Advances in microsurgical instrumentation and laboratory techniques, together with the development of novel drug delivery systems have expanded both the diagnostic and therapeutic scope of vitreoretinal surgery in pa­tients with posterior uveitis.

Therapeutic Vitrectomy

Since the original report of combined pars plana vitrectomy and lensectomy for complicated cataract in 1978,1 numerous reports describing the therapeutic benefit of vitrectomy in the management uveitis and its complications have appeared in the literature. No prospective, controlled clinical trail, however, has been conducted to critically evaluate the role of PPV as a single or combined procedure for this indication. A superb review of the literature and discussion of this subject by Drs. Matthias Becker and Janet Davis has recently been published.2 Based on this survey, visual acuity was stated as improved in 708 eyes (68 percent), unchanged in 202 eyes (20 percent) and worsened in 124 eyes (12 percent) despite the confounding co-morbidities of cystoid macular edema and cataract and the frequent need for additional surgical procedures. In­ter­me­diate uveitis was present in nearly half of these eyes.

Figure 1. Combined tractional/rhegmatogenous retinal detachment
in a patient with acute retinal necrosis syndrome.


Indications for therapeutic vitrectomy in uveitis have included the following: 1) significant media opacity (cat­a­ract, inflammatory or hemorrhagic vitreous opacification) causing visual loss or precluding adequate view of the posterior segment; 2) endophthalmitis or lens-induced uveitis; 3) inflammatory control; 4) structural complications of uveitis including, CME unresponsive to medical treatment, retinal detachment, epiretinal membrane (ERM), and chronic hypotony; 5) and most recently, sustained intravitreal drug delivery (See Table 1).

Perioperative Management

Inconsistent data exist as to the precise role of perioperative immunosuppressive therapy in eyes undergoing vitreoretinal surgery for uveitis. While complete inflammatory quiescence may not be attainable or realistic in some patients requiring urgent care, the experience from cataract surgery in uveitis suggests that vigorous efforts to establish a definitive diagnosis and aggressive control of perioperative inflammation are essential both for successful surgical outcomes and to reduce the risk of postoperative complications. For non-emergent procedures, it is certainly advisable to adequately suppress inflammatory activity utilizing topical, regional and systemic steroids with or without systemic ste­roid-sparing immunomodulatory the­rapy as necessary for a minimum of three months prior to surgery. This is particularly important if cataract and intraocular lens implantation is contemplated.

Preoperative ancillary assessment might include B-scan ultrasonography or ultrasonic biomicroscopy in the presence of media opacity or hy­po­tony to detect underlying chorioretinal pathology, such as and exudative retinal or choroidal detachment, and cyclitic membranes, which might in­fluence the surgical plan. Fluo­re­scein an­giography may disclose retinal ische­mia or neovascularization and serve as a surrogate marker for inflammatory activity in the postoperative period following vitrectomy. Optical coherence tomography is helpful in confirming the presence of epiretinal membranes and in distinguishing in­flammatory macular edema from that due to vitreomacular traction, thereby identifying cases that are more likely to respond to surgical in­tervention.

Media Opacity

Various surgical techniques have been proposed for the management of uveitic cataracts. Among them are pars pars plana lensectomy, and extracapsular cataract extraction (phaco­emusification) with or without IOL implantation, in combination with PPV, especially in the presence of significant vitreous opacification or un­derlying vitreoretinal pathology. Pars plana lensectomy/vitrectomy with complete removal of the posterior cap­sule remains the preferred technique in selected chronic uveitic entities, such as juvenile idiopathic arthritis-associated iridocylcitis,3 and in phacolytic uveitis. In other cases, a rim of anterior capsule may be re­tained should secondary placement of a ciliary sulcus posteior IOL be anticipated. Combined phacoemulsification with IOL implantation and PPV as a single procedure may be appropriate in selected patients with cataract and pathologic vitreous whose disease has been well-controlled preoperatively or is in remission as was reported recently, with improved visual acuity in 76 percent of 36 eyes with chronic uveitis.4 While IOL placement in the ciliary sulcus may theoretically reduce the incidence of postoperative sy­nech­iae, it may promote chronic flare and CME due to mechanical irritation of the iris and ciliary body.5,6 For this reason, in-the-bag placement is widely recommended. Traditionally, large, one-piece, all-PMMA lenses had been advocated. Recent studies suggest, however, that hydrophobic acrylic IOLs are associated with favorable outcomes, good capsular biocompatibility and lower rates of uveitis recurrence as compared to silicone IOLs.7,8 Progressive, vitreous opacification due to chronic inflammation, despite adequate treatment, or due to non-clearing vitreous hemorrhage may be visually significant, amblyogenic, or ob­scure underlying vitreoretinal path­ology and require PPV. Uveitic entities frequently associated with retinal neovascularization and vitreous hemorrhage include pars planitis, ocular sarcoidosis, idiopathic retinal vasculitis (Eales' disease), Adamantiades-Beh­çet's disease, and systemic lupus erythematosus. In addition to clearing the visual axis and addressing co-existent vitreoretinal pathology, the surgical goals also include treatment of underlying retinal ischemia or pars plana neovascularization with ablative laser photocoagulation.

