Final Vitrectomy gray group

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Final Vitrectomy gray group

  1. 1. UVEITIS & VITRECTOMY
  2. 2. Case Background (HPI) <ul><li>A 39-year-old woman with a 10 year history of bilateral uveitis, myopia, and hypercholesterolemia complains of complete vision loss in the right eye that developed progressively over a period of 5 days . </li></ul>ECM III-IV/ Color Group: Grey/ Fall 2009
  3. 3. Case background (S/S, PMH) <ul><li>Associated symptoms </li></ul><ul><li>Swollen right optic nerve </li></ul><ul><li>No pain </li></ul><ul><li>No headaches </li></ul><ul><li>No vertigo </li></ul><ul><li>No paralysis </li></ul><ul><li>No parasthesias </li></ul><ul><li>Pertinent PMH </li></ul><ul><li>No head trauma </li></ul><ul><li>No neurological disease </li></ul><ul><li>No diabetes </li></ul><ul><li>No major systemic infections </li></ul><ul><li>FHx: diabetes in both parents, cataracts in father, no neurological disease </li></ul>ECM III-IV/ Color Group: Grey/ Fall 2009
  4. 4. Case background (Rx) <ul><li>Medications (for uveitis only) </li></ul><ul><li>Humira: biweekly injections </li></ul><ul><ul><li>TNF inhibitor for downregulating inflammation </li></ul></ul><ul><li>Durezol </li></ul><ul><ul><li>Steroid eye drops </li></ul></ul><ul><li>Timolol </li></ul><ul><ul><li>Steroid eye drops </li></ul></ul>ECM III-IV/ Color Group: Grey/ Fall 2009
  5. 5. Uveitis & Vitrectomy <ul><li>Uveitis </li></ul><ul><ul><li>Swelling and irritation of the uvea (middle layer of eye, provides blood supply to retina) </li></ul></ul><ul><ul><li>S/S: redness, blurred vision, floaters, pain, photophobia </li></ul></ul><ul><li>Pars Plana Vitrectomy </li></ul><ul><ul><li>Microsurgical procedure </li></ul></ul><ul><ul><li>Removes vitreous gel from uvea </li></ul></ul><ul><ul><li>Replaced with silicone oil or gas </li></ul></ul><ul><ul><li>Aims to improve vision </li></ul></ul>ECM III-IV/ Color Group: Grey/ Fall 2009
  6. 6. Search strategy <ul><li>Pubmed- http://www.ncbi.nlm.nih.gov/pubmed/ </li></ul><ul><li>Search term: “uveitis” </li></ul><ul><li>Limits </li></ul><ul><ul><li>Humans </li></ul></ul><ul><ul><li>Meta-analysis </li></ul></ul><ul><ul><li>English </li></ul></ul><ul><ul><li>Adult: 19-44 years </li></ul></ul><ul><li>Results: 2 articles </li></ul>ECM III-IV/ Color Group: Grey/ Fall 2009
  7. 7. Clinical Question <ul><li>Does Pars Plana Vitrectomy (PPV)  improve vision acuity and reduce inflammation among patients with uveitis? </li></ul>ECM III-IV/ Color Group: Grey/ Fall 2009
  8. 8. Study Description <ul><li>Study: </li></ul><ul><ul><li>Becker, Matthias, and Janet Davis. “Vitrectomy in the Treatment of Uveitis.” American Journal of Opthalmology 140.6 (2005): 1096-1105. Web. 16 Oct. 2009 </li></ul></ul><ul><li>Review of the literature </li></ul><ul><li>Assesses whether vitrectomy improves vision, reduces disease, or ameliorates cystoid macular edema in patients with uveitis. </li></ul>ECM III-IV/ Color Group: Grey/ Fall 2009
  9. 9. Methods – Population <ul><li>Population </li></ul><ul><ul><li>44 articles reviewed (published 1981-2005) </li></ul></ul><ul><ul><li>1575 uveitis pts, 1762 vitrectomized eyes </li></ul></ul><ul><ul><li>Av. Age: 36 y.o. (11-70) </li></ul></ul><ul><ul><li>Preop duration: 48 months (6-118) </li></ul></ul><ul><ul><li>Dx of interm uveitis: 841 eyes </li></ul></ul>ECM III-IV/ Color Group: Grey/ Fall 2009
  10. 10. Methods – Intervention & Control <ul><li>Intervention </li></ul><ul><ul><li>Medline search: “vitrectomy AND uveitis AND NOT endophthalmitis” </li></ul></ul><ul><ul><li>Inclusion/Exclusion criteria </li></ul></ul><ul><ul><li>Data analysis in Excel </li></ul></ul><ul><ul><li>Median values used </li></ul></ul><ul><li>Comparison/Control </li></ul><ul><ul><li>Meta-analysis: not possible </li></ul></ul>ECM III-IV/ Color Group: Grey/ Fall 2009 VITRECTOMY IMMUNOSUPPRESSIVE TX CORTICOSTEROIDS
