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Pupillary Membrane Excision and Anterior Vitrectomy in Eyes after Uveitis
PUPILLARY MEMBRANE EXCISION AND ANTERIOR VITRECTOMY IN EYES AFTER UVEITIS M A N U E L P U I G - L L A N O , M.D., A. R O D M A N I R V I N E , AND R O B E R T D. S T O N E , M.D. San Francisco,
Eyes with dense postcataract pupillary membranes, chronic uveitis, extensive pe ripheral anterior synechiae, and hypotony usually respond poorly to intraocular surgery. 1 ' 2 Triester and Machemer 3 be lieve it inadvisable to perform membranectomy and vitrectomy in such eyes if chronic flare is present. The major con cern is the acceleration of the develop ment of phthisis bulbi. We report herein on three eyes that did well after vitrec tomy and membrane excision and show that hypotony is not necessarily a harbin ger of phthisis in such eyes. Our surgical objectives were twofold; to create a clear visual axis and to relieve the traction of the cyclitic membrane on the ciliary body and retina.
M.D.,
California
Fig. 1 (Puig-Llano, Irvine, and Stone). Case 1. Preoperative B-scan ultrasonogram, showing thick ened iris and pupillary membrane, thickened cho roid and elevation of the optic nerve head (axial length, 24.5 mm).
CASE REPORTS Case 1—A 1-year-old boy had an onset of juvenile rheumatoid arthritis and bilateral uveitis. H e devel oped secondary cataracts and underwent extracapsular lens extraction in both eyes at age 5 years. After initial improvement, vision gradually decreased in both eyes. We saw him in August 1975 at age 13 years, when visual acuity was counting fingers at four feet in the right eye and hand movements in the left eye. Intraocular pressure was 6 mm Hg in the right eye and 10 mm Hg in the left eye by applanation. Slit-lamp examination revealed band keratopathy, 2+ anterior chamber flare and occasional cells, secluded pupils, 360-degree peripheral anteri or synechiae, iris bombe, and postcataract mem branes bilaterally. The fundi could not be observed. In both eyes, ultrasonography showed the presence of a dense cyclitic membrane, a swollen choroid and optic nerve, and an attached retina. T h e axial length was 24.5 mm for either eye (Fig. 1). Bright flash electroretinogram showed evidence of good retinal function in both eyes. In November 1975 the patient underwent memFrom the Department of Ophthalmology, Univer sity of California, San Francisco, School of Medi cine, San Francisco, California. Reprint requests to A. Rodman Irvine, M.D., Room U-490, Department of Ophthalmology, Uni versity of California, San Francisco, CA 94143.
branectomy and anterior vitrectomy in the left eye via a limbal incision using scissors and the vitreous infusion section cutter. Postoperatively the uveitis flared up, but this cleared within two weeks. Three weeks postoperatively, visual acuity was 6/60 (20/200). The disk was swollen and there were hypotonic folds around the macula. T h e pressure was unrecordably low and there was 2+ flare in the anterior chamber. During the next 2V2 years visual acuity gradually increased to 6/15 (20/50) and Jaeger 1 at eight inches. The intraocular pressure remained 0 to 2 mm Hg and the anterior chamber flare persisted, but the swelling of the optic nerve and the folds around the macula gradually subsided. The axial length in this eye decreased to 20.5 mm with horizontal flattening of the cornea, and refraction was +20 diopters (Fig. 2). The unoperated right eye gradually lost all vision and showed total retinal detachment on ultrasound eight months after our first examination. Case 2—A 37-year-old woman with a long history of bilateral uveitis developed secondary cataracts and underwent extracapsular lens extraction in the right eye in 1968 and in the left eye in 1974. After initial improvement, vision subsequently decreased in both eyes. We saw her in April 1976 when visual acuity was hand movements in the right eye and counting fingers at 13 inches in the left eye. Slitlamp examination revealed early band keratopathy,
AMERICAN JOURNAL O F OPHTHALMOLOGY 87:533-535, 1979
533
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AMERICAN JOURNAL OF OPHTHALMOLOGY
Fig. 2 (Puig-Llano, Irvine, and Stone). Case 1. Two year postoperative B-scan ultrasonogram show ing normal corneal echoes, deep anterior chamber, normal iris diaphragm, swollen choroid, slightly elevated optic nerve head, and shortening of the globe (axial length, 20.5 mm).
