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UVEITIS CORNER: How to Approach Surgery for Uveitis Patients

Tailor your treatment plan to the patient.

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In this month’s issue of Retinal Physician, Sherveen Salek, MD, and Steven Yeh, MD, from Emory Eye Center in Atlanta, Georgia, discuss indications and data on vitrectomy for uveitis in their article, “Pars Plana Vitrectomy in Uveitis Management.” In their article, Drs. Salek and Yeh note that data are still scant on the role of vitrectomy in uveitis, and that the varied indications and therapies warrant further study. Here, Uveitis Corner editor Sunil Srivastava, MD, from Cole Eye Institute in Cleveland, Ohio, talks with Dr. Yeh to delve further into the practical issues surrounding vitrectomy for uveitis.

Dr. Srivastava: This was a great article. In cases where a patient with chronic uveitis presents with a nonemergency surgical condition, such as an epiretinal membrane (ERM) or macular hole, what are your immunosuppressive recommendations?

Dr. Yeh: I avoid operating on patients with active inflammation, but if the patient has a history of noninfectious uveitis, particularly granulomatous disease (sarcoidosis, sympathetic ophthalmia), I will consider intravenous corticosteroid administered intraoperatively followed by a 2-week to 3-week course of oral prednisone.

If the patient has been inactive and unlikely to develop a flare-up, I will treat them with postoperative antibiotics and topical corticosteroid and monitor them very closely for inflammation (eg, ERM in a well-controlled birdshot patient).

Dr. Srivastava: Are there any caveats to operating on patients with low IOP? How about in a surgical urgency such as a RRD (noninfectious): would you change your regimen pre-, intra-, or postoperatively?

Dr. Yeh: I warn the patient ahead of time that their IOP may stay low postoperatively and that there is some risk of failure of the ciliary body to recover, which can result in corneal edema, hypotony maculopathy, or worsening vision. For urgent situations, I tailor pre-, intra-, or postoperative immunosuppression to the risk of the individual. Again, there is a higher likelihood of needing steroid with severe, acute disease such as Behçet or chronic, smoldering granulomatous inflammation.

Dr. Srivastava: You discussed in your article the use of PPV for diagnostic purposes. If you perform an anterior chamber paracentesis for possible viral disease and the PCR is negative, but you still have suspicion, how quickly should you perform a PPV? Do you have any concern about a possible false negative if they are on antiviral therapy?

Dr. Yeh: If I am suspicious of a viral cause of uveitis, I think there is a 10% likelihood of a false negative PCR test. If there is significant vitreous opacity and therapeutic benefit to a vitrectomy, I’ll proceed with a PPV. Also, if there is any concern for lymphoma, I will proceed with diagnostic PPV.

Dr. Srivastava: There is some discussion on the use of PPV as a therapeutic procedure for intermediate uveitis. Rather than ask you to recommend doing this or not, can you tell me reasons I should or should not do it?

Dr. Yeh: Intermediate uveitis can be controlled medically in most cases and a large review by Becker and Davis of 44 studies related to vitrectomy for uveitis was of fair or poor evidence supporting vitrectomy.1 Many of the studies were subject to bias, retrospective in nature, and uncontrolled.

In patients with ERM, macular pucker, tractional retinal detachment, vitreomacular traction, dense vitreous opacity, and controlled inflammation, I will consider PPV. However, I have seen patients with incomplete PVDs following PPV for intermediate uveitis develop severe RD that were extremely difficult to repair. For this reason, I avoid PPV unless they have the above macular pathology.

Dr. Srivastava: Finally, I personally have begun intervening sooner in acute retinal necrosis (ARN) and performing a PPV prior to a detachment. What are your thoughts?

Dr. Yeh: There are limited series to support early PPV for ARN, although the high rate of RD particularly in patients with >50% retina involved has been described, and I agree with aggressive management medically and possibly surgically. For patients with >50% retina involved, if I see peripheral traction on necrotic retina, I have also begun to proceed with PPV as opposed to waiting for the normal retina to detach.

Immediate use of intravitreal injections appears to decrease RD risk per our series from Casey Eye Institute,2 so I think our collective outcomes have improved with earlier recognition, aggressive intravitreal antiviral therapy, and careful monitoring for peripheral traction. I think it is reasonable to proceed with earlier surgical intervention, although an incomplete hyaloidal dissection can result in severe ERM proliferation, which I have also been observed. RP

REFERENCES

  1. Becker M, Davis J. Vitrectomy in the treatment of uveitis. Am J Ophthalmol. 2005;140(6):1096-1105.
  2. Yeh S, Suhler EB, Smith JR, et al. Combination systemic and intravitreal antiviral therapy in the management of acute retinal necrosis syndrome. Ophthalmic Surg Lasers Imaging Retina. 2014;45(5):399-407.