Management of presumed trematode-induced granulomatous intermediate uveitis

PURPOSE

To describe the surgical management of presumed trematode-induced granulomatous intermediate uveitis (PTIGIU) not responding to medical treatment in controlling the inflammation.

METHODS

A prospective, interventional, single-center study in which patients with a history of fresh canal water contact and PTIGIU were enrolled. All patients underwent lensectomy-pars plana vitrectomy (PPV) and post-operative control of inflammation, functional and anatomical outcomes were assessed.

RESULTS

Fifteen eyes of 12 patients were included in the study with median age of 11.6 ± 4 yrs. Six months following lensectomy-PPV, inflammation was well controlled in all patients. The eyes were divided into two groups: Group A: 10 patients with an attached retina while Group B: 5 patients who were in the cicatricial stage with tractional retinal detachment. All patients in group A had CDVA of 20/40 or better, unlike patients in group B who failed to achieve a CDVA better than 20/70 throughout their follow-up. In group B, final anatomical success was achieved in only 40% with hypotony occurring in 20%.

CONCLUSION

PTIGIU is associated with the presence of ciliary body granuloma which, if left untreated, can lead to drastic outcomes. Early lensectomy-PPV represents a viable management option in cases resistant to medical treatment, with a favorable outcome.

Fuchs heterochromic iridocyclitis-associated glaucoma: a retrospective comparison of primary Ahmed glaucoma valve implantation and trabeculectomy with mitomycin C

Background: The aim of this study was to compare the safety and efficacy of primary trabeculectomy with mitomycin C and Ahmed glaucoma valve (AGV) implantation in patients with Fuchs heterochromic iridocyclitis (FHIC)-related glaucoma, a rare complication of an uncommon form of uveitis. Methods : In this retrospective comparative case series, 26 FHIC-associated glaucoma patients received trabeculectomy (n=12) or an AGV (n=14). Primary outcome measures were surgical success, defined as intraocular pressure (IOP) ≤21 mmHg, decreasing ≥20% from baseline, and no secondary glaucoma surgery. Secondary outcome measures were the number of glaucoma medications, complications, best corrected visual acuity (BCVA), and IOP. Results: The follow-up was 34.0±17.7 months in patients that received trabeculectomy and 33.4±18.6 months in AGV (P= 0.837). The cumulative probability of success rate was 41.7% for trabeculectomy and 85.7% for AGV, with no significant difference in complications (P>0.05). The IOP in patients that received trabeculectomy dropped from 23.4±3.3 mmHg to 21.6±5.2 mmHg at the final visit (P= 0.041). In patients that received AGV, the IOP decreased from 24±7.8 to 17.1±2.6 mmHg (P= 0.003). The number of glaucoma medications at baseline were 3.3±0.5 in those that received trabeculectomy and 3±0.6 in those that received AGV (P=0.233), and decreased to 2.4±1.0 (P=0.008) and 1.7±0.6 (P=0.002), respectively. BCVA was equal in both groups and did not change (P>0.05). Conclusion: Primary AGV had a higher success rate than trabeculectomy, with patients also needing fewer medications for the management of FHIC-associated glaucoma.

Fuchs heterochromic iridocyclitis-associated glaucoma: a retrospective comparison of primary Ahmed glaucoma valve implantation and trabeculectomy with mitomycin C

Background: The aim of this study was to compare the safety and efficacy of primary trabeculectomy with mitomycin C and Ahmed glaucoma valve (AGV) implantation in patients with Fuchs heterochromic iridocyclitis (FHIC)-related glaucoma, a rare complication of an uncommon form of uveitis. Methods : In this retrospective comparative case series, 26 FHIC-associated glaucoma patients received trabeculectomy (n=12) or an AGV (n=14). Primary outcome measures were surgical success, defined as intraocular pressure (IOP) ≤21 mmHg, decreasing ≥20% from baseline, and no secondary glaucoma surgery. Secondary outcome measures were the number of glaucoma medications, complications, best corrected visual acuity (BCVA), and IOP. Results: The follow-up was 34.0±17.7 months in patients that received trabeculectomy and 33.4±18.6 months in AGV (P= 0.837). The cumulative probability of success rate was 41.7% for trabeculectomy and 85.7% for AGV, with no significant difference in complications (P>0.05). The IOP in patients that received trabeculectomy dropped from 23.4±3.3 mmHg to 21.6±5.2 mmHg at the final visit (P= 0.041). In patients that received AGV, the IOP decreased from 24±7.8 to 17.1±2.6 mmHg (P= 0.003). The number of glaucoma medications at baseline were 3.3±0.5 in those that received trabeculectomy and 3±0.6 in those that received AGV (P=0.233), and decreased to 2.4±1.0 (P=0.008) and 1.7±0.6 (P=0.002), respectively. BCVA was equal in both groups and did not change (P>0.05). Conclusion: Primary AGV had a higher success rate than trabeculectomy, with patients also needing fewer medications for the management of FHIC-associated glaucoma.

