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Peripheral Cryoablation for Treatment of Active Pars Planitis: Long-Term Outcomes of a Retrospective Study

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Peripheral Cryoablation for Treatment of Active Pars Planitis: Long-Term Outcomes of a Retrospective Study Peripheral Cryoablation for Treatment of Active Pars Planitis: Long-Term Outcomes of a Retrospective Study ELLIOTT H. SOHN, BENJAMIN C. CHAON, DOUGLAS A. JABS, AND JAMES C. FOLK PURPOSE: To compare the long-term outcomes of pe- CONCLUSIONS: These data suggest that peripheral ripheral retinal cryoablation to conventional treatment retinal cryoablation therapy is an effective treatment for active pars planitis. for active pars planitis and may be better than DESIGN: Retrospective, interventional, comparative conventional regional corticosteroid injections and oral case series. corticosteroid therapy for induction of remission. (Am METHODS: Review at a single institution was conduct- J Ophthalmol 2016;162:35–42. Ó 2016 by Elsevier Inc. ed to compare the effect of cryotherapy to eyes with pars All rights reserved.) planitis to those receiving conventional therapy (topical, regionally injected, or oral corticosteroid therapy). Best- corrected visual acuity (VA), complications, resolution ARS PLANITIS IS A SUBSET OF INTERMEDIATE UVEITIS of cystoid macular edema (CME), and anterior chamber characterized by chronic vitreous inflammation and and vitreous inflammation were assessed. P the accumulation of fibroinflammatory debris over RESULTS: One hundred thirty-six eyes were treated the pars plana, occurring in the absence of any associated 1 conventionally, 50 eyes were treated with cryotherapy. infection or systemic disease. Clinically, these collections Median follow-up was 60.8 months (range 8.1– of inflammatory material resemble yellow-gray or white ag- 223.1 months) in the cryotherapy group and 45.0 months gregates visible in the mid- and posterior vitreous and col- (range 3.1–339.0 months) in the controls. There were no lections of inflammatory debris on the pars plana significant differences in baseline VA, anterior chamber (particularly inferiorly), known as ‘‘snowballs’’ and ‘‘snow- and vitreous inflammation, presence of CME, and prior banks,’’ respectively. The most frequent structural compli- use of regional corticosteroid injections. VA improved cation of pars planitis is macular edema, and most over time in the cryotherapy group (slope of L0.0018 treatment regimens are directed at controlling macular 2,3 logMAR units per month; P [ .023) but declined in edema. Other, less common structural complications the controls (slope of D0.0011 logMAR units per include traction retinal detachments and vitreous month; P [ .023). Kaplan-Meier survival estimates hemorrhage from neovascularization of the snowbank. demonstrated faster times to resolution of anterior cham- Although a subset of patients with pars planitis do not ber cell, vitreous cell, and CME in the cryotherapy- have macular edema or visual impairment and may be treated eyes. Hazard ratios of remission (adjusted for observed, the majority of patients need treatment. Con- confounding factors) for vitreous cell and CME for those ventional treatment regimens typically have used a step- treated with cryotherapy compared to controls were 4.73 ped approach starting with regional corticosteroid (95% confidence interval 1.63, 13.63; P [ .004) and injections (either periocular or intravitreal), followed by 6.85 (95% confidence interval 1.06, 44.78; P [ .044), oral corticosteroids, supplemented with immunosuppres- 2,3 respectively. No ocular complications were identified in sion as needed for more difficult or bilateral cases. the cryotherapy group. Regional corticosteroid injections have the potential for elevated intraocular pressure and cataract formation/ progression and typically have a duration of effect of 3 months, thereby requiring repetitive injections. Accepted for publication Nov 5, 2015. Although when used properly, oral corticosteroids and From the Department of Ophthalmology and Visual Sciences, Stephen immunosuppression can be administered with minimal A. Wynn Institute for Vision Research, University of Iowa Hospitals and Clinics, Iowa City, Iowa (E.H.S., B.C.C., J.C.F.); Departments of to no increase in side effects in adults, in children long- Ophthalmology and Medicine, Icahn School of Medicine at Mount term use of oral corticosteroids is avoided owing to the Sinai, New York, New York (D.A.J.); and Department of Epidemiology, risk of growth retardation.4–6 Furthermore, the chronic The Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland (D.A.J.). nature of the disease often requires long-term therapy; Benjamin C. Chaon is now at the University of Minnesota Department there is a low sustained, drug-free remission rate; and of Ophthalmology, Minneapolis, Minnesota. some patients’ uveitis will not be controlled by this Inquiries to Elliott H. Sohn, Department of Ophthalmology, University 7 of Iowa Hospitals and Clinics, 200 Hawkins Dr, Iowa City, IA 52242; approach. Although some clinicians have advocated e-mail: [email protected] therapeutic vitrectomy for pars planitis, a review 0002-9394/$36.00 Ó 2016 BY ELSEVIER INC.ALL RIGHTS RESERVED. 