The results obtained by pars plana vitrectomy in 24 eyes with chronic uveitis, including
endogenous intermediate and other types of uveitis, were retrospectively analyzed.
Vitrectomy and lensectomy were performed in 8, and vitrectomy alone in 16 eyes. The
mean follow-up period was 50 months, and mean patient age 38 years. There were 15
(71.4%) male and 6 (28.6%) female patients. Improvement of visual acuity was achieved
in 79% (19), and visual acuity of 0.1 in 58% of eyes. Visual acuity of <0.2, recorded in
14 eyes, was due to optic disc atrophy in 4, cystoid macular edema in 3, macular pucker
in 2, vascular obliteration in 2, and chorioretinal scars in 3 eyes. Postoperative complications
included cataract in 4, vitreous hemorrhage in 2, glaucoma in 1, and retinal detachment
in 3 eyes. Vitrectomy considerably reduced the severity of inflammatory reaction,
and allowed reduction or discontinuation of local and systemic steroid therapy

J. Šikić

S. Popović Suić

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Coll. Antropol. 25 Suppl. (2001) 71–76UDC 617.72-089Professional paperSurgical Treatment of UveitisJ. [iki} and S. Popovi} Sui}Department of Ophthalmology, Clinical Hospital Center Zagreb, Zagreb, CroatiaA B S T R A C TThe results obtained by pars plana vitrectomy in 24 eyes with chronic uveitis, includ-ing endogenous intermediate and other types of uveitis, were retrospectively analyzed.Vitrectomy and lensectomy were performed in 8, and vitrectomy alone in 16 eyes. Themean follow-up period was 50 months, and mean patient age 38 years. There were 15(71.4%) male and 6 (28.6%) female patients. Improvement of visual acuity was achievedin 79% (19), and visual acuity of 0.1 in 58% of eyes. Visual acuity of <0.2, recorded in14 eyes, was due to optic disc atrophy in 4, cystoid macular edema in 3, macular puckerin 2, vascular obliteration in 2, and chorioretinal scars in 3 eyes. Postoperative compli-cations included cataract in 4, vitreous hemorrhage in 2, glaucoma in 1, and retinal de-tachment in 3 eyes. Vitrectomy considerably reduced the severity of inflammatory reac-tion, and allowed reduction or discontinuation of local and systemic steroid therapy.IntroductionVitreoretinal surgery is a prominentand, we are inclined to believe, indispens-able procedure in the management ofcomplicated, chronic uveitis, includingendogenous intermediate and other typesof uveitis. Removal of fibrin, cellular andhemorrhagic opacities from the vitreousbody improves visual function in a largeproportion of patients operated on1–4. Thesample obtained during vitrectomy canthen be analyzed for the presence of bac-teria, antibodies or malignant cells. Ma-ny cases of severe complications of uveitiscan now be successfully treated by so-phisticated methods of vitreoretinal sur-gery. The more so, progression of the dis-ease has been observed to be significantlyslowed down by surgery in more than70% of eyes, especially in cases ofnoninfective chronic uveitis5–7. The devel-opment of cystoid macular edema is con-siderably reduced after vitrectomy, con-tributing greatly to the preservation ofvisual function. Endogenous uveitis mayhave a variable clinical course, from veryslow to uncontrolable development of thedisease with numerous exacerbationsand remissions that may lead to blind-ness8. Typical complications of this dis-ease include synechiae, cataract, second-ary glaucoma, vitreous opacities andhemorrhage, cystoid macular edema, pro-71Received for publication June 4, 2001.liferations with traction detachment, andchronic hypotonia with possible phthisis.Classic medicamentous treatment foruveitis consists of a combination of non-steroidal anti-inflammatory drugs andcorticosteroids, especially in a case of se-vere