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.

[Vitrectomy in vitreo-retinal complications associated with intermediate uveitis]

OBJECTIVE

To investigate the effects of vitrectomy in vitreo-retinal complications associated with intermediate uveitis.

METHODS

Retrospective case series of sixteen eyes of 16 patients in vitreo-retinal disease associated with intermediate uveitis in a 3-year period from Mar 2002 to Jun 2005 were included in the study. They were treated with vitrectomy and the mean follow-up was (14.25 +/- 7.90) months (range: 5-32 months). Visual acuity in final follow-up, post-operative complications and the recurrence of intermediate uveitis were retrospectively reviewed.

RESULTS

Four patients were associated with tuberculosis, rheumatoid arthritis, multiple sclerosis or Behcet disease, respectively. The remaining 12 cases had idiopathic diseases. Pre-operatively, all patients were treated with steroids for a long time and the mean treatment time was (9.94 +/- 2.67) months (range: 6-16 months). Pre-operative vitreo-retinal complications included severe vitreous organization (5 eyes), tractional retinal detachment (6 eyes), rhegmatogenous retinal detachment (1 eye), vitreous hemorrhages (2 eyes), epimacular membrane (2 eyes) accompanied with vitreous tissue, and peripheral retinal neovascularization (16 eyes). In the post-operative period, tractional retinal detachment in one eye and complicated cataract in 3 eyes were observed. Post-operatively, only 4 cases need long-term immunosuppression therapy (more than 6 months). Fourteen of 16 eyes achieved a final visual acuity equal to or better than baseline (X2 = 4.923, P < 0.05). Recurrent intermediate uveitis was not found in these patients.

CONCLUSIONS

The results of this study suggest that pars plana vitrectomy may have a beneficial effect on the intermediate uveitis which was severe or uncontrolled by immunosuppressive drugs and accompanied with vitreo-retinal complications. The beneficial effects include improving visual acuity, reducing need for long-term immunosuppression treatment.

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.

[Preference for transscleral cryocoagulation of peripheral exudate in intermediate ubitis before traditional methods of treatment]

The term intermediate uveitis (IU) describes an anatomic distribution of ocular inflammation rather than a distinct clinicopathologic condition and includes pars planitis, chronic posterior cyclitis and peripheral uveitis. In the treatment of IU corticosteroids and cytostatic agents are of value but since the disease tends to have a long course they produce perminant side effects. Especially this therapy is undesirable in children. In some patients immunosuppressive therapy is not effective, particularly with peripheral neovascularization. Cryotherapy performed in 11 patients (16 eyes, 5 men, 6 women, mean age 22.9 +/- 8.1 years) with IU controlled inflammation during 13-37 months and prevented vitreous hemorrhage.

Pars plana vitrectomy in patients with intermediate uveitis

OBJECTIVE

To describe the effect of pars plana vitrectomy in patients with intermediate uveitis.

METHODS

Retrospective analysis of the clinical course and visual outcome following pars plana vitrectomy in patients with intermediate uveitis.

RESULTS

Thirty-two patients (43 eyes) were included in the study. Pars plana vitrectomy was combined with cataract surgery in 22 of 43 eyes. The intermediate uveitis was associated with sarcoidosis in 16 eyes and multiple sclerosis in five eyes, and was idiopathic in 22 eyes. The mean (+/-SD) follow-up was 45.6 (+/-38) months (range: 6-146 months). In 19 of 43 eyes (44.1%), there was improvement in the course of uveitis, allowing the discontinuation of immunosuppressive treatment in seven patients. Cystoid macular edema resolved in 12 of 37 eyes (32.4%). Forty of 43 eyes achieved a better or retained their initial visual acuity. The remaining three eyes deteriorated by two or more lines in the Snellen chart due to the progression of cataract, chronic cystoid macular edema, and glaucomatous optic atrophy, respectively.

CONCLUSIONS

The results of this study suggest that pars plana vitrectomy may have a beneficial effect on the course of uveitis and the associated complications of cystoid macular edema, thereby reducing the need for long-term immunosuppression. Pars plana vitrectomy combined with simultaneous cataract surgery can improve the visual outcome in these patients.

Long-term results of pars plana vitrectomy in the management of intermediate uveitis

Pars plana vitrectomy is a useful tool for the management of certain complications in chronic intermediate uveitis. Media opacities obscuring the visual axis, vitreous membranes causing tractional retinal detachment, macular puckers, and ciliary traction leading to hypotony are clear indications for this approach. Furthermore, it has been suggested that vitrectomy may have a favorable long-term effect on the course of disease. The procedure may achieve regression of inflammation, tapering of immunosuppression, and improvement of cystoid macular edema. However, randomized prospective trials are still needed to define the role of vitrectomy in altering the course of uveitis.

