Professional Documents
Culture Documents
Uveitis 1 PDF
Uveitis 1 PDF
Purpose: To assess the visual outcomes of cataract surgery in eyes that received fluocinolone acetonide
implant or systemic therapy with oral corticosteroids and immunosuppression during the Multicenter Uveitis
Steroid Treatment (MUST) Trial.
Design: Nested prospective cohort study of patients enrolled in a randomized clinical trial.
Participants: Patients that underwent cataract surgery during the first 2 years of follow-up in the MUST Trial.
Methods: Visual outcomes of cataract surgery were evaluated 3, 6, and 9 months after surgery using log-
arithmic visual acuity charts. Change in visual acuity over time was assessed using a mixed-effects model.
Main Outcome Measures: Best-corrected visual acuity.
Results: After excluding eyes that underwent cataract surgery simultaneously with implant surgery, among
the 479 eyes in the MUST Trial, 117 eyes (28 eyes in the systemic, 89 in the implant group) in 82 patients un-
derwent cataract surgery during the first 2 years of follow-up. Overall, visual acuity increased by 23 letters from
the preoperative visit to the 3-month visit (95% confidence interval [CI], 17e29 letters; P < 0.001) and was stable
through 9 months of follow-up. Eyes presumed to have a more severe cataract, as measured by inability to grade
vitreous haze, gained an additional 42 letters (95% CI, 34e56 letters; P < 0.001) beyond the 13-letter gain in eyes
that had gradable vitreous haze before surgery (95% CI, 9e18 letters; P < 0.001) 3 months after surgery, making
up for an initial difference of 45 letters at the preoperative visit (95% CI, 56 to 34 letters; P < 0.001). Black
race, longer time from uveitis onset, and hypotony were associated with worse preoperative visual acuity (P <
0.05), but did not affect postsurgical recovery (P > 0.05, test of interaction). After adjusting for other risk factors,
there was no significant difference in the improvement in visual acuity between the 2 treatment groups (implant
vs. systemic therapy, 2 letters; 95% CI, 10 to 15 letters; P ¼ 0.70).
Conclusions: Cataract surgery resulted in substantial, sustained, and similar visual acuity improvement in
the eyes of patients with uveitis treated with the fluocinolone acetonide implant or standard systemic
therapy. Ophthalmology 2016;123:183-190 ª 2016 Published by Elsevier on behalf of the American Academy of
Ophthalmology.
Cataract is a common complication of uveitis. It can result prospective study showed that eyes with active
from inflammation as part of the disease process or from the inflammation within 3 months before cataract surgery
corticosteroids used to treat the inflammation. Cataract were more likely to have postoperative macular edema
surgery in the setting of uveitis differs from senile cataract and that a short perioperative course of oral
and can pose additional challenges and risks.1,2 Although corticosteroids, started 2 days before surgery, significantly
the outcomes of cataract surgery in uveitic eyes are not as reduced the incidence of postoperative macular edema.6
well studied as those in nonuveitic eyes, most studies sug- Hence, preoperative addition or increase in systemic
gest poorer visual outcomes and more postoperative com- therapy, mainly corticosteroids, has become a standard
plications among patients with uveitis. Furthermore, many approach in cataract surgery for uveitic eyes.
of these studies are weighted toward the results of cataract An alternative approach to systemic therapy for treating
surgery in patients with anterior uveitides.2e6 intermediate uveitis, posterior uveitis, and panuveitis is the
Preoperative control of inflammation is crucial for cata- fluocinolone acetonide implant (Retisert; Bausch & Lomb,
ract surgery in uveitic eyes. A systematic review of the Rochester, NY), which is designed to provide sustained,
literature showed that eyes with controlled inflammation at steady-state levels of corticosteroids directly to the eye for
the time of cataract surgery had better visual outcomes.3 A up to 3 years. In the Multicenter Uveitis Steroid Treatment
2016 Published by Elsevier on behalf of the American Academy of Ophthalmology http://dx.doi.org/10.1016/j.ophtha.2015.09.022 183
ISSN 0161-6420/15
Downloaded for hendsun Goh (hendsunh@ymail.com) at Universitas Tarumanagara from ClinicalKey.com by Elsevier on July 31, 2018.