inflammatory reaction. Immunosup-pressive drugs should be used with greatcaution and in strictly selected cases, be-cause of the possible adverse side effects.Surgical treatment of chronic uveitis bylensectomy and pars plana vitrectomy foropacified vitreous marked the beginningof modern surgical management of thedisease9. Experimental studies haveshown that vitreous body is in relationwith the activation of secondary immuneresponse10,11, thus the removal of the vit-reous may have a very beneficial effect onthe clinical course of the disease.Results of surgical treatment of com-plicated cases of uveitis were analyzed inthis retrospective study.Material and MethodsData of 21 patients with chronic, com-plicated uveitis, i.e. 24 eyes submitted topars plana vitrectomy from January 1988till March 1994, were analyzed (Table 1).All patients had been previouslytreated with steroidal and nonsteroidalanti-inflammatory drugs, and with che-motherapy when necessary. Multiple ex-acerbations of the disease and weaker re-sponses to medicamentous therapy wererecorded in majority of patients (Table 2).The main reasons for surgical treat-ment included impaired visual acuity dueto inflammatory infiltration, presence ofvitreous debris and vitreous opacity. Incases with complicated cataract or retinaldetachment, lensectomy and cerclage, i.e.scleral buckling with vitrectomy, werecarried out. Most of our patients were re-ferred from other ophthalmologic centers,where thorough clinical and laboratoryexaminations had been performed. Ultra-sonography was used in patients in whomfundus vizualization was impossible dueto vitreous opacities.The clinical course of the disease, i.e.pre- and postoperative inflammatory ac-tivity, and pre- and postoperative occur-rence of acute disease exacerbations wereobserved. Clinical and laboratory exami-nations showed uveitis associated withjuvenile rheumatoid arthritis in 3, vascu-litis in 4, Behcet’s disease in 1, and en-dogenous intermediate uveitis in 16 eyes.The follow-up period ranged from 6 to 84months (mean 50 months) and patients’age from 5 to 69 years (mean 38 years).There were 15 (71.4%) males and six(28.6%) females.Pars plana vitrectomy was carried outusing the standard surgical procedurethrough three sclerotomies 4 mm fromthe limbus. Vitrectomy with lensectomywas performed in 8 eyes, with careful re-moval of all lens material with the cap-sule. Pars plana vitrectomy with preser-vation of the transparent lens was donein 16 eyes. During the procedure, effortswere made to remove the entire vitreous.Due attention was paid to vitrectomy ofthe vitreous base and possible ciliarybody membranes, which was achieved byscleral intendation of the area.Surgical therapy for vitreous hemor-rhage with posterior vitreous detachmentwas performed in 9, and membranectomyin 12 eyes. Operation for macular puckerand traction retinal detachment wereperformed in 6 eyes each. Internal tam-72J. [iki} et al.: Surgical Treatment of Uveitis, Coll. Antropol. 25 Suppl. (2001) 71–76TABLE 1ETIOLOGY OF UVEITISDiagnosis No. ofeyesJuvenile rheumatoid arthritisVasculitisBehcet’s diseaseIntermediate uveitisTotal3411624ponades with silicone oil and gas (air) in-jection were carried out in 2 eyes each.Endolaser photocoagulation was used in8 eyes with neovascular alterations, whe-reas cryocoagulation was performed in 4eyes. During the postoperative period,corticosteroids were locally and parabul-barly applied, with administration of an-ti-inflammatory drugs and chemothera-peutics when necessary.ResultsDuring the study period, vitrectomywas carried out in 24 eyes with chronic,complicated uveitis. All patients had pre-viously received medicamentous therapywith steroidal and nonsteroidal anti-in-flammatory