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Tanawade R, Tsierkezou L, Bindra M, Patton NP, Jones NP
1
The Royal Eye Hospital
Manchester, UK
To report the outcomes of pars plana vitrectomy (PPV) with epiretinal
membrane (ERM) peel, with or without internal limiting membrane (ILM)
peel, in patients with chronic uveitis
To assess the perioperative control of inflammation
To assess factors affecting outcome and complications
Design
▪Retrospective interventional non-comparative case series
Inclusion criteria
▪All consecutive patients with uveitis and ERM undergoing PPV with ERM +/- ILM peel
during the period 2005 –2012
▪Minimum post-operative follow-up of 6 months
Procedure
▪20-gauge or 23-gauge vitrectomy with ERM peel (all eyes)
▪ILM peel in selected patients
▪Internal tamponade using gas or silicone oil
▪Phacoemulsification with IOL implantation and posterior capsulectomy in selected cases
Total 16 eyes (Male 7, Female 9)
Mean age 47.3 years (14 –68)
Mean follow-up 18.5 months (6 - 40)
Mean duration of ERM 21.3 months (3- 84)
Procedure
▪16 vitrectomy (8:23G, 8:20G)
▪16 ERM peel (+10 ILM peel)
▪1 phacoemulsification + IOL,
▪1 posterior capsulectomy
▪14 gas tamponade, 2 silicone oil
▪5 surgeons
•Mean logMAR VA (n=14), excluding 2 eyes with severe preoperative pathology (VA- HM & PL)
Preoperative - 0.92 (Range 0.3 –2)
Postoperative at 6 months - 0.81 (Range 0.22 –2)
•Improved - 5 eyes (31.25%)
•Mean logMAR gain –0.54
•4/5 eyes included ILM peel
•Stable - 5 eyes (31.25%)
•Reduced - 6 eyes (37.5%)
Causes of reduced VA (6 eyes)
▪Cataract (3) - 2 eyes improved subsequently following cataract surgery
▪Silicone oil in AC and persistent preoperative hypotony (1)
▪Progression of pre-existing severe pathology (2: fungal macular granuloma, tractional RD)
Complications
▪3 iatrogenic retinal breaks (treated intra-operatively, no subsequent RD)
▪3 post-vitrectomy cataract
▪2 fibrinous uveitis
▪1 transient hypotony
▪1 transient ocular hypertension
Systemic / Periocular
▪Preoperative baseline
▪Oral Prednisolone 5-25mg (7), enhanced in 4 patients
▪Mycophenolate mofetil (4)
▪Azathioprine (3)
▪Intraoperative
▪Intravitreal triamcinolone acetonide (5) or bevacizumab (2 eyes)
▪Intravenous methylprednisolone 1g (1)
▪Postoperative
▪Intravitreal triamcinolone acetonide (1 eye at 5 months post-operatively)
Topical Prednisolone 1% increased a week prior to surgery in 3 patients, to 6 times/day
Uveitis in 13/16 eyes returned to preoperative level in 3 weeks,
Mean return - 5 weeks (1 –44)
Pre-operative
▪ERM - 6 eyes
▪ERM + macular edema - 5 eyes
▪ERM + vitreomacular traction (VMT)
+ macular edema - 5 eyes
Post-operative (at 3 months)
▪Resolution of VMT - 5 eyes
▪Reduction in macular edema - 8 eyes
(included 3/5 eyes with visual gain)
46-year-old male with chonic intermediate uveitis
Study
Procedure
No of
e
yes
Visual
outcome
Dev
et al
Ophthalmology
1999
Visual outcomes after PPV for
ERM
associated with pars
planitis
7
71%
at 3-54 mths
(= / >3 lines)
Kiryu
et al,
Jap J Ophthalmol
2003
PPV for ERM associated
with
Sarcoidosis
11
45% at 12
mths
(=
/ > 2 lines)
Our study
PPV + ERM+/
-ILM peel +/- combined
procedures in chronic uveitis
16
31.25% (n=16) and 36% (n=14)*
at 6
mths
(=
/ > 2 lines)
* Excluding 2
eyes with severe
preoperative visual loss (HM, PL)
ERM +/- ILM peel in uveitis is a safe procedure but improves VA in only a minority
with ERM with or without macular oedema
ILM peel may enhance outcomes (4 of 5 with improved VA underwent ILM peel,
compared to 2 of 6 with reduced VA)
Vitreomacular traction may respond particularly well with good anatomic success
Adequate peri-operative control of inflammation is essential
Cataract appears to be the most common cause of reduced vision in the initial
postoperative period