracts and may promote inflammatory disease remission specifically in intermediate uveitis.

[Pharmacological treatment strategies and surgical options for uveitis]

BACKGROUND

Modern treatment of uveitis aims at a complete control of inflammatory activity, preservation of visual function and the prevention of secondary organ damage as a consequence of the underlying inflammatory disease and its treatment.

OBJECTIVE

This article gives an update about the strategies of pharmacological and surgical options for uveitis.

MATERIAL AND METHODS

The outcomes reported here are based on a PubMed search using the terms <"uveitis" AND "therapy"> and <"uveitis" AND "surgery" OR "surgical treatment">. All prospective studies and case series with more than 20 cases as well as review articles from the last 5 years along with cited cross-references were evaluated.

RESULTS

Local and systemic corticosteroids form the foundation of treatment after exclusion of an infectious etiology. If uveitis activity is not controlled within 6 weeks or if the daily corticosteroid dosage is unacceptably high, a treatment escalation using immunomodulatory drugs is required. If a complete control of inflammatory activity is not achieved, in a third phase treatment is supplemented by antibody-based treatment or cytokines, so-called biologics, with the aim of complete long-term freedom from disease without local or systemic steroid treatment. This target is achieved in 65-80% and guarantees long-term functional stability and anatomical integrity. Early treatment escalation in cases of persisting or recurrent activity as a rule prevents new secondary organ damage. Surgical options are utilized for diagnostic purposes, the administration of intravitreal drugs and for treatment of secondary complications.

CONCLUSION

Just like the majority of immunological diseases, uveitis is a chronic disease requiring long-term and possibly lifelong treatment and remission (absence of inflammation without treatment) is achieved in only <20%. Surgical interventions can be performed with a good prognosis, if the optic nerve head and macula are not involved. They have a substantially lower complication rate when freedom from symptoms exists preoperatively for at least 3 months.

Visual and Clinical Outcome of Macular Edema Complicating Pediatric Noninfectious Uveitis

PURPOSE

To investigate the clinical course and visual outcome of macular edema (ME) in pediatric patients with chronic noninfectious uveitis.

DESIGN

Retrospective case series.

METHODS

The databases of the uveitis clinics of 4 tertiary medical centers in Israel and the UK were searched for all children treated for uveitic ME in the years 2005-2015. Data were collected from the medical records as follows: demographics, diagnosis, visual acuity, clinical and imaging findings, and treatment given specifically for ME. Findings at baseline and at 3, 6, 12, and 24 months were evaluated.

RESULTS

The cohort included 25 children (33 eyes) of mean age 8.5 ± 3.4 years. The most common diagnosis was intermediate uveitis, in 14 children (7 idiopathic, 7 pars planitis). Uveitis was active at ME diagnosis in 28 eyes (84.8%). Median duration of follow-up was 48 months. Median time to resolution of ME was 6 months, with complete resolution in 25 eyes (75.8%) by 24 months. Baseline visual acuity was ≥20/40 in 8 eyes (24.2%), increased to 57.6% at 3 months (P < .0001), and remained stable thereafter. Treatment regimens included corticosteroids (systemically and/or locally), immunosuppression, and biologic therapies. No correlation was found between outcome and either structural characteristics of ME or specific treatment strategy.

CONCLUSIONS

The prognosis of pediatric uveitic ME is favorable despite its chronic course. Larger randomized controlled trials are needed to define differences among treatment regimens.

Long-term results of pars plana vitrectomy as an anti-inflammatory therapy of pediatric intermediate uveitis resistant to standard medical treatment

PURPOSE

To evaluate the efficacy of pars plana vitrectomy (PPV) as an anti-inflammatory therapy in pediatric recurrent intermediate uveitis.

METHODS

A retrospective study evaluated the long-term results of PPV indicated for intermediate uveitis with a mean observation period of 10.3 years (range 7-15.6 years) in 6 children (mean age 8 years, range 6-12 years). Pars plana vitrectomy was performed on 10 eyes in the standard manner and was initiated by vitreous sampling for laboratory examination. Data recorded were perioperative or postoperative vitrectomy complications, anatomic and functional results of PPV, and preoperative and postoperative best-corrected Snellen visual acuity.

RESULTS

No perioperative or postoperative complications were observed. Bacteriologic, virologic, mycotic, and cytologic analysis of the vitreous was negative in all tested children. Five eyes were subsequently operated on for posterior subcapsular cataracts. An average preoperative visual acuity of 0.32 improved to an average postoperative visual acuity of 0.8.

CONCLUSIONS

In the case of systemic immunosuppressive treatment failure in pediatric uveitis, particularly in eyes with cystoid macular edema, we recommend PPV relatively early.

Analysis of clinical features and visual outcomes of pars planitis

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.

