Combined pars plana vitrectomy and phacoemulsification to restore visual acuity in patients with chronic uveitis

articles Combined pars plana vitrectomy and phacoemulsification to restore visual acuity in patients with chronic uveitis Sofia Androudi, MD, Muna Ahmed, MD, Tito Fiore, MD, Periklis Brazitikos, MD, C. Stephen Foster, MD Purpose: To report the outcomes of combined phacoemulsification and pars plana vitrectomy (PPV) to restore visual acuity in patients with cataract and posterior segment involvement secondary to chronic uveitis. Setting: Ocular Immunology and Uveitis Service, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA. Methods: This study comprised 34 patients (20 women, 14 men; 36 eyes) with posterior segment involvement secondary to chronic uveitis who had combined phacoemulsification and PPV from 1998 to 2002. The main outcome measures were visual acuity, intraocular pressure, and cystoid macular edema. Results: The mean patient age was 45 years 6 16.09 (SD). The mean duration of uveitis before surgery was 56 6 44.17 months. In 24 eyes (66.7%), an intraocular lens (IOL) was implanted during surgery; 12 eyes (33.3%) were left aphakic. Five eyes (13.8%) received an intraocular steroid injection intraoperatively. Visual acuity improved in 26 eyes (72.2%), deteriorated in 5 (13.9%), and was unchanged in 5 (13.9%). The main reason for decreased visual acuity was refractory macular edema. During the follow-up, 2 IOLs were explanted secondary to lens intolerance. One IOL was repositioned because of iris capture by the haptics, and 1 dislocated inferiorly, causing monocular diplopia. The mean follow-up was 23.4 6 16.7 months. Conclusions: Results indicate that combined phacoemulsification and PPV is a feasible technique for the removal of cataract and pathologic vitreous in eyes with chronic uveitis. Although the exact role of vitrectomy in patients with uveitis remains to be determined, the combined surgery successfully restored useful vision in most cases. J Cataract Refract Surg 2005; 31:472–478 ª 2005 ASCRS and ESCRS

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ataract formation is a common complication of chronic or recurrent uveitis. It results from the inflammation itself or the use of topical or systemic steroids. Often, posterior segment involvement coexists because of direct involvement by the disease or secondary to inflammation sequelae such as vitreous membranes, retinal traction detachment, and cystoid macular edema (CME). With the advent of small-incision cataract surgery, the surgical management of cataract evolved signifi-


2005 ASCRS and ESCRS Published by Elsevier Inc.

cantly. In addition, rapid parallel developments in instrumentation and vitrectomy equipment led to increased sophistication in pars plana vitrectomy (PPV) and expanded its role as a diagnostic and therapeutic procedure.1 Combining phacoemulsification with PPV in eyes with significant cataract and coexisting posterior segment involvement is becoming increasingly common and has been reported as a first-line surgical management in patients with diabetic retinopathy,2–4 eye 0886-3350/05/$-see front matter doi:10.1016/j.jcrs.2004.06.040

COMBINED PPV AND PHACOEMULSIFICATION IN PATIENTS WITH UVEITIS

trauma,5 or macular holes.6,7 After Diamond and Kaplan described lensectomy combined with vitrectomy in patients with uveitis in 19788 and 1979,9 there were few reports of this combined procedure,10–17 particularly in cases of uveitis. To our knowledge, reports of combined phacoemulsification14–16 and PPV in uveitic patients have been sporadic and in all cases, patients with uveitis were a small subgroup. We report a relatively large number of patients with uveitis who had phacoemulsification and PPV as a single surgical procedure to restore visual acuity.