[Early vitrectomy in endogenous juvenile uveitis intermedia--a long-term study]

BACKGROUND

The intermediate uveitis is one of the most common intraocular manifestations of inflammation during infancy and adolescence. The success of intensive pharmacological treatment is rather limited and often associated with heavy side effects.

PATIENTS AND METHODS

In 25 eyes with juvenile uveitis intermedia (age of the patients between 5 and 18 years, mean 13.5 years) and visual acuities between 0.02 and 0.4 (mean 0.19) an early vitrectomy was performed after failure of conservative treatment and peripheral cryocoagulation.

RESULTS

Almost all patients (22 out of 25) showed an improvement of visual acuity within the first 6 months of the surgery. Among the patients with a remarkable improvement of visual acuity 7 eyes had a chronic cystoid macular oedema which showed a regression postoperatively. Additionally, the number and the course of inflammatory periods could be reduced postoperatively. An increase of preexisting lens opacities, however, has not been noticed even after a follow-up period of 10 years.

CONCLUSIONS

The results show that an early vitrectomy in cases of juvenile uveitis intermedia often leads to a stabilization or an improvement of visual acuity and a regression of the inflammatory attacks (episodes). Therefore, in children and adolescents with endogenous uveitis intermedia a pars plana vitrectomy instead of a long-term systemic immunosuppression associated with heavy side-effects should be considered.

Vitreoretinal surgery in intermediate uveitis

Between 1987 and 1992, vitrectomies were performed in 42 eyes with intermediate uveitis. Pre- and postoperative clinical and ophthalmological parameters were reviewed. Especially the pre- and postoperative time courses of visual acuity were analyzed. We looked for parameters influencing the final visual results. Furthermore, we revised pre- and postoperative recurrent exacerbations of the disease and the duration and dosage of postoperative corticosteroid therapy. The best final visual results were reached in eyes with the best preoperative visual acuities. Anatomic retinal findings and the preoperative duration of intermediate uveitis predominantly influenced the final visual results. Overall, 75% of our patients reached visual acuities of above 20/200. When asked to state their opinion about the final functional result, 80% of the patients were contented. We advocate vitrectomy in patients with intermediate uveitis after intensive follow-up and careful consideration. The anatomic integrity of the retina, a good preoperative visual acuity, and a short preoperative duration of intermediate uveitis are the most important factors influencing the final visual results.

[Results of pars plana vitrectomy in chronic uveitis in childhood]

During 1986-1991 vitreous surgery was performed in 5 girls and 8 boys (age range 2-15 years) with chronic uveitis. In 6 cases a combined lensectomy-vitrectomy was performed because cataract was present, so that the results generally refer to 19 eyes. We found a low rate of postoperative complications. During a follow-up period of 6 months to 5 years (average 2 years and 1 month), 12 of the 19 eyes showed a significant visual improvement. Preoperatively, 8 eyes were found to be affected by cystoid macular edema; in 7 of these cases remarkable regression of the edema was observed after surgery. In two-thirds of cases the intensity of the inflammation decreased, so that the dose of corticosteroids could be reduced postoperatively. Our results suggest that vitrectomy for chronic uveitis in children is a relatively safe and successful treatment. In order to prevent irreversible complications and amblyopia surgery should be performed in an early stage of the disease.

[Pars plana vitrectomy in uveitis]

A vitrectomy was performed in 30 eyes suffering from different forms of uveitis. An improvement of visual acuity was obtained in 29 cases and was explained by removal of vitreous haze and/or of the cataract, but not by the improvement of the inflammatory process.

[Value of vitrectomy in intermediate uveitis and Behçet's disease with hyalitis. A study of 400 cases]

Can vitrectomy help to understand the vitreous role in intermediate uveitis and Behçet's disease with vitritis without retinal detachment? 400 vitrectomies were decided because of vitreous changes but, over all, if macular changes were seen clinically or on the angiogram in 58 Behçet's disease and 342 intermediate uveitis including 59 children cases. Visual acuity, clinical, angiographical and visual field controls, recurrences, reduction of the medical treatment and growth were followed during 1 to 9 years. The vitrectomy products were compared to those of other inflammatory origin vitreous, the both representing 149 cases. Vitrectomy at the early stage of only posterior interface changes prevent the macular edema but this one is irreversible. The preexisting angiographical lesions have not regressed but they are generally quiet. The RD incidence is lower even if it is possible after vitrectomy, in 1.2% of the cases (1% in late vitrectomies). Recurrences and further medical treatment are reduced. This psychological point of view is important. Thus, vitrectomy at alone posterior interface change stage avoid ocular complications. Its pathogenic role in intermediate uveitis is not demonstrated; it seems more a secondary than a primary process.