35 http://dx.doi.org/10.1016/j.ajo.2015.11.009 concluded that methodological problems and study con- for this project, which adhered to the principles of the founders resulted in insufficient evidence to support or Declaration of Helsinki. refute its use.8 In 1973, Aaberg and associates reported Data were extracted from review of patient charts at the in 23 eyes in 14 patients affected by pars planitis that pe- time of pars planitis diagnosis (the ‘‘baseline’’ visit) and at ripheral retinal ablation directed at the inflammatory ex- consecutive follow-up visits. Follow-up visits were grouped udates overlying the pars plana with transconjunctival as sequential 3-month ‘‘contiguous visit windows’’ extend- cryopexy (cryotherapy) was effective at decreasing vitritis ing until the last follow-up visit (eg, the 3-month follow-up and improving visual acuity.9 These observations subse- window extended from 1.5 to 4.5 months post-baseline, the quently were supported by data from other small case se- 6-month follow-up visit window from 4.5 to 7.5 months ries; however, these studies evaluated the effect of post-baseline, etc). Data collected at presentation, base- cryotherapy on relatively few eyes and were limited by a line, and follow-up visits included (1) best-corrected relatively short duration of follow-up.10–13 Snellen visual acuity; (2) presence or absence of cystoid There are limited data on the long-term effectiveness of macular edema identified by stereoscopic funduscopic ex- peripheral retinal cryoablation therapy in controlling amination and/or fluorescein angiography, which was intraocular inflammation, improving visual acuity out- confirmed by optical coherence tomography imaging comes, and reducing structural complications of pars plani- when this modality became available (2004); (3) grading tis. Our retrospective study compared the long-term of anterior chamber cell; (4) grading of vitreous chamber clinical outcomes of eyes receiving cryotherapy to those cell; (5) lenticular status (phakic, aphakic, pseudophakic); receiving conventional therapy for active pars planitis. (6) use of topical corticosteroid medications; (7) use of oral We sought to determine if cryotherapy resulted in better vi- corticosteroid medications; (8) use of periocular corticoste- sual outcomes and faster time to resolution of cystoid mac- roid injections within the previous 120 days; (9) treatment ular edema, vitreous, and anterior chamber cell compared of glaucoma with topical medication; (10) interval glau- to conventional therapy. coma surgery; (11) interval cataract surgery; and (12) pres- ence of retinal detachment. Also noted in treated eyes was the date of the first cryotherapy and the total number of cryotherapy treatments per eye. Visual acuity data were converted to logMAR (loga- METHODS rithm of the minimal angle of resolution) values (logMAR ¼ log [1/Snellen visual acuity]) to allow for sta- A RETROSPECTIVE, INTERVENTIONAL, COMPARATIVE tistical analysis. The following logMAR values were study of all known patients with active pars planitis treated assigned: for hand motion, 3.3 logMAR; light perception, in the Department of Ophthalmology and Visual Sciences 4.3 logMAR; and no light perception, 5.3 logMAR. Each at the University of Iowa from January 1, 1983 (near the difference of þ0.3 logMAR between the baseline and time cryotherapy for pars planitis was first used at the Uni- follow-up visual acuity corresponds to a loss of 3 lines on versity of Iowa) to January 1, 2013 was conducted. The re- an Early Treatment Diabetic Retinopathy Study (ETDRS) cords of patients with ICD-9 diagnosis code 363.21 eye chart and a doubling of the visual angle.10,11 corresponding to a diagnosis of pars planitis were reviewed Much of the grading of anterior chamber cell and vitre- for inclusion in this study. Included patients met the ous chamber cell was performed prior to publication of the following criteria: (1) presence of intraocular inflammation Standardization of Uveitis Nomenclature’s (SUN) publica- in the vitreous in at least 1 eye; (2) presence of inflamma- tion of their standardized grading schema.1 However, the tory vitreous debris with snowbanks on the pars plana of the grading used appears to correspond reasonably well with inflamed eye; and (3) a follow-up ophthalmic evaluation the SUN schema. The early grading used a 1 3 1mm performed at least 3 months after the diagnosis of pars beam on the brightest illumination on slit-lamp bio- planitis. Exclusion criteria included (1) serologic evidence microscopy and had the following
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