For personal use only. No other uses without permission. Copyright ©2018. Elsevier Inc. All rights reserved.
Ophthalmology Volume 123, Number 1, January 2016
Outcomes
The primary outcome of the current study was best-corrected visual
acuity, measured using logarithmic visual acuity charts8,9 accord-
ing to a standardized protocol. Secondary outcomes included bi-
nary categorizations of visual acuity patterns. The change from the
preoperative to the first available postoperative visit was defined in
2 ways. For the purposes of this study, we considered a 5-letter
improvement or more or a visual acuity outcome of 20/40 or
better to be clinically meaningful. We first calculated the propor-
tion of eyes with an improvement based on the number of letters (5
or 10 letters of improvement), and then the proportion of eyes that
Figure 1. Flowchart showing the selection of uveitic eyes with cataract improved to 20/40 or better at the first postoperative visit was
surgery during the Multicenter Steroid Treatment Trial for inclusion in analyzed. The proportion of eyes with visual acuity of 20/40 or
analysis. VA ¼ visual acuity. better at the first postoperative visit also was considered.
184
Downloaded for hendsun Goh (hendsunh@ymail.com) at Universitas Tarumanagara from ClinicalKey.com by Elsevier on July 31, 2018.
For personal use only. No other uses without permission. Copyright ©2018. Elsevier Inc. All rights reserved.
Sen et al
Cataract Surgery Outcomes in Uveitis
Table 1. Characteristics of Patients and Eyes Undergoing Cataract Surgery in the Multicenter Uveitis Steroid Treatment Trial
Treatment Group
Overall Systemic Implant P Value*
Patient characteristics
Participants, no. (%) 82 22 (27) 60 (73)
Demographics
Age at preoperative visit (yrs), median (IQR) 46 (31e53) 53 (38e58) 44 (31e51) 0.20
Male gender, no. (%) 27 (33) 5 (23) 22 (37) 0.29
Black race, no. (%) 15 (18) 3 (14) 12 (20) 0.75
Clinical characteristics at the time of randomization in the MUST Trial
Posterior uveitis or panuveitis, no. (%) 52 (63) 12 (55) 40 (67) 0.44
Systemic disease, no. (%) 22 (27) 4 (18) 18 (30) 0.40
Eye characteristics
Eligible eyes, no. (%) 117 28 (24) 89 (76)
Time since uveitis onset at the preoperative visit (yrs),z median (IQR)y 2 (1e5) 1 (0e3) 2 (1e5) 0.18z
Preoperative visual acuity (standard letters), no. (%)
Median (IQR) 56 (25e69) 43 (5e59) 60 (38e72) 0.09
20/40 or better 29 (25) 5 (18) 24 (27) 0.33
Worse than 20/100 50 (43) 18 (64) 32 (36) 0.031
20/200 or worse 33 (28) 12 (43) 21 (24) 0.09
Preoperative vitreous haze ungradable, no. (%) 26 (22) 12 (43) 14 (16) 0.003
Preoperative intraocular pressure (mmHg), no. (%)y
Median (IQR) 18 (14e23) 16 (13e20) 18 (15e24) 0.037
7 5 (4) 3 (11) 2 (2)
8e23 84 (72) 21 (75) 63 (72)
24e29 19 (16) 2 (7) 17 (19)
30 8 (7) 2 (7) 6 (7)
IQR ¼ interquartile range (i.e. the 25th to 75th percentile); MUST ¼ Multicenter Uveitis Steroid Treatment.