Pars Planitis: Epidemiology, Clinical Characteristics, Management and Visual Prognosis

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.

Surgical management of severe complications arising from uveitis in juvenile idiopathic arthritis

PURPOSE

Evaluate outcomes from severe ocular complications of juvenile idiopathic arthritis following surgery.

METHODS

Eleven eyes of 7 patients underwent complete vitrectomy and peeling of the inner limiting membrane. Inclusion criteria were: anteroposterior segment involvement, hypotony, inflammation control of less than 3 months, compliance issues, rapidly progressive disease. Phacoemulsification was allowed if the patient was >6 years old and inflammation free >3 months. The alternative was a complete lensectomy.

RESULTS

Visual acuity improved from a logMAR of 1.48 to 0.37 (p < 0.0001), and 0.20 at 6 and 12 months (p < 0.0001). No flare-up was observed within the first 6 months. Five eyes developed inflammation between 7 and 19 months. Glaucoma developed in 5 eyes at a median of 16 months. No patient developed cystoid macular edema.

CONCLUSION

Extensive pars plana vitrectomy and cataract extraction can lead to significant improvement in visual acuity. Patients continue to require long-term immunosuppression and adequate follow-up.

Combined phacoemulsification, primary intraocular lens implantation, and pars plana vitrectomy in children with uveitis

PURPOSE

To evaluate the outcome of combined cataract surgery with primary intraocular lens (IOL) implantation and pars plana vitrectomy (PPV) in children with uveitis.

METHODS

Data regarding visual acuity (VA), inflammatory status, medical therapy, and complications was collected from the medical charts of 17 children (21 eyes) with chronic uveitis who underwent combined cataract surgery and PPV at the Eye Clinic, Sahlgrenska/Mölndal, between 2002 and 2011.

RESULTS

Seventy-six percent of the children had juvenile idiopathic arthritis. Median preoperative VA was 1.70 logMAR and median VA after 12 months was 0.17 logMAR. Postoperatively, glaucoma developed in 7 eyes, cystoid macular edema in 3 eyes, and visual axis opacification requiring treatment in 5 eyes.

CONCLUSIONS

Although combined phacoemulsification, primary IOL implantation, and PPV in children with uveitis resulted in favorable visual outcome and stable inflammation in a majority of children, the technique should so far be reserved for uveitic cases with vitreous pathology.

Review of Intermediate Uveitis

The purpose of this article is to highlight evidence about the medical and surgical management of intermediate uveitis (IU). Updated understandings of the immunopathology of IU were reviewed in this retrospective literature review. Literature selection for this review was based on the PubMed database (National Library of Medicine) and OVID database (Wolters Kluwer). Articles deemed relevant were selected and highlighted. Intermediate uveitis is most often a benign form of uveitis. Since intermediate uveitis has been described in association with different systemic disorders, the initial diagnostic evaluation should serve to exclude masquerade syndromes and infectious diseases in which immunosuppression may be ineffective or contraindicated. Although the pathogenesis of intermediate uveitis is not fully understood, identification of proinflammatory molecules involved in the IU has contributed to the development and implementation of new therapies. Studies about the use of various immunosuppressants, biological agents and surgical treatment on IU have provided more evidence for managing IU. Nevertheless, corticosteroids remain the mainstay of treatment. The treatment options of intermediate uveitis are evolving, with the development of various immunosuppressants and biological agents. The management of intermediate uveitis should be tailored individually, based on specific causes of the disease and associated complications.

25-gauge Vitrectomy for complicated chronic endogenous/autoimmune uveitis: predictors of outcomes

PURPOSE

To describe the course of inflammation and identify predictors of successful outcome in chronic endogenous/autoimmune uveitic patients following 25-gauge vitrectomy.

METHODS

In this retrospective study, charts of 74 patients (74 eyes) undergoing vitrectomy for complicated uveitis that had a minimum of 12 months follow-up were reviewed. Successful outcome measures were improvement (≥ 0.3 logMAR) of visual acuity (VA), decreased inflammatory activity (≥ 1+), and reduction of required drugs (more than one). Logistic regression techniques were used to identify predictors of successful outcomes.

RESULT

A total of 44 (59%) of the 74 patients showed VA improvement, 38 (51%) showed decreased inflammatory activity, and 30 (40%) required fewer drugs following vitrectomy. Independent predictor for VA improvements was accompanying cataract extraction, for postoperative inflammatory decrease was the absence of preoperative cystoid macular edema and greater preoperative activity of inflammation, and for the reduction in the number of required drugs was preoperative presence of epiretinal membrane formation.

CONCLUSION

25-gauge vitrectomy may be beneficial in patients with complicated chronic endogenous uveitis in terms of VA and control of inflammation. Accompanying cataract extraction, when necessitated, during vitrectomy and the absence of preoperative cystoid macular edema were indicators of better outcomes. Establishing predictors may assist clinicians in better patient selection.