APRIL, 1979
revealed Staphylococcus epidermidis. She was treat ed with systemic and periocular antibiotics and corticosteroids. When we saw her in July 1975 the right eye had visual acuity of hand movements and she was able to follow the light and perceive entopic images. The intraocular pressure was 8 mm Hg. Slit-lamp examination revealed diffuse cellular keratic precipitates, shallow anterior chamber with 3+ flare and 2+ cells, a white pupillary membrane with seclusion and occlusion of the pupil and sector iridectomy, iris bombe, and complete angle closure. The fundus could not be visualized. The left eye was normal. Ultrasonography of the right eye con firmed the presence of a dense cyclitic membrane and attached retina. T h e bright flash electroretino gram showed good retinal function. Two attempts to create a laser iridotomy were unsuccessful and the right eye remained unchanged. In November 1975 the patient underwent iridectomy, membranectomy, and anterior vitrectomy through a limbal approach, using scissors and the vitreous infusion suction cutter. Postoperatively the right eye did well. Visual acuity improved to 6/12 (20/40) over the next six months, despite the persistence of some degree of cystoid macular edema. The intraocular pressure remained about 11 mm Hg and the angle remained totally closed. She has been followed-up for 2V2 years with no change. DISCUSSION
mild corneal edema, complete angle closure, moder ate flare and no cells, secluded pupils, and white, dense postcataract membranes in both eyes. In the left eye, a small opening was present in the pupil allowing observation of a swollen disk and marked retinal pigment epithelial scarring involving the macula. Intraocular pressure measured 0 to 4 mm Hg on several occasions in both eyes. Ultrasonography showed that the retina was attached, the choroid thickened, and the disk swollen in both eyes. The axial length was 18.5 mm bilaterally. Bright flash electroretinogram showed evidence of good retinal function in both eyes. In June 1976 the patient underwent excision of the cyclitic membrane and anterior vitrectomy using scissors and the Roto-Extractor,' through a limbal approach in the right eye. The immediate postopera tive inflammatory reaction was severe, but cleared within five months. Visvial acuity improved to 3/240 (2/160) at distance and 6/120 (20/400) at near for the remainder of the two year follow-up. The eye main tained an intraocular pressure of zero, and anterior chamber flare was present. The optic nerve swelling persisted and the axial length shortened to 18 mm. The cornea showed marked irregular flattening and she wore a refraction of +25 diopters. In the unoperated eye, vision decreased to hand movements three months after the initial examina tion. The intraocular pressure was zero and the eye remained unchanged on ultrasound examination. Case 3—A 71-year-old woman underwent intracapsular cataract extraction in the right eye in May 1975. Three weeks postoperatively, she had de creased vision and hypopyon in the operated eye. Smears and cultures from the anterior chamber
Postcataract and cyclitic membranes are common complications of severe or chronic uveitis. When hypotony occurs in chronic uveitis it is frequently a sign of imminent atrophy and disorganization of the globe. Other investigators 1 - 3 have em phasized the poor surgical prognosis of such eyes and have recommended delay ing surgery until the uveitis remains qui escent for a long time. Deciding on the activity of the inflammation in cases of chronic uveitis, however, has been most difficult 4,5 (and S. J. Kimura, personal communication, 1978). Our cases show the value of ultrasonography and bright flash electroretinography in determining whether to operate on such eyes. When these tests indicate that the retina is at tached and functioning, surgery may be undertaken in the presence of hypotony, or its near equivalent, normal pressure and a totally occluded angle. Other inves tigators have reported poor results in uveitic cases when using a pars plana approach to attack pupillary membranes. 3 Possibly the limbal approach is safer in
VOL. 87,NO. 4
VITRECTOMY AFTER UVEITIS