Patients and Methods The clinical records of patients with uveitis who had combined phacoemulsification and PPV at the Immunology and Uveitis Service, Massachusetts Eye and Ear Infirmary, from 1998 to 2002 were reviewed. Eyes with vitreous biopsy or concomitant cataract surgery and patients with incomplete follow-up data were excluded from the study. Institutional review board approval for the chart review was obtained. Patients had a combined procedure if they had (1) intermediate or diffuse uveitis that could benefit from vitrectomy as a result of the removal of media opacities and vitreous debris and (2) a lens opacity that interfered with their visual perception or the ophthalmologist’s visualization of the posterior segment. In eyes with minimal media opacities, the decision to operate was based mostly on the patient’s need to further improve visual acuity. In all patients, the uveitis was under control for at least 3 months before surgery. In some cases, supplementary perioperative antiinflammatory therapy (100 mg of intravenous methylprednisolone) was given as described.18 Preoperative evaluation included a routine eye examination and fluorescein angiography in eyes in which assessment of the macula was hampered by the degree of crystalline lens or vitreous opacity. Preoperative diagnoses were grouped anatomically according to the International Uveitis Study Group recommendations.19 Accepted for publication June 2, 2004. From the Ocular Immunology and Uveitis Service, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA. None of the authors has a financial or proprietary interest in any material or method mentioned. Supported in part by a Hellenic-Harvard Foundation Award (Dr. Androudi). Reprint requests to C. Stephen Foster, MD, Massachusetts Eye & Ear Infirmary, Harvard Medical School, 243 Charles Street, Boston, Massachusetts 02114-3069, USA. E-mail: [email protected].

Preoperatively, cyclopentolate 1% and phenylephrine 10% were administered every 20 minutes 1 hour before surgery. The same physician (C.S.F.) performed all surgeries using monitored local anesthesia administered with a standard peribulbar block comprising a mixture of lidocaine hydrochloride 2% and bupivacaine hydrochloride 0.75% with hyaluronidase. General anesthesia was administered in children and mentally retarded patients. Phacoemulsification preceded the vitrectomy in all cases. The technique comprised a superior clear corneal incision with instillation of viscoelastic material into the anterior chamber. Posterior synechias were lysed, and flexible iris retractors (Alcon/Grieshaber) were used when pupil dilation was inadequate (!3.0 mm). After capsulorhexis and cortical cleaving hydrodissection were performed, the nucleus was emulsified using the linear mode and divide-and-conquer or phaco-chop technique. Residual cortical material was removed by automated irrigation/aspiration. The capsular bag was expanded with viscoelastic material, and a 10-0 nylon suture was placed to secure the corneal wound. In some eyes, the viscoelastic material was left in the anterior chamber during subsequent vitreoretinal surgery to stabilize the posterior capsule. Peritomy of the conjunctiva was followed by creation of the sclerotomy entries at the superonasal, superotemporal, and inferotemporal quadrants. The entries were created 3.5 mm posterior to the limbus using an MVR blade after a preplaced 7-0 polyglactin (Vicryl) suture was positioned in the inferotemporal quadrant to secure the infusion cannula. The 4.0 to 6.0 mm cannula was connected to a 500 mL bottle of a balanced salt solution. The vitrectomy was done using a Charles irrigating vitrectomy lens. The assistant applied episcleral pressure with a cottontipped applicator to facilitate complete removal of the vitreous; the vitreous base was shaved, and all ciliary membranes were peeled. In eyes with neovascularization of the vitreous base, peripheral scattered argon laser photocoagulation was performed in 3 to 4 rows in and posterior to the area of neovascularization. After the vitrectomy was complete, the sclerotomies were sutured with 7-0 Vicryl and the peripheral retina was examined for iatrogenic retinal breaks. The corneal suture was removed and the incision enlarged for intraocular lens (IOL) implantation in eyes that were not left aphakic. In some cases, 0.1 mg of dexamethasone sodium phosphate (Decadron) or, after 1999, triamcinolone acetonide (Kenalog-40), was placed in the vitreous cavity at the end of surgery. Postoperatively, patients were treated with prednisone acetate 1% drops 8 times daily for 1 week. All patients had follow-up evaluations at 1 day, 1 and 2 weeks, and 1 month. They were evaluated approximately every month thereafter. For cases lost to follow-up, data were obtained by communication with the referring physician. Each examination included best corrected visual acuity, anterior segment biomicroscopy, refraction, intraocular pressure measurement (IOP), and fundus biomicroscopy.

