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Editor,

Pars plana vitrectomy (PPV) has been a natural accompaniment to pharmacotherapy in the treatment of ocular inflammatory diseases as it offers a surgical means to clear vitreous opacities and repair structural complications (Becker & Davis 2005). Recently, the evolution of sutureless 25-G vitrectomy system has led to minimization of the surgically induced trauma from peritomy and sclerotomy sites.

Apart from a single article reporting on combined sutureless PPV and phacoemulsification in uveitic eyes with cataract and posterior segment pathology (Soheilian et al. 2008), a systematic evaluation of the peer-reviewed literature recovered no studies or case series reporting the outcome of sutureless 25-gauge PPV in uveitic eyes.

Fifteen cases (14 patients) underwent 25-gauge PPV as a therapeutic procedure at the Department of Ophthalmology, Aristotle University of Thessaloniki, Greece. The mean patient age was 40 ± 19.7 (median: 32, range: 10–65 years). The mean duration of uveitis prior to surgery was 39.2 ± 44.5 (range: 1–168 months). The mean follow-up time was 17.2 ± 11.4 (range: 2–38 months). (All values above are expressed as mean ± SD). Institutional review board (IRB) approval was obtained for this study.

Table 1 summarizes the uveitis diagnosis, the pre and postoperative visual acuity (VA) values and postoperative complications for our study population.

Table 1.   Pre and postoperative visual acuity and complication in each case.
 DiseaseIndicationMean duration of uveitis (months)Pre-operative BCVAPostoperative BCVAComplications
  1. ARN = acute retinal necrosis, BCVA = best corrected visual acuity, BRVO = branch retinal vein occlusion, CF = counting fingers, ERM = epiretinal membrane, JIA = juvenile idiopathic arthritis, HM = hand motion, IMT = immunomodulatory therapy, MS = multiple sclerosis, nv = neovascularization, r/o = rule out, w/o = without, Pt = patient, sil-oil = silicone oil.

 1Behçet’sVitreous heme28HM20/100None; macular ischemia
 2Behçet’sVitreous heme28HM20/60None
 3Toxoplasmosisr/o endophthalmitis96CF20/40None; pt received antitoxoplasmic drugs postoperative
 4ARNRetinal detachment220/20020/100Cataract progression; extraction with sil-oil removal
 5SarcoidosisBRVO + Vitreous heme3820/20020/80Cataract progression
 6Behçet’sVitreous heme18CF20/80Cataract progression
 7ToxoplasmosisERM2720/8020/25None; mild macular oedema
 8MSVitreous heme41CF20/30Cataract progression
 9ToxocaraRetinal detachment2HMLPPhthisis
10Behçet’sVitreous heme14CF20/80Cataract progression
11SarcoidosisERM3720/10020/30None
12Behçet’sRetinal detachment1CF20/25None; pt started IMT postoperative
13WegenerVitreous heme11CF20/40IMT
14SarcoidosisERM7820/8020/30None
15JIAVitreous heme168HM20/100Severe hypotony

None of the eyes developed postoperative wound leakage, choroidal detachment or vitreous haemorrhage. Transient intraocular pressure (IOP) elevation postoperatively occurred in 7/15 patients (46.6%) and was normalized with medical treatment in all cases. One case (#15) with juvenile idiopathic arthritis uveitis (a single-eyed patient) showed extreme hypotony the first postoperative day, and we injected a mixture of 20% C3F8, without any improvement. We proceeded with triamcinolone acetonide injection, but still the hypotony persisted and recovered only after i.v. pulse methylprednisolone infusion, followed by tapering doses of oral steroids; we assume that the patient suffered from ciliary body shutdown that resulted in zero pressure readings, despite the absence of apparent surgical wound leakage.

One patient developed (#9) phthisis, secondary to a toxocara granuloma-related retinal detachment. This case was complicated primarily by severe proliferative vitreoretinopathy (PVR) and tractional retinal detachment with retinal breaks. Postoperatively, PVR continued to develop under silicone oil and despite the appropriate medical therapy.

Although sutureless 25-gauge PPV has been reported as a surgical approach for other forms of posterior segment involvement, there are some special considerations when it comes to uveitic cases.

Intraocular surgery may improve (Giuliari et al. 2010; Quinones et al. 2010) or exacerbate inflammation (Foster & Opremcak 2002) through activation of the underlying inflammatory process. Moreover, the procedure itself may result in an unusually severe inflammatory response, abnormal or excessive bleeding and/or unexpected postoperative intraocular pressure responses (hypertension or hypotony). It is clear that the most important factor contributing to a successful outcome is both pre and postoperative controls of the intraocular inflammation by topical, periocular and systemic steroids or immunosuppressive agents (Foster & Opremcak 2002).

Although the final role of vitrectomy in the management of patients with uveitis remains to be determined, our experience reveals that the 25 g surgical technique is a safe and efficacious approach in selected uveitis cases.

References

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  2. References
  • Becker M & Davis JL (2005): Vitrectomy in the treatment of uveitis. Am J Ophthalmol 140: 10961105.
  • Foster CS & Opremcak EM (2002): Therapeutic surgery: cornea, iris, cataract, glaucoma, vitreous, retinal. In: Foster CS & Vitale A (eds). Diagnosis and treatment of uveitis. Philadelphia: WB Saunders, 222235.
  • Giuliari GP, Chang PY, Thakuria P et al. (2010): Pars plana vitrectomy in the management of paediatric uveitis: the Massachusetts eye research and surgery institution experience. Eye 24: 713.
  • Quinones K, Choi JY, Yilmaz T et al. (2010): Pars plana vitrectomy versus immunomodulatory therapy for intermediate uveitis: a prospective, randomized pilot study. Ocul Immunol Inflamm 18: 411417.
  • Soheilian M, Mirdehghan SA & Peyman GA (2008): Sutureless combined 25-gauge vitrectomy, phacoemulsification, and posterior chamber intraocular lens implantation, for management of uveitic cataract associated with posterior segment disease. Retina 28: 941946.