drugs, and possibly chemo-therapy. However, surgical therapy wasindicated for frequent exacerbations ofthe disease and impairment of visual acu-ity. In some patients, medicamentoustherapy had to be continued during thepostoperative period (Table 3).Pars plana vitrectomy with lensecto-my was performed in 8, and vitrectomyalone in 16 eyes. Vitreous hemorrhageand debris were operatively treated in 9,and membranes and neovascularizationin 12 eyes. Operative treatment for trac-tion retinal detachment and macularpucker was performed in 6 eyes each. Lo-cal application of steroids led to the devel-opment of cataract and glaucoma in 2eyes. Intraoperative vitreal hemorrhageand iatrogenic ruptures were observed in4 and 3 eyes, respectively. During thepostoperative course, secondary cataractdeveloped in 4, vitreous hemorrhage in 2,glaucoma in one and retinal detachmentin 3 eyes. Preoperative visual acuity inour patients ranged from light perceptionand hand movement to 0.2.The results obtained were very satis-factory. Visual acuity was improved in 19(79%), unchanged in two, and deterio-rated in three patients. Visual acuity of0.1 was achieved in 58% of eyes. Poorervisual acuity was recorded in one patient73J. [iki} et al.: Surgical Treatment of Uveitis, Coll. Antropol. 25 Suppl. (2001) 71–76TABLE 2PREOPERATIVE LOCAL AND SYSTEMIC TREATMENT OF UVEITISJuvenile rheu-matoid arthritisVasculitisDiagnosisBehcet’s diseaseIntermediateuveitisNo. of eyesLocal therapySteroidal therapyNonsteroid drugsChemotherapy3322144013111011616580TABLE 3POSTOPERATIVE LOCAL AND SYSTEMIC TREATMENT OF UVEITISJuvenile rheu-matoid arthritisVasculitisDiagnosisBehcet’s diseaseIntermediateuveitisNo. of eyesLocal therapySteroidal therapyNonsteroid drugsChemotherapy3210043002111011612070with Bahcet’s disease and in two patientswith vasculitis. Patients with endoge-nous intermediate uveitis had best visualprognosis, whereas of those with severepreoperative inflammatory reaction theresults were by far less satisfactory.Visual acuity of <0.2, recorded in 14eyes, was caused by optic disk atrophy in4, cystoid macular edema in 3, macularpucker in 2, vascular obliteration in 2, andchorioretinal scars in 3 eyes (Table 4).DiscussionUveitis presents a very complex prob-lem from the diagnostic and therapeuticpoint of view, the more so as the diseaseetiology is unknown in more than 50% ofcases. This retrospective study of vitrec-tomy in treatment of uveitis complica-tions showed that this procedure can beof great help for visual function recoveryand preservation. Total vitrectomy wasfound to evidently reduce the autoimmu-ne process, and decrease the rate and se-verity of inflammatory recurrences. Thedevelopment of cataract is a common phe-nomenon in chronic uveitis, thus surgicaltherapy by pars plana vitrectomy is con-sidered a treatment of choice, allowingthe removal of the entire lens mass, de-creasing the possible development of sy-nechiae and cleansing the optic zone12. Incases of cataract occuring as a postvi-trectomy complication, implantation of apolymethyl methacrylate (PMMA) lensinto the posterior chamber was perfor-med13. In this study, there was no severe74J. [iki} et al.: Surgical Treatment of Uveitis, Coll. Antropol. 