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Fluorescein angiography or optical coherence tomography was done when necessary to assess the macular status. Additional examinations (visual field testing, potential acuity meter) were done when indicated. Intraocular lens centration was evaluated postoperatively after the pupil was dilated with tropicamide 0.5% and phenylephrine 5%. Centration measurements were assessed with a Haag-Streit 10 ocular. Decentration was considered significant when the IOL’s optic edge was visible with 5.0 mm or less of pupil dilation.

Results The chart review identified 36 eyes (34 patients) with uveitis that had combined phacoemulsification and PPV as a therapeutic procedure at the Massachusetts Eye and Ear Infirmary from 1998 to 2002. The mean patient age was 45 years 6 16.09 (SD) (range 8 to 82 years). The mean duration of uveitis before surgery was 56 6 44.17 months (range 6 to 204 months). The mean follow-up was 23.4 6 16.7 months (range 5 to 57 months). The main indication for surgical intervention was reduced visual acuity from lens and vitreous opacities. Preoperative diagnoses according to the International Uveitis Study Group recommendations were intermediate uveitis (8 cases, 22.2%), posterior uveitis (16 cases, 44.4%), and panuveitis (12 cases, 33.3%). Despite a thorough medical and laboratory investigation, 12 eyes (33.3%) were diagnosed with idiopathic uveitis (Table 1). Table 2 shows the preoperative treatment regimens used to achieve uveitis quiescence at the time of the combined surgery. In 24 eyes (66.7%), an IOL was implanted during surgery; 12 eyes (33.3%) Table 1.

Preoperative diagnoses.

Diagnosis Idiopathic uveitis

Cases

6

Juvenile idiopathic arthritis

4

Inflammatory bowel disease

3

Multiple sclerosis

3

Systemic vasculitis

2

HLA-B27 associated

2

Behc¸et’s disease

1

Syphilis

1

Sympathetic ophthalmia

1

Multifocal chorioditis panuveitis

1

474

Treatment regimens before combined cataract surgery

and PPV. Regimen

Eyes (%)

None

9 (25.0)

MTX only

8 (22.2)

MTX C CSA

3 (8.3)

MTX C prednisone*

2 (5.5)

Topical steroid drops only

4 (11.1)

Azathioprine

3 (8.3)

NSAIDs

3 (8.3)

Prednisone only*

2 (5.5)

Daclizumab

1 (2.7)

INF C prednisone*

1 (2.7)

CSA Z cyclosporine, INF Z interferon, MTX Z methotrexate, NSAIDs Z nonsteroidal antiinflammatory drugs *Prednisone dose O7.5 mg

were left aphakic. Twenty-one IOLs were 1- or 3-piece acrylic, 1 was silicone, 1 was poly(methyl methacrylate) (PMMA), and 1 was an anterior chamber. Visual Acuity Postoperatively, visual acuity improved in 26 eyes (72.2%); the improvement was significant (ie, more than 2 lines) in 23 eyes. Visual acuity deteriorated in 5 eyes (13.9%) and was unchanged in 5 (13.9%). The reasons for decreased visual acuity were severe macular edema (n =3), retinal detachment surgery (n Z 1), and progression of end-stage glaucoma (n Z 1). Unchanged visual acuity was attributed to CME in 2 eyes and to optic nerve involvement secondary to uveitis, macular scar, and CME with postsurgical epiretinal membrane formation in 1 eye each. Table 3 shows the preoperative and postoperative visual acuities.

12

Sarcoidosis

HLA Z human leucocyte antigen

Table 2.

Intraocular Pressure The mean preoperative IOP was 18.7 6 5 mm Hg (range 4 to 27 mm Hg). Nine eyes (25.0%) were known to have glaucoma and were being treated with antiglaucoma agents. Postoperatively, transient IOP elevation occurred in 8 eyes (22.2%) and was normalized with medical treatment in all. One eye with idiopathic panuveitis developed persistent hypotony immediately after surgery, which normalized over 4 months after an intraocular injection of 4 mg triamcinolone acetonide. At last follow-up, the mean IOP was 18 6 5 mm Hg (range 5 to 33 mm Hg). There

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Table 3.