*Unless otherwise specified, P values compare the distribution of all primary categories excluding missing values.
y
Missing values: 1 preoperative intraocular pressure observation missing (1%) from implant group, and 2 observations missing time since uveitis at
the preoperative visit in the implant group (2%).
z
Based on a log transformation of time since uveitis onset at the preoperative visit.
therapy. Two eyes receiving systemic therapy and 15 of those (3%) were left aphakic. There was no difference by treatment
receiving implant therapy originally were randomized to receive group. In the implant group, 86 eyes (97%) had an intraocular lens
the other treatment. The most common reasons for exclusion placed, and in the systemic therapy group, 27 eyes (96%) had an
included aphakia or pseudophakia at enrollment (n ¼ 202 eyes), intraocular lens placed (P ¼ 0.91).
no surgery during follow-up (n ¼ 113), or concurrent cataract Overall, visual acuity improved by 23 letters (95% confidence
and implant surgery (n ¼ 22). interval [CI], 18e29 letters; P < 0.001) from the preoperative visit
Demographic characteristics at the preoperative visit were to the 3-month postoperative visit. The visual acuity was stable
similar between treatment groups, with 33% of patients being men, thereafter with an additional 2 letters at 6 months (95% CI, 0 to 4
18% of patients being black, and a median age of 46 years overall letters; P ¼ 0.05) that vanished by 9 months (P ¼ 0.62). This
(Table 1). Fifty-two patients (63%) had posterior uveitis or pan- pattern of improvement at 3 months that remained stable through 9
uveitis, with a nonsignificantly higher proportion in the implant months was seen in both treatment groups (Fig 2). The point
group (67%) compared with the systemic group (55%). Preopera- estimate of improvement was larger for eyes receiving systemic
tive visit visual acuities for eyes in the implant group were better therapy (29 letters; 95% CI, 17e43 letters; P < 0.001) as
than those in the systemic therapy group (median, 60 vs. 43 letters, compared with eyes receiving implant therapy (21 letters; 95%
respectively; P ¼ 0.090), but this difference did not achieve con- CI, 16e27 letters; P < 0.001). However, the difference between
ventional statistical significance. However, the proportion of eyes the groups in visual improvement was not statistically significant
with visual acuity worse than 20/100 was significantly higher in (mean, 9 letters for implant vs. systemic therapy; 95% CI, 23
the systemic group than in the implant group (64% vs. 36%, to 6 letters; P ¼ 0.24).
respectively; P ¼ 0.031). Time since uveitis onset (or duration of In the multivariate model, a number of factors were associated
uveitis) was similar between the 2 treatment groups, with an with worse visual acuity at the preoperative visit (Table 2). Eyes
overall median of 2 years (interquartile range, 1e5 years). The that had ungradable preoperative vitreous haze had a
proportion of eyes with ungradable vitreous haze at the preop- preoperative visual acuity that was 45 letters worse (45 letters)
erative visit was significantly higher in the systemic treatment than in eyes that were gradable (95% CI, 56 to 34 letters; P
group (43% vs. 16%; P ¼ 0.003; Table 1). Preoperative < 0.0001); eyes of black patients had a preoperative visual
intraocular pressure was within the normal range in both acuity that was 12 letters worse than those of nonblack patients
groups, but the median was 2-mmHg higher for eyes in (95% CI, 22 to 2 letters; P ¼ 0.021), and preoperative
the implant group, a magnitude that was statistically significant hypotony (intraocular pressure, 7 mmHg) was associated with
(P ¼ 0.037), but not clinically meaningful. a visual acuity of 8 letters worse as compared with eyes with
Cataract surgery included intraocular lens placement in the normal intraocular pressure (8e23 mmHg). For each decade
overwhelming majority of eyes (113 eyes [97%]); the other 4 eyes since uveitis diagnosis, there was a 4.7-letter worse preoperative
185
Downloaded for hendsun Goh (hendsunh@ymail.com) at Universitas Tarumanagara from ClinicalKey.com by Elsevier on July 31, 2018.
For personal use only. No other uses without permission. Copyright ©2018. Elsevier Inc. All rights reserved.
