Nonprogressive tractional inferior retinal elevation in intermediate uveitis

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.

Clinical characteristics of intermediate uveitis in adults according to criteria of the SUN working group

PURPOSE

To analyse the clinical characteristics of adult patients with pars planitis (PP-IU), non-pars planitis (NPP-IU) and multiple sclerosis-associated intermediate uveitis (MS-IU) and distinguish between groups.

METHODS

Seventy-three adult patients with intermediate uveitis (IU) reviewed retrospectively and divided as PP-IU, NPP-IU and MS-IU according to 'The standardization of uveitis nomenclature working group classification criteria.' Demographic and clinical characteristics, OCT and fluorescein angiography (FA) findings, complications and treatments were recorded.

RESULTS

A total of 134 eyes of 73 patients were included, and 42 of the patients were classified as PP-IU, 12 as NPP-IU, and 19 as MS-IU. If a patient presenting with blurred vision, or tent-shaped vitreous band/snowballs/snowbank on examination, or vascular leakage on FA and accompanying neurological symptoms, the frequency of demyelinating plaque detection on cranial MRI and the risk of MS-IU increased. Mean BCVA was increased from 0.22 ± 0.30 logMAR to 0.19 ± 0.31 logMAR (p = 0.021). Gender, initial BCVA, snowbank formation, disc oedema and periphlebitis on examination, and disc leakage/occlusion on FA were found predictive of decreased BCVA at final visit (p < 0.05).

CONCLUSIONS

The clinical features of these three groups are similar, some features that can guide the differential diagnosis. It may be recommended to periodically evaluate "suspicious" patients with MRI for MS.

Total exudative retinal detachment in a child with pars planitis- a challenging case with optimistic results

We describe a case report of pediatric pars planitis complicated with massive exudative retinal detachment (ERD). A 7-year-old presented with visual acuity (VA) in the right eye (RE) of 6/9 and in the left eye (LE) 6/15. Fundoscopy revealed BE inferior retinoschisis, vitritis and snowballs. He was treated with systemic immunosuppressants. RE retinoschisis resolved within 2 months. Three years later presented with LE VA 6/60 and total ERD. Systemic and intravitreal steroids were administered. Due to refractoriness, he underwent 360° scleral buckle and drainage of subretinal fluid. No retinal breaks or traction were detected. Five months postoperatively LE VA was 6/7.5. Long-term stable outcome was maintained. We report a challenging total ERD as a complication of pars planitis. Although extensive and non-responsive to medical therapy, complete resolution and improvement in vision was achieved with surgical intervention and systemic immunosuppression. We speculate that uncontrolled chronic vasculitic process culminated in diffuse ERD.

Intermediate Uveitis: A Review

PURPOSE

This review aims to provide an update on the clinical presentation, etiologies, complications, and treatment options in intermediate uveitis (IU).

METHODS

Narrative literature review.

RESULTS

IU affects all age groups with no clear gender predominance and has varied etiologies including systemic illnesses and infectious diseases, or pars planitis. In some instances, IU may be the sole presentation of an underlying associated condition or disease. Management of IU and its complications include administration of corticosteroids, antimetabolites, T-cell inhibitors, and/or biologics, along with surgical interventions, with varying degrees of effectiveness across literature. In particular, increasing evidence of the safety and efficacy of immunomodulatory agents and biologics has seen greater adoption of these therapies in clinical practice.

CONCLUSIONS

IU is an anatomical description of uveitis, involving intraocular inflammation of the vitreous, peripheral retinal vasculature, and pars plana. Various treatment options for intermediate uveitis are currently used in practice.

Clinical characteristics and treatment of pars planitis: an adalimumab experience

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.

Retinal detachment and uveitis at a tertiary center over 10 years: the King Khaled Eye Specialist Hospital (KKESH) Uveitis Survey Study Group

PURPOSE

To evaluate the frequency, etiology, treatment, and visual prognosis of retinal detachment (RD) in patients with uveitis.

METHODS

A retrospective review was performed in 707 consecutive patients (1042 eyes) with uveitis, of whom 97 (13.7%) (157 eyes [15.1%]) had RD.

RESULTS

There were 126 (12.1%) eyes with exudative retinal detachment (ERD), 16 (1.5%) with tractional retinal detachment (TRD), and 15 (1.4%) with rhegmatogenous retinal detachment (RRD). Panuveitis was most commonly associated with RD (144 (91.1%) eyes). Infectious causes were more common in RRD, and non-infectious etiologies were most common in ERD and TRD. Oral prednisone was the initial therapy in ERD. Additionally, in these cases, cyclosporine was prescribed most frequently (47.1% patients), followed by azathioprine (26.4% patients). Fourteen (87.5%) eyes with TRD and all RRD cases underwent surgery. In patients with ERD, the mean best-corrected visual acuity (BCVA) was 1.1 ± 0.7 LogMAR at baseline and 0.6 ± 0.2 LogMAR at last visit (p = 0.001). In patients with TRD, mean BCVA was 0.7 ± 0.4 LogMAR at baseline and 0.6 ± 0.4 LogMAR at last visit (p = 0.056). In patients with RRD, mean BCVA was 1.6 ± 0.9 LogMAR at baseline and 20 1.3 ± 0.9 LogMAR at last visit (p = 0.185).