Preoperative and postoperative visual acuities. Number (%)

Visual Acuity

Preoperative

Postoperative

!20/200

16 (44.4)

8 (22.2)

20/200 to 20/50

18 (50.0)

10 (27.8)

2 (5.6)

18 (50.0)

O20/50

Two IOLs (acrylic) were explanted because of lens intolerance. Another IOL was dislocated inferiorly, causing monocular diplopia. The patient, however, refused surgery to reposition the lens. In 19 eyes (52.7%), an Nd:YAG laser capsulotomy was performed to treat posterior capsule opacification (PCO).

Discussion was no statistically significant difference between the preoperative IOP and postoperative IOP at the last follow-up visit (P Z .4, paired-sample t test). During the follow-up, 2 eyes with known glaucoma required placement of an Ahmed valve to control the progression of glaucoma. Cystoid Macular Edema Preoperative CME, confirmed by fluorescein angiography, was present in 9 eyes (25%). Postoperatively, angiography showed CME in 16 eyes; 6 had persistent edema that was identified preoperatively, and 10 were identified as new cases. In 4 of the latter, the edema was transient and resolved during the follow-up period. Postoperatively, CME resolved in 3 cases that were diagnosed preoperatively with macular edema. Complications Intraoperative. The posterior capsule ruptured in 2 eyes (5.5%). A rigid anterior chamber IOL was implanted in 1 of the eyes and a sulcus-fixated, singlepiece PMMA lens in the other. Immediate Postoperative. No eye developed choroidal detachment or vitreous hemorrhage. Transient corneal edema developed immediately after surgery in 16 eyes (44.4%) and resolved without sequelae in all cases. Hyphema, which occurred in 3 eyes (8.3%), was transient and resolved without sequelae. Iris capture by the IOL haptics occurred in 1 eye (silicone IOL), requiring repositioning of the IOL. Pupillary block resulting from fibrinous membrane formation occurred in 1 eye; it resolved after a neodymium:YAG (Nd:YAG) peripheral iridotomy and treatment with topical steroids. Long-term (O2 Weeks). One patient developed retinal detachment 1 month after surgery that was repaired with silicone oil. Although the patient initially had a 4-line improvement in visual acuity, the RD repair led to a final acuity of counting fingers.

Posterior segment involvement often coexists with cataract in uveitic patients and can preclude a successful cataract surgery outcome. Conversely, the presence of cataract hampers posterior segment evaluation for inflammatory cells and renders the goals of attempted vitreoretinal surgery difficult, dangerous, or even impossible to achieve. In these cases, a combined anterior and posterior segment approach might be the procedure of choice to treat cataract and remove a persistent inflammatory vitreal component. Diamond and Kaplan8,9 first described combined lensectomy–vitrectomy in patients with uveitis. Lensectomy was accomplished through a pars plana approach8–12,17 in most studies; cataract extraction by an extracapsular technique13 or by phacoemulsification14–16 was seldom reported (Table 4). In a prospective nonrandomized study, Senn and coauthors14 compared cases having combined phacoemulsification and PPV and cases with vitrectomy and subsequent cataract surgery as a 2-step procedure. Their study included 8 patients with uveitis, 4 having combined surgery and 4, a 2-step approach. The most frequent complication, fibrin formation, occurred in all 4 cases of combined surgery but in only 1 case (23%) in which a 2-step approach was used. The authors did not give information about the preoperative and postoperative control of inflammation in their uveitis subgroup. Hurley and Barry15 retrospectively studied combined PPV and phacoemulsification in 5 patients, 2 of whom had uveitis. Visual acuity improved in these 2 cases, with no reported complications. Koenig and coauthors16 describe combined phacoemulsification, PPV, and posterior chamber IOL implantation in 2 patients with pars planitis, 1 of whom developed PCO. In both cases, inflammatory precipitates accumulated on the anterior surface of the IOL, causing persistent inflammation. Our results demonstrate that with adequate preoperative control of inflammation, uveitis patients with

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Table 4.

Summary of reported combined cataract extraction and PPV with or without IOL implantation in patients with uveitis.