Ophthalmology Volume 123, Number 1, January 2016
Discussion
Figure 2. Mean visual acuity over time for eyes with cataract surgery Cataract is among the most common structural complica-
during the Multicenter Steroid Treatment Trial stratified by treatment tions of uveitis and its treatment with corticosteroids, and
(implant [grey] vs. systemic [black] therapy). The 95% confidence intervals cataract surgery is among the most common surgical pro-
are included for each treatment group at each interval. cedures performed on patients with uveitis. Several studies
have reported that substantial visual gain occurs in most
visual acuity (95% CI, 9 to 0.4 letters; P ¼ 0.033). After uveitic eyes after cataract surgery.2e4,10e14 Although cata-
adjusting for other risk factors, there was no significant difference ract is a well-recognized occurrence with the fluocinolone
in the preoperative visual acuity for the 2 treatment groups (implant acetonide implant and cataract surgery is needed in more
vs. systemic therapy: median, 6 letters; 95% CI, 4 to 15 letters; than 90% of eyes by 3 years after implantation,15 the MUST
P ¼ 0.22). Trial provided the first opportunity to compare the outcomes
Only the ability to grade preoperative vitreous haze was asso- of cataract surgery in eyes with the implant with those of
ciated significantly with the amount of improvement in visual patients treated with systemic therapy. The current study
acuity after cataract surgery (Table 2). For eyes with gradable showed statistically significant, clinically meaningful, and
vitreous haze, visual acuity improved by a mean of 13 letters sustained (for up to 9 months after surgery) improvement
from the preoperative visit to the 3-month postoperative visit
in visual acuity of similar magnitude after cataract surgery
(95% CI, 9e18 letters; P < 0.001) and showed a significant
additional gain at 6 months (mean, 3 letters; 95% CI, 1e4 letters; in both eyes treated with systemic therapy and those
P ¼ 0.001) that had vanished by 9 months (P ¼ 0.52). Eyes that treated with the fluocinolone acetonide implant. Overall,
were not gradable for vitreous haze at the preoperative visit had an 62% of eyes achieved a visual acuity of 20/40 or better
additional mean improvement of 42 letters (95% CI, 35 to 56 after surgery. This success proportion is lower than that
letters; P < 0.001) from the preoperative visit to the 3-month reported for uncomplicated cataract surgery in the general
postoperative visit beyond that observed with gradable vitreous public (96%),16 but similar to that reported in other
haze, for a mean total improvement of 55 letters. The difference in studies of uveitic cataract surgery.3
improvement was such that eyes with preoperative ungradable In a meta-analysis of the outcomes of cataract surgery,
vitreous haze had postoperative visual acuities that were not sta- Mehta et al3 estimated that the overall percent of eyes with
tistically or clinically significantly different from those with grad-
uveitis achieving 20/40 or better postoperative visual acuity
able preoperative vitreous haze (mean, 3 letters; 95% CI, 12 to
7 letters; P ¼ 0.55). After adjusting for other risk factors, there was was 68% and that anterior approaches, intraocular lens
no significant difference in the improvement in visual acuity be- placement, nonsilicone lenses, and operating on eyes with
tween the 2 treatment groups (implant vs. systemic therapy: mean, inactive uveitis were associated with better outcomes.
2 letters; 95% CI, 10 to 15 letters; P ¼ 0.70). Uveitis class was not evaluated systematically, but Fuchs
Overall, most eyes improved by a clinically meaningful amount heterochromic uveitis seemed to respond better than other
between the preoperative and first postoperative visit (Table 3). types of uveitis; intermediate uveitis seemed to have a
Ninety-two eyes (79%) had an improvement of 5 letters or more similar success rate to the overall rate; and the one
and 77 eyes (67%) had an improvement of 10 letters or more. In panuveitis evaluated, Behçet’s disease, had worse
fact, 72 eyes (62%) had a postoperative visual acuity of 20/40 or outcomes. In this regard, there was a suggestion from our
better, including 45 eyes (63%) that improved from worse than 20/
40 to 20/40 or better, all of whom had at least a 5-letter gain. Very
data that posterior uveitis and panuveitis may show a
few eyes experienced a 5-letter or more decline in visual acuity; 5 worse response than intermediate uveitis. Such a result
eyes (4%) had a decline of 5 letters or more and only 3 eyes (3%) would not be surprising because patients with posterior
had a decline of 10 letters or more. uveitis are more likely to encounter permanent structural
Similar to what was seen in the analysis of mean change in damage that may limit visual improvement. Because the
visual acuity, eyes with ungradable vitreous haze at the MUST Trial enrolled patients with only intermediate
186
Downloaded for hendsun Goh (hendsunh@ymail.com) at Universitas Tarumanagara from ClinicalKey.com by Elsevier on July 31, 2018.