  11. 11. Methods - Outcome <ul><li>Outcome </li></ul><ul><ul><li>Improvement of visual acuity </li></ul></ul><ul><ul><li>Reduction in medication </li></ul></ul><ul><ul><li>Reduction in inflammation </li></ul></ul><ul><ul><li>Quality of evidence: CII-3 </li></ul></ul><ul><ul><li>Vitrectomy possibly relevant – suggestive, not conclusive </li></ul></ul><ul><ul><li>Recommendation: better evidence required to establish causality </li></ul></ul>ECM III-IV/ Color Group: Grey/ Fall 2009
  12. 12. Internal Validity Assessment <ul><li>Low internal validity </li></ul><ul><li>Threats to internal validity: </li></ul><ul><ul><li>Irregular follow up </li></ul></ul><ul><ul><li>Poor records of concomitant therapies </li></ul></ul><ul><ul><li>Heterogeneous diagnoses studied together </li></ul></ul><ul><ul><li>Measurements differ </li></ul></ul><ul><ul><li>Selection bias </li></ul></ul><ul><ul><li>Confounding bias </li></ul></ul><ul><ul><li>Historical bias </li></ul></ul><ul><ul><li>Instrument/technology bias </li></ul></ul><ul><ul><li>Experimenter bias </li></ul></ul>ECM III-IV/ Color Group: Grey/ Fall 2009 CONCLUSION Unable to establish correlation between intervention (PPV) and outcome (improved vision, reduced inflammation)
  13. 13. Importance/ Relevance <ul><li>Pars Plana vitrectomy MAY improve vision and reduce systemic medication use in uveitis patients </li></ul><ul><li>Therapy could be promising </li></ul><ul><li>Further investigation is necessary </li></ul>ECM III-IV/ Color Group: Grey/ Fall 2009
  14. 14. External Validity ECM III-IV/ Color Group: Grey/ Fall 2009 Is this study generalizable to our patient? Yes! Note: most patients in the study had intermediate uveitis, therefore the study is most generalizable to patients with this form of the disease Study Our Patient Age Average: 36 y.o. 39 y.o. Duration of uveitis Median: 48 months (range= 6 months-10 yrs) 10 years Pre-operative therapy Coricosteroids (80%) Immunosuppress. (30%) Corticosteroids immunosuppresants
  15. 15. Summary of Results <ul><li>Outcomes </li></ul><ul><li>Visual outcomes (39/44 articles) </li></ul><ul><ul><li>68% improvement </li></ul></ul><ul><ul><li>20% unchanged </li></ul></ul><ul><ul><li>12% worsened </li></ul></ul><ul><li>Reduction in systemic medication </li></ul><ul><ul><li>(25/44 studies) </li></ul></ul><ul><li>Reduction in inflammation post-operatively </li></ul><ul><ul><li>(18/41 articles) </li></ul></ul>ECM III-IV/ Color Group: Grey/ Fall 2009
  16. 16. Summary of Results (Continued) <ul><li>Methodological weaknesses </li></ul><ul><li>No RCTs  no meta-analysis </li></ul><ul><li>Case selection bias </li></ul><ul><li>Irregular follow-up </li></ul><ul><li>Lack of controls </li></ul><ul><li>Small numbers of patients </li></ul>ECM III-IV/ Color Group: Grey/ Fall 2009
  17. 17. Summary of Results (Continued) <ul><li>The Value of Vitrectomy </li></ul><ul><li>Despite weaknesses, 41/44 authors recommended vitrectomy for uveitis therapy </li></ul><ul><li>Well-designed, randomized studies would be useful for further analysis </li></ul>ECM III-IV/ Color Group: Grey/ Fall 2009
  18. 18. Conclusion <ul><li>Vitrectomy MAY be useful for uveitis </li></ul><ul><li>Methodological weaknesses necessitate further investigation </li></ul><ul><li>Further study and analysis is required before recommending therapy to patients </li></ul>ECM III-IV/ Color Group: Grey/ Fall 2009
  19. 19. Questions? ECM III-IV/ Color Group: Grey/ Fall 2009

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