Study*

Cohort 9

Approach/IOL Placement

Pre-op/Intra-op Treatment

Complications

VA Results

CME/Other

Diamond

25 eyes, 20 patients

Lensectomy– vitrectomy via PP approach; aphakia

Preop oral prednisone 4 days before Sx until 4 weeks after Sx; all eyes 400 mg dexamethasone intraop in the vitreous cavity

3 RDs

Improved in 24 of 25 eyes; CME caused moderate postop improvement; success attributed to oral steroids

Resolution of preop CME in 4 of 12 eyes; documented decrease in severity of uveitis attacks

Smith10

12 eyes, 10 patients

Lensectomy– vitrectomy via PP approach; aphakia

Topical periocular & systemic steroids as necessary

3 choroidal detachments; 2 hyphemas; 2 vitreous hemorrhage; 2 glaucoma; long term—3 ERM, 1 RD

Improved in all eyes; CME caused moderate postop improvement

7 eyes with preop CME; CME improved postop in 2 cases, resolved in 2 cases

Flynn11

7 eyes; 7 patients with JIA

Lensectomy– vitrectomy via PP approach; aphakia

5 patients on systemic steroids, 1 on immunosupressant

Transient hypotony 4 cases; 1 choroidal detachment; 2 glaucoma

Improved in all eyes; CME & glaucoma caused moderate postop improvement

3 eyes with preop CME; resolved in all cases; 3 new CME cases postop

Girard12

23 eyes

Lensectomy– vitrectomy via PP approach; fragmentation; aphakia

1 hypotony; Most patients on long-term systemic 1 glaucoma steroids; reduced and stopped postop

Improved in 21 cases

1 eye with preop CME; 2 with postop CME; remission of uveitis

Foster13

20 eyes (7 with uveitis)

Extracapsular and PPV

ND

2 glaucoma; 1 pupillary block

ND

Uveitis exacerbation in 3 cases; Nd:YAG capsulotomy in 5 cases; CME in 3 cases postop

Senn14

4 eyes with combined surgery; 4 eyes with sequential

Phaco–PPV; IOL all cases

No separate data for uveitis population

Fibrin in all combined surgery cases

No separate data for uveitis population

No separate data for uveitis population

Hurley15

5 cases (2 with uveitis)

Phaco–PPV; PMMA IOL all cases

ND

NR

VA improved in uveitis population

NR

Koenig16

18 cases (2 with uveitis)

Phaco–PPV; PMMA IOL all cases

ND

1 pupillary block

VA improved in uveitis population

Low-grade inflammation, LEC deposits 2 cases

Topical, systemic steroids, and immunosuppression as necessary

No separate data for combined surgery subgroup

No separate data for combined surgery subgroup

No separate data for combined surgery subgroup

Heiligenhaus17 28 cases with Lensectomy– uveitis having PPV vitrectomy via PP approach 10 cases

CME Z cystoid macular edema; ERM Z epiretinal membrane; JIA Z juvenile idiopathic arthritis; LEC Z lens epithelial cell; ND Z no data; Nd:YAG Z neodymium:YAG; NR Z none reported; Phaco Z phacoemulsification; PMMA Z poly(methyl methacrylate); PP Z pars plana; PPV Z pars plana vitrectomy; RD Z retinal detachment; Sx Z surgery; VA Z visual acuity *First author

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cataract and posterior segment involvement can benefit from a combined surgical approach. Visual acuity improved in 26 cases (72.2%) in our series. The most frequent long-term complication (19 eyes, 52.7%) was PCO requiring an Nd:YAG capsulotomy. We suspect the incidence might increase with a longer follow-up. The relatively low incidence of fibrin formation in our series (1 eye) can be explained by the emphasis on adequate preoperative and postoperative inflammation control. The CME resolved in 3 of the 9 cases with preoperative CME. Although the therapeutic effect of the combined lensectomy and vitrectomy in cases of CME has been reported,9–11 one cannot ignore that the cataract surgery itself can disrupt the blood–aqueous barrier and produce or aggravate existing CME. Although combined phacoemulsification and PPV has been reported as a surgical approach for other forms of posterior segment involvement, there are special considerations in eyes with uveitis.

outcomes, higher capsular biocompatibility, and lower rates of uveitis recurrence.22 3. Previous studies8–10 advocate core vitrectomy for vitreous removal in combined procedures. In light of the recent improvements in intravitreal surgery instrumentation, this 20- to 25-year-old recommendation should probably be reconsidered. Furthermore, removal of vitreous and immunocompetent inflammatory cells is reported to be associated with a decreased incidence and severity of uveitis recurrence.9 Also, experimental studies show that persistence of vitreous is associated with reactivation of a secondary immune response.26 4. An IOL can be implanted before or after the vitrectomy. We prefer the phacoemulsification– vitrectomy–IOL implantation sequence27 because it preserves the advantages of small-incision cataract surgery and facilitates PPV by eliminating prismatic effects and reflexes from the IOL.