Inflammatory Control

While essential in the management of endophthalmitis and lens-induced uveitis, PPV may also modulate the natural history of inflammation in pa­tients with intermediate or diffuse uveitis. It has been hypothesized, but not proven, that the permanent re­moval of antigenic load and pro-in­flammatory mediators through vitrectomy affects a change in the immunologic milieu of the eye that promotes inflammatory control and facilitates the efficacy of anti-inflammatory therapy.

Among the uncontrolled reports for which data are available, especially in the context of intermediate uveitis, a reduction in systemic medical therapy was noted in more than half the cases with a nearly uniform clearing of the vitreous following PPV.2 Specifically, many investigators have reported a reduction in the frequency and severity of inflammatory recurrences,1, 9-19 while others conclude that the course of long-standing uveitis is not influenced by vitrectomy.20,21 It is possible that vitreous inflammation is a secondary manifestation of the underlying im­mu­no­path­ology of autoimmune uveitis, where antigen-specific T-cells are activated extraocularly (in the spleen and lymph nodes) with subsequently homing to the eye, and that vitreous removal creates the illusion of quiescence while "sub-clinical" intraocular inflammation persists unabated.

Other surrogate markers for inflammatory activity, such as vascular leakage on fluorescein angiography or abnormalities detected with electroretinography, may be useful in this regard. For these reasons, it is not clear if PPV should precede systemic therapy as proposed by Dr. Henry Kaplan26 in his therapeutic step-ladder algorithm for the management of in­ter­mediate uveitis or whether all pa­tients should have preoperative IMT as advocated by Dr. Stephen Foster.23

Structural Complications

PPV in uveitis often requires additional vitreoretinal procedures, such as separation of the posterior hyaloid and membrane peeling, retinal detachment repair, laser photocoagulation and/or cryotherapy to address structural complications.

 • CME. CME refractory to medical therapy is a relative indication for PPV, especially in the presence of another structural complication, such as ERM or vitreomacular traction seen clinically or on OCT. Case selection is important, as chronic CME is less likely to respond to surgery due to the presence of permanent architectural damage. This damage is suggested by the presence of fixed cysts clinically, widening of the foveal avascular zone on fluorescein angiography, and attenuation or the central retinal thickness on OCT. Three studies have been undertaken that specifically address the effect of PPV on recalcitrant CME in uveitis.24-26 Among one group of nine patients undergoing PPV without membrane peeling,24 seven of 11 eyes had an improvement of four or more lines of Snellen acuity within four weeks. CME improved by clinical examination and on fluorescein angiography in nine eyes and by clinical examination alone in two eyes. Of the six eves with a diagnosis of pars planitis, only three were among those noted to improve. Dr. Junichi Kiryu and associates reported an im­prove­ment in visual acuity in 56 percent and clinical resolution of CME in 78 percent of 18 eyes of 14 patients with sarcoid uveitis who underwent PPV for medically unresponsive CME.25 Mem­brane peeling was performed in half of these patients, while remainder had posterior vitreous detachments without ERM formation. Of note, half of these patients re­quired supplemental systemic ste­roids, periocular steroids or acetazolamide postoperatively to resolve their macular edema.

Another group performed PPV for CME in 42 eyes of 32 patients with intermediate uveitis with resolution of CME in 59 percent and im­provement in visual acuity in 50 per­cent.26 In the previously mentioned survey of the literature, Drs. Becker and Davis calculated that the median reported percentage of patients per study with CME decreased from 36 percent preoperatively to 18 percent postoperatively.2 It is likely, however, that with the expanding indications for the use of intravitreal steroids in the treatment of CME in general, and in uve­itis in particular,27-29 PPV may become relegated to the final interventional measure in the management of this complication.