For personal use only. No other uses without permission. Copyright ©2018. Elsevier Inc. All rights reserved.
Sen et al
Cataract Surgery Outcomes in Uveitis
Table 2. Adjusted* Risk Factors Affecting Visual Acuity at the Preoperative Visit and Affecting the Preoperative to Postoperative Visit
Change in Visual Acuity in the Multicenter Uveitis Steroid Treatment Trial
uveitis, posterior uveitis, or panuveitis, its results ay not be that eyes undergoing cataract surgery after the implantation
comparable directly with those of series including eyes with had a better visual acuity gain and less postoperative
anterior uveitis. Nevertheless, the proportion of eyes with a inflammation than the fellow eyes, which were untreated or
postoperative visual acuity of 20/40 or better in the MUST managed with regional corticosteroid injections.15 No details
Trial is on the same order as that in the meta-analysis. were given in this article about the duration of inactive
The level of vision before cataract surgery differed be- disease or preoperative regimens in the nonimplant group,
tween the 2 treatment groups, and it was likely that eyes in the whereas given the duration of effect of the implant, these
systemic group had worse cataracts at the time of surgery. eyes were receiving preoperative corticosteroid therapy
Eyes receiving systemic therapy were significantly more comparable with that resulting from systemic therapy. In this
likely to have a preoperative visual acuity worse than 20/100 regard, the MUST results suggest that eyes with intermediate
and, assuming that inability to grade the vitreous haze is a uveitis, posterior uveitis, or panuveitis will have similar
marker for denser cataract, worse cataracts. Reasons for this postoperative visual improvement whether the eye has been
difference are unknown, but it is possible that ophthalmolo- treated with an implant or with systemic therapy.
gists were likely to operate sooner on eyes treated with Although black patients and eyes with hypotony were
implant therapy because cataract surgery is an expected and associated with poorer preoperative visual acuity, they were
nearly universal complication of implant therapy.7,15,17 It is not associated with any worse likelihood of visual
also possible that eyes with more severe cataracts in the improvement after cataract surgery. The risk factors that
implant group had simultaneous cataract and implant surgery were associated with lower preoperative visual acuity (black
and were excluded from this study. Nevertheless, there was no race, disease duration, hypotony) are known risk factors for
significant difference in the visual improvement between the 2 poorer visual acuity in eyes with uveitis.18e20 Longer dis-
treatment groups, even after adjusting for other risk factors. ease duration is known to be associated with poorer out-
Sheppard et al17 evaluated cataract outcomes in uveitic eyes comes and more structural complications,18,21,22 and
that received the fluocinolone acetonide implant and compared hypotony, which likely is reflective of the chronicity and
them with those of fellow, nonimplanted eyes. They reported severity of the underlying disease, has been associated with
187
Downloaded for hendsun Goh (hendsunh@ymail.com) at Universitas Tarumanagara from ClinicalKey.com by Elsevier on July 31, 2018.
For personal use only. No other uses without permission. Copyright ©2018. Elsevier Inc. All rights reserved.