1. Intraocular surgery can exacerbate the inflamma-

Combined surgery has several advantages. Only a single operation is necessary, reducing the patient’s discomfort, decreasing costs, and speeding visual recovery. The disadvantages include increased surgical time and the need for 2 surgeons in cases in which the surgeon is not trained in both cataract and vitreoretinal surgery. Although the final role of vitrectomy in the management of patients with uveitis remains to be determined, our results show that in selected cases, the combined approach, as opposed to lens extraction alone, is compatible with improved vision. However, the combined procedure does not ‘‘cure’’ uveitis. Remissions and exacerbations can occur anytime in the postoperative period; therefore, careful attention to postoperative control of inflammation is still necessary.

tion10 by activating the underlying inflammatory process; also, the procedure itself can cause an unusually severe inflammatory response, abnormal or excessive bleeding, and unexpected postoperative IOP responses (hypertension or hypotony). It is clear that the most important factor in a successful outcome is preoperative and postoperative control of intraocular inflammation by topical, periocular, and systemic steroidal or immunosuppressive agents.20 2. Intraocular implantation in patients with uveitis has always been controversial; however, recent studies suggest that posterior chamber IOLs are well tolerated in some cases.18,21,22 Because there is no typical ‘‘uveitis patient,’’ whether to implant an IOL should be evaluated on an individual basis. The major risk factors for IOL intolerance requiring IOL explanation in uveitic eyes are intermediate uveitis, panuveitis, juvenile idiopathic arthritis, and chronic diseases difficult to control (eg, sarcoidosis).23 Recent studies show that hydrophilic acrylic has good uveal biocompatibility but worse capsular biocompatibility.24 Eyes with silicone IOLs have a higher rate of relapse of uveitis and of postoperative complications.25 Hydrophobic acrylic IOLs are reported to have favorable

References 1. Brazitikos PD. The expanding role of primary pars plana vitrectomy in the treatment of rhegmatogenous noncomplicated retinal detachment. Semin Ophthalmol 2000; 15:65–77 2. Menchini U, Azzolini C, Camesasca FI, Brancato R. Combined vitrectomy, cataract extraction, and posterior chamber intraocular lens implantation in diabetic patients. Ophthalmic Surg 1991; 22:69–73 3. Blankenship GW. Posterior chamber intraocular lens implantation during pars plana lensectomy and vitrectomy

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4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