such patients, because it avoids the risks of putting instruments through the cycli tic membrane that commonly lies over the pars plana. That hypotony persisted postoperatively in Cases 1 and 2 may indicate that the circumferential traction of the cyclitic membrane on the ciliary body was not completely relieved. However, the ciliary body may have been permanently dam aged by the uveitis. These two cases pro vide a unique opportunity to follow-up uveitic eyes with chronic hypotony. In both cases, the operated eye has main tained useful vision for over two years while the unoperated eye has had severe visual loss. In each case the chronic hypotony has been associated with some shortening of the globe as well as swelling of the choroid, as indicated by ultrasonography. This has produced marked hyperopia, but with +20 to + 2 5 diopter corrections these patients have useful vision. SUMMARY
Three patients with uveitis and dense pupillary membranes, total synechial clo
535
sure of the angle, and low or normal pressure, underwent membranectomy and anterior vitrectomy via a limbal ap proach using scissors and a vitrectomy instrument. Postoperatively all regained useful vision that has been maintained for over two years despite the persistence of angle closure in all cases and severe hypotony in two. REFERENCES 1. Gordon, D. M.: Lens extraction in uveitis. Cone. Ophthalmol. Acta 21:809, 1970. 2. Jarre, N. M.: The fens. Annual review. Arch. Ophthalmol. 90:136, 1973. 3. Triester, C , and Machemer, R.: Pars plana approach for pupillary membranes. Arch. Ophthal mol. 96:1014, 1978. 4. Aronson, S. B., Moore, T. E., Jr., and O'Day, D. M.: The effect of structural alteration on anterior ocular inflammation. Am. J. Ophthalmol. 70:886, 1970. 5. Aronson, S. B., Fish, M. B., Pollycore, M., and Coon, M. A.: Altered vascular permeability in ocular inflammatory disease. Arch. Ophthalmol. 85:455, 1971. 6. Jack, R. L., Hutton, W. L., and Machemer, R.: Ultrasonography and vitrectomy. Am. J. Ophthal mol. 78:265, 1-974. 7. Fuller, D. G., Knighton, R. W., and Machemer, R.: Bright-flash electroretinography for evaluation of eyes with opaque vitreous. Am. J. Ophthalmol. 80:214, 1975.
Eyes with dense postcataract pupillary membranes, chronic uveitis, extensive pe ripheral anterior synechiae, and hypotony usually respond poorly to intraocular surgery. 1 ' 2 Triester and Machemer 3 be lieve it inadvisable to perform membranectomy and vitrectomy in such eyes if chronic flare is present. The major con cern is the acceleration of the develop ment of phthisis bulbi. We report herein on three eyes that did well after vitrec tomy and membrane excision and show that hypotony is not necessarily a harbin ger of phthisis in such eyes. Our surgical objectives were twofold; to create a clear visual axis and to relieve the traction of the cyclitic membrane on the ciliary body and retina.
M.D.,
California
Fig. 1 (Puig-Llano, Irvine, and Stone). Case 1. Preoperative B-scan ultrasonogram, showing thick ened iris and pupillary membrane, thickened cho roid and elevation of the optic nerve head (axial length, 24.5 mm).
CASE REPORTS Case 1—A 1-year-old boy had an onset of juvenile rheumatoid arthritis and bilateral uveitis. H e devel oped secondary cataracts and underwent extracapsular lens extraction in both eyes at age 5 years. After initial improvement, vision gradually decreased in both eyes. We saw him in August 1975 at age 13 years, when visual acuity was counting fingers at four feet in the right eye and hand movements in the left eye. Intraocular pressure was 6 mm Hg in the right eye and 10 mm Hg in the left eye by applanation. Slit-lamp examination revealed band keratopathy, 2+ anterior chamber flare and occasional cells, secluded pupils, 360-degree peripheral anteri or synechiae, iris bombe, and postcataract mem branes bilaterally. The fundi could not be observed. In both eyes, ultrasonography showed the presence of a dense cyclitic membrane, a swollen choroid and optic nerve, and an attached retina. T h e axial length was 24.5 mm for either eye (Fig. 1). Bright flash electroretinogram showed evidence of good retinal function in both eyes. In November 1975 the patient underwent memFrom the Department of Ophthalmology, Univer sity of California, San Francisco, School of Medi cine, San Francisco, California. Reprint requests to A. Rodman Irvine, M.D., Room U-490, Department of Ophthalmology, Uni versity of California, San Francisco, CA 94143.