 • ERM. Epiretinal membranes are common in eyes with uveitis, and when not associated with CME, may not necessarily be associated with decreased visual acuity. Symptomatic ERM, as in non-uveitic eyes, may be approached with standard PPV and membrane peeling techniques provided inflammation is well-controlled, with addition of periocular and/or intravitreal steroids intraoperatively, especially in the presence of CME. Final visual acuity may be limited by the development of cataract and mem­brane recurrence.30,31

Retinal Detachment

Uveitis was found to be an independent risk factor for rhegmatogenous retinal detachment with a prevalence of 3.1 percent in one large uveitic population.32 While a final reat­tach­ment rate of 88 percent was achieved using either scleral buckling or vitrectomy techniques, 67 percent had a final visual acuity worse than 20/200, attributable in part to the high incidence of preoperative proliferative vitreoretinopathy.

Complicated retinal detachments are frequently encountered in patients with necrotizing viral retinitis (CMV, ARN, PORN). These may be successfully repaired in a high percentage of cases with vitrectomy techniques, and frequently require long-term tamponade with silicone oil (See Figure 1).33.34 Tractional complications not infrequently seen in patients with ocular toxocariasis, toxoplasmosis, pars planitis and other entities associated with retinal neovascularization are best managed PPV and may be facilitated by bimanual membrane dissection (See Figure 2).35

Figure 2. Prominent epiretinal fibrosis and tractional retinal detachment in a patient with Toxocara canis.


Selected cases of hypotony due to uveitis are amenable to surgical therapy, especially those in which irrever­si­ble damage to the ciliary processes has not occurred. Chronic uveitis can lead to the development of cyclitic membranes and hypotony, both by increasing outflow through ciliary traction and by decreasing secretion through direct ciliary epithelial damage. Should anti-inflammatory therapy fail to reverse hypotony, preoperative as­ses­sment of the ciliary body with UBM is helpful in identifying the pre­sence or absence of the ciliary pro­cesses and the location and thickness of the epiciliary membranes. PPV with 360-degree scleral indentation, vitreous base dissection and bimanual epiciliary membranectomy may affect a sustained rise in intraocular pressure with improved vision in eyes with in­tact ciliary processes. In those with atro­phic ciliary processes, silicone oil being useful in preventing phthisis.36


Sustained Drug Delivery

The Food and Drug Administration has approved, Retisert, (Bausch & Lomb), a 0.59-mg fluocinolone acetonide, non-biodegradable, intravitreal sustained drug-delivery implant for the treatment of chronic non-infectious posterior uveitis based on the findings of two pivotal studies.37,38 De­vice implantation is similar to that of the Vitrasert (ganciclovir, B&L) implant and may be more facile due to its relatively smaller size. Sur­gical complications are similar and include retinal detachment, intraocular infection, vitreous hemorrhage and wound de­hiscence. As expected, continuous steroid exposure produced cataract re­quiring surgery in 90.3 percent of im­planted eyes and elevated IOP in 64 percent, with approximately 32 per­cent of patients expected to re­quire filtering surgery. With judicious patient selection, the benefits can be significant, with a reduction in inflammatory recurrence from the 40- to 54-percent range to the 7- to 14-percent range at 34 weeks. Visual acuity improved three lines or more among 19 to 21 percent of im­planted patients after 34 weeks with 15 to 17 percent of these individuals maintaining this level of improvement after one year. Moreover, the requirement for systemic corticosteroid therapy was re­duced from a 47 to 63 percent range to a 5 to 10 percent range at 34 weeks.

Vitreoretinal surgery is an essential tool in the management of chronic uve­itis that presents a diagnostic di­lem­ma, as it allows the differentiation among infectious, inflammatory and ne­oplastic eti­ologies, and so, specific di­rected treatment. Vitreoretinal techniques are useful in the management complicated cat­aract, vitreous opacification, end­oph­thal­mitis, lens-induced uve­itis, and structural complications, such as retinal detachment and hy­potony, and are possibly relevant to outcomes of improved vi­sion, inflammatory control, and re­duced CME.2

More convincing evidence for the role of PPV in the management of uve­itis, especially in the light of expanding therapeutic indications with sustained drug delivery modalities, awaits more critical evaluation in well-de­signed, randomized, controlled, collaborative trials or hypothesis-based case series with defined outcome mea­sures.


Dr. Vitale is chief of the Uveitis Ser­vice and a member of the Vit­re­o­retinal Division at the John A. Moran Eye Center, University of Utah. Con­tact him at He is a consultant to Bausch & Lomb.

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