Pars plana vitrectomy in the management of paediatric uveitis: the Massachusetts Eye Research and Surgery Institution experience

PURPOSE

To assess the effectiveness and safety of pars plana vitrectomy (PPV) in the management of chronic paediatric uveitis.

METHODS

We reviewed records of patients 16 years old or younger who underwent PPV due to persistent uveitis. Data including inflammatory status, ocular findings, visual acuity, dosage and duration of various medical therapies, surgical techniques and complications were collected.

RESULTS

Twenty-eight eyes of 20 patients were included in the study. The diagnoses of uveitis included pars planitis in 15 eyes (54%), idiopathic panuveitis in 8 eyes (29%), and juvenile idiopathic arthritis-associated iridocyclitis in five eyes (18%). Six eyes presented with associated retinal vasculitis. The mean age at the time of PPV was 11.2 years. The mean follow-up after surgery was 13.5 months. All 28 eyes had active uveitis with or without medical therapy at the time of PPV. At last follow-up, uveitis control was achieved with or without adjuvant medical therapy in 27 eyes (96%). These included five of the six eyes with persistent retinal vasculitis. Two eyes that had 20-G PPV developed intra-operative retinal tears. Four eyes with pre-operative clear lenses developed cataract within the first 6 months after PPV.

CONCLUSIONS

PPV is effective and safe in the management of chronic paediatric uveitis and its complications. It was able to reduce the amount of systemic medications required to control inflammation in this study. Patients with uveitis complicated by retinal vasculitis, however, are more likely to require long-term medical therapy to achieve inflammatory control.

Cataract surgery in pediatric uveitis

Uveitis in children is associated with several sight-threatening ocular complications, including the formation of cataracts. The surgical management of uveitic cataracts in children is both challenging and controversial and, unlike in adult uveitic cataracts, surgery has historically been associated with poor visual outcomes. Juvenile idiopathic arthritis-associated uveitis in particular poses unique therapeutic challenges and the issue of correction of aphakia in these patients remains a contentious one. The growing use of immunotherapies and, where needed, targeted biologic agents in childhood uveitis increases our potential to implant lenses and predict outcomes. The authors review the available evidence base for the treatment of these children.

Usefulness of aqueous humor analysis for the diagnosis of posterior uveitis

PURPOSE

To assess the clinical usefulness of aqueous fluid analysis for the diagnosis and treatment of patients suspected of having infectious posterior uveitis (PU).

DESIGN

Case-control study.

PARTICIPANTS

From 2002 through 2005, 152 eyes from 152 patients with active PU (16 of whom were immunosuppressed) underwent diagnostic aqueous testing. As controls, 20 patients with Fuchs' heterochromic uveitis and 20 patients with age-related cataract were included.

METHODS

Aqueous samples were examined by real-time polymerase chain reaction (PCR) and by pathogen-specific analysis of intraocular antibody production (Goldmann-Witmer coefficient [GWC]) for herpes simplex virus (HSV), varicella zoster virus (VZV), cytomegalovirus (CMV), and the parasite Toxoplasma gondii.

MAIN OUTCOME MEASURES

Results of aqueous analysis and any adverse effects of aqueous sampling. Correlations between the results of aqueous testing and clinical characteristics as well as the treatment of patients.

RESULTS

Of 152 patients, 44 (29%) had positive results for at least one diagnostic assay (37/136 [28%] immunocompetent and 7/16 [44%] immunocompromised patients). None of the controls had positive results using PCR or GWC. A positive result was obtained predominantly in patients with focal chorioretinitis (37/87 [40%]) and in extensive retinitis (7/9 [78%]), whereas in multifocal chorioretinitis, neuroretinitis, and retinal vasculitis only a few samples demonstrated positive results (2/19, 1/29, and 0/10, respectively). Of 37 immunocompetent PU patients with positive results, 28 (76%) cases were caused by T. gondii, whereas viral infections were most common in immunocompromised patients (5/7 [71%]). In immunocompetent and toxoplasmosis PU patients, GWC was the most informative assay (34/37 [92%] and 28/30 [93%], respectively), in contrast to immunosuppressed patients (PCR positive in 5/7 and GWC positive in 4/7). Independent of the immune status of patients, positive PCR results were observed more frequently in viral infections than in toxoplasmosis (P<0.001). As a consequence of aqueous analysis, change of treatment was necessary in 36 patients (24%). None of the patients experienced complications during or after aqueous sampling.

CONCLUSIONS

Despite the posterior location of inflammation, aqueous analyses with PCR and GWC for HSV, VZV, CMV, and T. gondii revealed an infectious cause in 29% of patients with PU.