branectomy and anterior vitrectomy in the left eye via a limbal incision using scissors and the vitreous infusion section cutter. Postoperatively the uveitis flared up, but this cleared within two weeks. Three weeks postoperatively, visual acuity was 6/60 (20/200). The disk was swollen and there were hypotonic folds around the macula. T h e pressure was unrecordably low and there was 2+ flare in the anterior chamber. During the next 2V2 years visual acuity gradually increased to 6/15 (20/50) and Jaeger 1 at eight inches. The intraocular pressure remained 0 to 2 mm Hg and the anterior chamber flare persisted, but the swelling of the optic nerve and the folds around the macula gradually subsided. The axial length in this eye decreased to 20.5 mm with horizontal flattening of the cornea, and refraction was +20 diopters (Fig. 2). The unoperated right eye gradually lost all vision and showed total retinal detachment on ultrasound eight months after our first examination. Case 2—A 37-year-old woman with a long history of bilateral uveitis developed secondary cataracts and underwent extracapsular lens extraction in the right eye in 1968 and in the left eye in 1974. After initial improvement, vision subsequently decreased in both eyes. We saw her in April 1976 when visual acuity was hand movements in the right eye and counting fingers at 13 inches in the left eye. Slitlamp examination revealed early band keratopathy,
AMERICAN JOURNAL O F OPHTHALMOLOGY 87:533-535, 1979
533
534
AMERICAN JOURNAL OF OPHTHALMOLOGY
Fig. 2 (Puig-Llano, Irvine, and Stone). Case 1. Two year postoperative B-scan ultrasonogram show ing normal corneal echoes, deep anterior chamber, normal iris diaphragm, swollen choroid, slightly elevated optic nerve head, and shortening of the globe (axial length, 20.5 mm).
APRIL, 1979
revealed Staphylococcus epidermidis. She was treat ed with systemic and periocular antibiotics and corticosteroids. When we saw her in July 1975 the right eye had visual acuity of hand movements and she was able to follow the light and perceive entopic images. The intraocular pressure was 8 mm Hg. Slit-lamp examination revealed diffuse cellular keratic precipitates, shallow anterior chamber with 3+ flare and 2+ cells, a white pupillary membrane with seclusion and occlusion of the pupil and sector iridectomy, iris bombe, and complete angle closure. The fundus could not be visualized. The left eye was normal. Ultrasonography of the right eye con firmed the presence of a dense cyclitic membrane and attached retina. T h e bright flash electroretino gram showed good retinal function. Two attempts to create a laser iridotomy were unsuccessful and the right eye remained unchanged. In November 1975 the patient underwent iridectomy, membranectomy, and anterior vitrectomy through a limbal approach, using scissors and the vitreous infusion suction cutter. Postoperatively the right eye did well. Visual acuity improved to 6/12 (20/40) over the next six months, despite the persistence of some degree of cystoid macular edema. The intraocular pressure remained about 11 mm Hg and the angle remained totally closed. She has been followed-up for 2V2 years with no change. DISCUSSION
mild corneal edema, complete angle closure, moder ate flare and no cells, secluded pupils, and white, dense postcataract membranes in both eyes. In the left eye, a small opening was present in the pupil allowing observation of a swollen disk and marked retinal pigment epithelial scarring involving the macula. Intraocular pressure measured 0 to 4 mm Hg on several occasions in both eyes. Ultrasonography showed that the retina was attached, the choroid thickened, and the disk swollen in both eyes. The axial length was 18.5 mm bilaterally. Bright flash electroretinogram showed evidence of good retinal function in both eyes. In June 1976 the patient underwent excision of the cyclitic membrane and anterior vitrectomy using scissors and the Roto-Extractor,' through a limbal approach in the right eye. The immediate postopera tive inflammatory reaction was severe, but cleared within five