Original Paper
Ophthalmologica
Ophthalmologica 2014;232:179–186 DOI: 10.1159/000365230
Received: January 29, 2014 Accepted after revision: June 12, 2014 Published online: October 18, 2014
Surgical Management of Severe Complications Arising from Uveitis in Juvenile Idiopathic Arthritis Beate J. Langner-Wegscheider a Marc D. de Smet b, c
a Department of Ophthalmology, Medical University of Graz, Graz, Austria; b Retina and Inflammation, MIOS SA, Lausanne, Switzerland; c Department of Ophthalmology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
Abstract Purpose: Evaluate outcomes from severe ocular complications of juvenile idiopathic arthritis following surgery. Methods: Eleven eyes of 7 patients underwent complete vitrectomy and peeling of the inner limiting membrane. Inclusion criteria were: anteroposterior segment involvement, hypotony, inflammation control of less than 3 months, compliance issues, rapidly progressive disease. Phacoemulsification was allowed if the patient was >6 years old and inflammation free >3 months. The alternative was a complete lensectomy. Results: Visual acuity improved from a logMAR of 1.48 to 0.37 (p < 0.0001), and 0.20 at 6 and 12 months (p < 0.0001). No flare-up was observed within the first 6 months. Five eyes developed inflammation between 7 and 19 months. Glaucoma developed in 5 eyes at a median of 16 months. No patient developed cystoid macular edema. Conclusion: Extensive pars plana vitrectomy and cataract extraction can lead to significant improvement in visual acuity. Patients continue to require long-term immunosuppression and adequate follow-up. © 2014 S. Karger AG, Basel
© 2014 S. Karger AG, Basel 0030–3755/14/2323–0179$39.50/0 E-Mail [email protected] www.karger.com/oph
Introduction
Severe vision loss is still common among patients with juvenile idiopathic arthritis (JIA). Appropriate medical management, early referral and monitoring have significantly improved the ocular prognosis, while an aggressive medical management policy has reduced the odds of serious complications [1–4]. Cataract formation occurs in 10–30% of JIA patients [5, 6]. Fifteen percent of patients were reported to have hypotony [3]. Macular thickening is seen in over 80% of affected patients by optical coherence tomography (OCT) with 40% having evidence of macular edema [7]. While these complications appear as a result of ocular inflammation, they may persist and progress despite adequate therapy [3, 6]. Adequate management of the ocular complications of JIA requires first an aggressive medical treatment. Nonetheless, surgery is frequently required, particularly in patients with a younger age of onset. The timing, the choice of procedure and the extent of the intervention will vary for each patient based on the past and present disease course, patient compliance and the surgeon’s own experience. However, an adequate treatment plan should also anticipate and minimize the risk of future complications. Certain ocular characteristics increase the risk of complications such as lower age at presentation, delays in presentation, male gender, anterior flare, hypotony and preMarc D. de Smet Specialized Eye Center in Uveitis and Retina Avenue du Léman 32 CH–1005 Lausanne (Switzerland) E-Mail mddesmet1 @ mac.com
Downloaded by: UCSF Library & CKM 169.230.243.252 - 4/15/2015 6:39:12 AM
Key Words Juvenile idiopathic arthritis · Uveitis · Complications · Surgical management · Anterior vitrectomy · Posterior vitrectomy · Ocular hypotony
Methods Patients meeting the following criteria were identified by searching an electronic database containing all patients operated by the same surgeon (M.d.S.). Children (age
Ophthalmologica
Ophthalmologica 2014;232:179–186 DOI: 10.1159/000365230
Received: January 29, 2014 Accepted after revision: June 12, 2014 Published online: October 18, 2014
Surgical Management of Severe Complications Arising from Uveitis in Juvenile Idiopathic Arthritis Beate J. Langner-Wegscheider a Marc D. de Smet b, c
a Department of Ophthalmology, Medical University of Graz, Graz, Austria; b Retina and Inflammation, MIOS SA, Lausanne, Switzerland; c Department of Ophthalmology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
Abstract Purpose: Evaluate outcomes from severe ocular complications of juvenile idiopathic arthritis following surgery. Methods: Eleven eyes of 7 patients underwent complete vitrectomy and peeling of the inner limiting membrane. Inclusion criteria were: anteroposterior segment involvement, hypotony, inflammation control of less than 3 months, compliance issues, rapidly progressive disease. Phacoemulsification was allowed if the patient was >6 years old and inflammation free >3 months. The alternative was a complete lensectomy. Results: Visual acuity improved from a logMAR of 1.48 to 0.37 (p < 0.0001), and 0.20 at 6 and 12 months (p < 0.0001). No flare-up was observed within the first 6 months. Five eyes developed inflammation between 7 and 19 months. Glaucoma developed in 5 eyes at a median of 16 months. No patient developed cystoid macular edema. Conclusion: Extensive pars plana vitrectomy and cataract extraction can lead to significant improvement in visual acuity. Patients continue to require long-term immunosuppression and adequate follow-up. © 2014 S. Karger AG, Basel
© 2014 S. Karger AG, Basel 0030–3755/14/2323–0179$39.50/0 E-Mail [email protected] www.karger.com/oph
Introduction
Severe vision loss is still common among patients with juvenile idiopathic arthritis (JIA). Appropriate medical management, early referral and monitoring have significantly improved the ocular prognosis, while an aggressive medical management policy has reduced the odds of serious complications [1–4]. Cataract formation occurs in 10–30% of JIA patients [5, 6]. Fifteen percent of patients were reported to have hypotony [3]. Macular thickening is seen in over 80% of affected patients by optical coherence tomography (OCT) with 40% having evidence of macular edema [7]. While these complications appear as a result of ocular inflammation, they may persist and progress despite adequate therapy [3, 6]. Adequate management of the ocular complications of JIA requires first an aggressive medical treatment. Nonetheless, surgery is frequently required, particularly in patients with a younger age of onset. The timing, the choice of procedure and the extent of the intervention will vary for each patient based on the past and present disease course, patient compliance and the surgeon’s own experience. However, an adequate treatment plan should also anticipate and minimize the risk of future complications. Certain ocular characteristics increase the risk of complications such as lower age at presentation, delays in presentation, male gender, anterior flare, hypotony and preMarc D. de Smet Specialized Eye Center in Uveitis and Retina Avenue du Léman 32 CH–1005 Lausanne (Switzerland) E-Mail mddesmet1 @ mac.com
Downloaded by: UCSF Library & CKM 169.230.243.252 - 4/15/2015 6:39:12 AM
Key Words Juvenile idiopathic arthritis · Uveitis · Complications · Surgical management · Anterior vitrectomy · Posterior vitrectomy · Ocular hypotony
Methods Patients meeting the following criteria were identified by searching an electronic database containing all patients operated by the same surgeon (M.d.S.). Children (age