25 Suppl. (2001) 71–76TABLE 4PRE- AND POSTOPERATIVE VISUAL ACUITY IN 24 OPERATED EYESPreoperative visual acuity No. ofeyesPostoperativevisual acuityNo. ofeyesLight perception (LP)Hand movement in front of the eye (HM)Visual acuity 0.01Visual acuity 0.1Visual acuity 0.2512322LP0.010.10.20.4LPHM0.010.10.20.40.7HM0.10.30.030.60.71.01111111332111111111postoperative inflammatory reaction, re-ported elsewhere14. A mild reaction dur-ing the first few postoperative days andone case of bulbar hypotonia15 were ob-served.Analysis of the study material showedneovascularizations, cystoid macularedema and severe inflammatory reactionto compromise the result of surgical pro-cedure16. This refers to vascular prolifer-ations in particular; therefore, laser pho-tocoagulation or cryotherapy was used insuch cases4. Removal of epiretinal mem-branes and macular pucker gave verygood results, thus relieving retinal tra-ctions. Cystoid macular edema was ob-served in 5 (21%) eyes. Vitrectomy provedto be very useful, bacause the regressionof edema was recorded few months post-operatively.In conclusion, vitrectomy proved to bea highly successful method in treatmentof chronic uveitis with its complications,such as vitreous hemorrhage and opacity,cataract, neovascularizations and ciliarymembranes, traction retinal detachmentand hypotonia. Vitrectomy was found todiminish the inflammatory response andthe severity of the autoimmune process,to relieve the optic zone, and to lead tothe reduction or discontinuation of im-munosupressive and steroidal therapy.This was confirmed by the results achie-ved in our series of patients. Visual func-tion improvement was achieved in 79% ofcases, which proved the importance ofvitrectomy as a method of surgical treat-ment in cases of complicated chronic uve-itis.R E F E R E N C E S1. ALGVERE, P., H. ALANKO, K. DICKHOFF,Acta Ophthalmol 59 (1981) 727. — 2. BRINKMAN, C.J., A. J. OTTO, A. C. BREEBAART, Curr Res., 9(1990) 1137. — 3. BRINKMAN, C. J., A. J. OTTO, A.KIJLSTRA, A. C. BREEBAART, Curr Eye Res., 9(1990) 125. — 4. DIAMOND, J. G., H. J. KAPLAN,Arch Ophthalmol., 96 (1978) 1798. — 5. FLYNN, H.W. J., J. L. DAVIS, W. W. CULBERTSON, Ophthal-mology, 95 (1988) 1114. — 6. FOSTER, C. S., L. P.FONG, G. SINGH, Ophthalmology 96 (1989) 281. —7. FREYLER, H., M. VELIKAY, Klin MonatsblAugenheilkd., 185 (1984) 263. — 8. GIRARD, L. J., J.RODRIGUEZ, M. L. MAILMAN, T. J. ROMANO, Re-tina, 5 (1985) 107. — 9. HEIMANN, K., U. TAVAKO-LIAN, H. PAULMANN, Berl Dtsch Ophthalmol Ges.,78 (1981) 249. — 10. KLÖTI, R., Klin Monatsbl Au-genheilkd., 192 (1988) 425. — 11. MIELER, W. F., B.R. WILL, H. LEWIS, T. M. AABERG, Ophthalmology95 (1988) 859. — 12. NOLTHEMIUS, P. A. T., A. F.DEUTMAN, Ophthalmologica, 186 (1983) 11. — 13.NUSSENBLATT, R. B., Ophthalmology, 93 (1986)984. — 14. SMITH, R. E., W. A. GODFREY, S. J. KI-MURA, Trans Am Acad Ophthalmol Otolaryngol., 82(1973) 760. — 15. ULBIG, M., A. KAMPIK, Klin Mo-natsbl Augenheilkd., 194 (1989) 10. — 16. WERRY,H., H. HONEGGER, Klin Monatsbl Augenheilkd.,191 (1987) 9.J. [iki}Clinical Hospital Center Zagreb, Department of Ophthalmology, Ki{pati}eva 12,10 000 Zagreb, Croatia75J. [iki} et al.: Surgical Treatment of Uveitis, Coll. Antropol. 25 Suppl. (2001) 71–76KIRUR[KO LIJE^ENJE UVEITISAS A @ E T A KAutori prikazuju rezultate pars plana vitrektomije u retrospektivnoj studiji na 24oka s kroni~nim uveitisom, uklju~uju}i intermedijalni endogeni kao i druge vrste uvei-tisa. Vitrektomija je u~injena na 16, a vitrektomija i lensektomija na 8 o~iju. Prosje~novrijeme pra}enja bilo je 50 mjeseci, a prosje~na dob bolesnika 38 godina. Pobolj{anavidna o{trina postignuta je u gotovo 80% bolesnika, dok je u 20% zadr`ana ista ili jebila pogor{ana. Uzrok tome bile su atrofija vidnog `ivca u 4, cistoidni makularni edemu 3, makularni paker u 2, vaskularna obliteracija u 2 i korioretinalni o`iljci u 3 oka.Vitrektomija se pokazala kao vrlo uspje{na metoda u kirur{kom lije~enju kroni~noguveitisa i njegovih komplikacija jer smanjuje intenzitet upalne reakcije kao i njenopojavljivanje. Tako|er, vitrektomijom se smanjuje i lokalna i sistemska upotreba ste-roida.76J. [iki} et al.: Surgical Treatment of Uveitis, Coll. Antropol. 25 Suppl. (2001) 71–76

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