months. Visvial acuity improved to 3/240 (2/160) at distance and 6/120 (20/400) at near for the remainder of the two year follow-up. The eye main tained an intraocular pressure of zero, and anterior chamber flare was present. The optic nerve swelling persisted and the axial length shortened to 18 mm. The cornea showed marked irregular flattening and she wore a refraction of +25 diopters. In the unoperated eye, vision decreased to hand movements three months after the initial examina tion. The intraocular pressure was zero and the eye remained unchanged on ultrasound examination. Case 3—A 71-year-old woman underwent intracapsular cataract extraction in the right eye in May 1975. Three weeks postoperatively, she had de creased vision and hypopyon in the operated eye. Smears and cultures from the anterior chamber
Postcataract and cyclitic membranes are common complications of severe or chronic uveitis. When hypotony occurs in chronic uveitis it is frequently a sign of imminent atrophy and disorganization of the globe. Other investigators 1 - 3 have em phasized the poor surgical prognosis of such eyes and have recommended delay ing surgery until the uveitis remains qui escent for a long time. Deciding on the activity of the inflammation in cases of chronic uveitis, however, has been most difficult 4,5 (and S. J. Kimura, personal communication, 1978). Our cases show the value of ultrasonography and bright flash electroretinography in determining whether to operate on such eyes. When these tests indicate that the retina is at tached and functioning, surgery may be undertaken in the presence of hypotony, or its near equivalent, normal pressure and a totally occluded angle. Other inves tigators have reported poor results in uveitic cases when using a pars plana approach to attack pupillary membranes. 3 Possibly the limbal approach is safer in
VOL. 87,NO. 4
VITRECTOMY AFTER UVEITIS
such patients, because it avoids the risks of putting instruments through the cycli tic membrane that commonly lies over the pars plana. That hypotony persisted postoperatively in Cases 1 and 2 may indicate that the circumferential traction of the cyclitic membrane on the ciliary body was not completely relieved. However, the ciliary body may have been permanently dam aged by the uveitis. These two cases pro vide a unique opportunity to follow-up uveitic eyes with chronic hypotony. In both cases, the operated eye has main tained useful vision for over two years while the unoperated eye has had severe visual loss. In each case the chronic hypotony has been associated with some shortening of the globe as well as swelling of the choroid, as indicated by ultrasonography. This has produced marked hyperopia, but with +20 to + 2 5 diopter corrections these patients have useful vision. SUMMARY
Three patients with uveitis and dense pupillary membranes, total synechial clo
535
sure of the angle, and low or normal pressure, underwent membranectomy and anterior vitrectomy via a limbal ap proach using scissors and a vitrectomy instrument. Postoperatively all regained useful vision that has been maintained for over two years despite the persistence of angle closure in all cases and severe hypotony in two. REFERENCES 1. Gordon, D. M.: Lens extraction in uveitis. Cone. Ophthalmol. Acta 21:809, 1970. 2. Jarre, N. M.: The fens. Annual review. Arch. Ophthalmol. 90:136, 1973. 3. Triester, C , and Machemer, R.: Pars plana approach for pupillary membranes. Arch. Ophthal mol. 96:1014, 1978. 4. Aronson, S. B., Moore, T. E., Jr., and O'Day, D. M.: The effect of structural alteration on anterior ocular inflammation. Am. J. Ophthalmol. 70:886, 1970. 5. Aronson, S. B., Fish, M. B., Pollycore, M., and Coon, M. A.: Altered vascular permeability in ocular inflammatory disease. Arch. Ophthalmol. 85:455, 1971. 6. Jack, R. L., Hutton, W. L., and Machemer, R.: Ultrasonography and vitrectomy. Am. J. Ophthal mol. 78:265, 1-974. 7. Fuller, D. G., Knighton, R. W., and Machemer, R.: Bright-flash electroretinography for evaluation of eyes with opaque vitreous. Am. J. Ophthalmol. 80:214, 1975.