478

for diabetic complications. Graefes Arch Clin Exp Ophthalmol 1989; 227:136–138 Kokame GT, Flynn HW Jr, Blankenship GW. Posterior chamber intraocular lens implantation during diabetic pars plana vitrectomy. Ophthalmology 1989; 96:603– 610 Batman C, C ¸ ekic¸ O, Totan Y, et al. Combined phacoemulsification, vitrectomy, foreign-body extraction, and intraocular lens implantation. J Cataract Refract Surg 2000; 26:254–259 Simcock PR, Scalia S. Phaco-vitrectomy for full-thickness macular holes. Acta Ophthalmol Scand 2000; 78:684–686 Lahey JM, Francis RR, Fong DS, et al. Combining phacoemulsification with vitrectomy for treatment of macular holes. Br J Ophthalmol 2002; 86:876–878 Diamond JG, Kaplan HJ. Lensectomy and vitrectomy for complicated cataract secondary to uveitis. Arch Ophthalmol 1978; 96:1798–1804 Diamond JG, Kaplan HJ. Uveitis: effect of vitrectomy combined with lensectomy. Ophthalmology 1979; 86:1320–1327; discussion by JH Elliott, 1328–1329 Smith RE, Kokoris N, Nobe JR, et al. Lensectomyvitrectomy in chronic uveitis. Trans Am Ophthalmol Soc 1983; 81:261–273; discussion, 273–275 Flynn HW Jr, Davis JL, Culbertson WW. Pars plana lensectomy and vitrectomy for complicated cataracts in juvenile rheumatoid arthritis. Ophthalmology 1988; 95: 1114–1119 Girard LJ, Rodriguez J, Mailman ML, Romano TJ. Cataract and uveitis management by pars plana lensectomy and vitrectomy by ultrasonic fragmentation. Retina 1985; 5:107–114 Foster RE, Lowder CY, Meisler DM, et al. Combined extracapsular cataract extraction, posterior chamber intraocular lens implantation, and pars plana vitrectomy. Ophthalmic Surg 1993; 24:446–452 Senn P, Schipper I, Perren B. Combined pars plana vitrectomy, phacoemulsification, and intraocular lens implantation in the capsular bag: a comparison to vitrectomy and subsequent cataract surgery as a twostep procedure. Ophthalmic Surg Lasers 1995; 26:420– 428 Hurley C, Barry P. Combined endocapsular phacoemulsification, pars plana vitrectomy, and intraocular lens implantation. J Cataract Refract Surg 1996; 22:462–466 Koenig SB, Mieler WF, Han DP, Abrams GW. Combined phacoemulsification, pars plana vitrectomy, and

17.

18.

19.

20.

21.

22.

23. 24.

25.

26.

27.

posterior chamber intraocular lens insertion. Arch Ophthalmol 1992; 110:1101–1104 Heiligenhaus A, Bornfeld N, Foerster MH, Wessing A. Long term results of pars plana vitrectomy in the management of complicated uveitis. Br J Ophthalmol 1994; 78:549–554 Papaliodis GN, Nguyen QD, Samson CM, Foster CS. Intraocular lens tolerance in surgery for cataracta complicata: assessment of four implant materials. Semin Ophthalmol 2002; 17:120–123 Bloch-Michel E, Nussenblatt RB. International Uveitis Study Group recommendations for the evaluation of intraocular inflammatory disease [letter]. Am J Ophthalmol 1987; 103:234–235 Foster CS, Opremcak EM. Therapeutic surgery: cornea, iris, cataract, glaucoma, vitreous, retinal. In: Foster CS, Vitale AT, eds, Diagnosis and Treatment of Uveitis. Philadelphia, PA, WB Saunders, 2002; 222–235 Foster CS, Fong LP, Singh G. Cataract surgery and intraocular lens implantation in patients with uveitis. Ophthalmology 1989; 96:281–287; discussion by HJ Kaplan, 287–288 Alio´ JL, Chipont E, BenEzra D, Fakhry MA. Comparative performance of intraocular lenses in eyes with cataract and uveitis; the International Ocular Inflammation Society Study Group of Uveitic Cataract Surgery. J Cataract Refract Surg 2002; 28:2096–2108 Harper SL, Foster CS. Intraocular lens explantation in uveitis. Int Ophthalmol Clin 2000; 40(1):107–116 Abela-Formanek C, Amon M, Schauersberger J, et al. Results of hydrophilic acrylic, hydrophobic acrylic, and silicone intraocular lenses in uveitic eyes with cataract; comparison to a control group. J Cataract Refract Surg 2002; 28:1141–1152 Borgioli M, Coster DJ, Fan RFT, et al. Effect of heparin surface modification of polymethymethacrylate intraocular lenses on signs of postoperative inflammation after extracapsular cataract extraction; one-year results of a double-masked multicenter study. Ophthalmology 1992; 99:1248–1254; discussion by SA Obstbaum, 1254–1255 Brinkman CJJ, Otto AJ, Kijlstra A, Breebaart AC. The influence of vitrectomy and lensectomy on experimental uveitis. Curr Eye Res 1990; 9(suppl):125–130 Mackool RJ. Pars plana vitrectomy and posterior chamber intraocular lens implantation in diabetic patients [letter]. Ophthalmology 1989; 96:1679–1680

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