CONCLUSION

In Saudi Arabia, ERD is observed in 12.1% of the eyes with uveitis, and less than 2% of eyes had TRD or RRD. Visual prognosis is usually good after ERD. Infection is the most frequent cause of RRD associated with uveitis and the visual prognosis is poor.

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.

Retinoschisis in Pars Planitis

PURPOSE

To describe the course of retinoschisis in patients with pars planitis (PP).

METHODS

Chart review of PP patients seen July 2012-September 2014 at a single institution.

RESULTS

Included were 34 patients (68 eyes). Uveitis was bilateral in all cases. Thirteen eyes (19%) developed retinoschisis. In six patients (86%), the schisis was bilateral. The average follow-up of patients with schisis was 7 years; the average best-corrected visual acuity (BCVA) was 20/22 at last follow-up. Schisis was noted to develop or progress in patients with both active and inactive inflammation. Five eyes of five patients underwent vitrectomy; three for disease control, with scleral buckle to reduce residual traction. Two eyes required vitrectomy for retinal detachment with progressive schisis, despite inactive uveitis. Seven eyes remained stable without intervention.

CONCLUSIONS

Retinoschisis is a common complication in patients with PP. It is typically bilateral, and may develop or progress, despite control of uveitis.

Scleral Buckling for Rhegmatogenous Retinal Detachment Associated with Pars Planitis

Purpose. To evaluate the surgical outcome of scleral buckling (SB) in rhegmatogenous retinal detachment (RRD) patients associated with pars planitis. Methods. Retrospective review of RRD patients (32 eyes of pars planitis RRD and 180 eyes of primary RRD) who underwent SB. We compared primary and final anatomical success rates and visual outcomes between two groups. Results. Primary and final anatomical success were achieved in 25 (78.1%) and 31 (96.8%) eyes in the pars planitis RRD group and in 167 eyes (92.7%) and 176 eyes (97.7%) in primary RRD group, respectively. Both groups showed significant visual improvement (p < 0.001) and there were no significant differences in final visual acuity. Pars planitis RRD group was associated with higher rate of postoperative proliferative vitreoretinopathy (PVR) development (12.5% versus 2.8%, p = 0.031). Pars planitis and high myopia were significant preoperative risk factors and pseudophakia was borderline risk for primary anatomical failure after adjusting for various clinical factors. Conclusions. Pars planitis associated RRD showed inferior primary anatomical outcome after SB due to postoperative PVR development. However, final anatomical and visual outcomes were favorable. RRD cases associated with pars planitis, high myopia, and pseudophakia might benefit from different surgical approaches, such as combined vitrectomy and SB.

Clinical characteristics of intermediate uveitis in adult Turkish patients

AIM

To describe the clinical characteristics of Turkish patients with intermediate uveitis (IU) and to investigate the effect of clinical findings and complications on final visual acuity (VA).

METHODS

We retrospectively analyzed the medical records of patients with IU who had at least 6mo of follow-up and were older than 16y.

RESULTS

A total of 78 eyes of 45 patients were included in the study and the mean follow-up period was 19.4mo. The mean age at the time of presentation was 42.9s. Systemic disease associations were found in 17.7% of cases; sarcoidosis (8.8%) and multiple sclerosis (6.6%) were the most common diseases. Recurrence rate (odds ratio=45.53; 95%CI: 2.181-950.58), vitritis equals to or more than 3+ cells (odds ratio=57.456; 95%CI: 4.154-794.79) and presenting with VA less than 20/40 (odds ratio=43.81; 95%CI: 2.184-878.71) were also found as high risk factors for poor final VA. At the last follow-up examination, 67.9% of eyes had VA of 20/40 or better.

CONCLUSION

IU is frequently seen at the beginning of the fourth decade of life. The disease is most commonly idiopathic in adult Turkish patients. Patients with severe vitritis at presentation and patients with frequent recurrences are at high risk for poor visual outcome.

Laser photocoagulation in intermediate uveitis associated with retinoschisis

PURPOSE

To describe cases of pars planitis associated with retinoschisis, in which laser photocoagulation was carried out.

METHODS

Retrospective review.

RESULTS

Three pars planitis cases were associated with retinoschisis and underwent laser photocoagulation. All cases were idiopathic. Retinoschisis was located in the inferior retinal quadrants in all cases and all of them were in bullous formation. None of the cases developed retinal detachment.

CONCLUSION

As well as posterior vitreous detachment, or peripheral retinal tears, retinoschisis may accompany pars planitis. Laser photocoagulation of the pars plana is effective in these cases both as a treatment and to prevent sight-threatening complications like retinal detachment.