Ophthalmology Volume 123, Number 1, January 2016
Table 3. Risk Factors for Visual Acuity Improvement in Eyes Undergoing Cataract Surgery in the Multicenter Uveitis Steroid Treatment
Trial
Postoperative Visual
‡5-Letter Improvement ‡10-Letter Improvement Acuity 20/40 or Better
(n [ 117) (n [ 115)* (n [ 117)
95% Confidence 95% Confidence P Odds 95% Confidence P
Odds Ratio Interval P Value Odds Ratio Interval Value Ratio Interval Value
Patient characteristics
Demographics
Age at preoperative visit (yrs) 1.0 0.9e1.1 0.47 1.0 0.9e1.1 0.19 1.0 0.9e1.1 0.13
Gender
Female Ref Ref Ref
Male 1.2 0.4e3.1 0.76 0.9 0.4e2.1 0.79 1.7 0.7e4.1 0.24
Race
Nonblack Ref Ref Ref
Black 0.9 0.3e2.8 0.82 1.3 0.4e4.0 0.59 0.7 0.3e2.1 0.57
Clinical characteristics at the time
of randomization in the MUST Trial
Uveitis class
Intermediate uveitis Ref Ref Ref
Posterior uveitis or panuveitis 0.3 0.1e1.1 0.06 0.4 0.2e1.1 0.07 1.0 0.4e2.4 0.98
Systemic disease
No Ref Ref
Yes 1.0 0.3e2.8 0.96 1.0 0.4e2.6 0.97 1.6 0.6e4.1 0.34
Eye characteristics
Treatment
Systemic Ref Ref Ref
Implant 1.4 0.5e4.0 0.49 1.0 0.5e2.5 0.99 1.36 0.6e3.3 0.49
Time from uveitis onset at preoperative 1.0 0.9e1.1 0.96 1.0 0.9e1.1 0.91 1.0 0.9e1.1 0.36
visit (yrs), centered at 2 yrs
Preoperative intraocular pressure (mmHg)
7 1.3 0.1e14.2 0.80 2.3 0.2e22.4 0.47 0.2 0.0e1.3 0.09
8e23 Ref Ref Ref
24e29 1.4 0.4e5.4 0.62 1.5 0.5e4.6 0.51 1.1 0.4e3.3 0.80
30 0.7 0.1e4.0 0.74 1.2 0.2e6.3 0.86 0.9 0.2e4.2 0.93
Preoperative vitreous haze
Gradable Ref Ref Ref
Ungradable 3.7 0.8e16.7 0.08 7.9 1.8e35.1 0.007 1.7 1.1e2.7 0.03
poorer visual acuity in patients with uveitis.19,21,22 Although with worse outcomes and evidenced by more macular
these factors were associated with poorer overall vision, edema. Unfortunately, the follow-up schedule and visit win-
none of them had an impact on improvement in visual acuity dows in this study (in which the preoperative visit could be as
after surgery (P > 0.05, test of interaction). The only much as 6 months before surgery) precluded the evaluation of
characteristic associated with better gains in vision after the effect of inactive uveitis in the 3 months before surgery.
surgery was ungradable vitreous haze before surgery. As Similarly, the surgical data collection did not include infor-
noted above, it is likely that ungradable vitreous haze before mation on the use of perioperative oral corticosteroids.
surgery was a marker for denser and worse cataract, Our study is limited by the relatively small number of
resulting in worse visual acuity before surgery and bigger eyes in the systemic treatment group. We were unable to
gains in acuity at the postoperative visits. measure the severity of cataract directly and instead used a
The typical recommendation is to defer cataract surgery in surrogate (inability to grade vitreous haze) to attempt to
uveitic eyes until the uveitis has been inactive for a minimum account for the impact of severity. The large majority of
of 3 months before surgery and to pretreat patients with sys- eyes showed an improvement in visual acuity, which limited
temic corticosteroids briefly before cataract surgery and for a our ability to perform multivariate analyses of risk factors
short time after surgery. A systematic review and meta-analysis related to visual acuity threshold. Nearly all eyes had
of the literature found that active uveitis at the time of cataract placement of an intraocular lens, limiting any power to
surgery was associated with poorer outcomes. A prospective evaluate the effect of aphakia. Finally, the small number of
study of cataract surgery6 demonstrated that active uveitis eyes with a decline made it impossible to evaluate for risk
within 3 months before cataract surgery and failure to use factors related to decline. Nevertheless, our study suggested
perioperative systemic corticosteroids each were associated that patients with intermediate uveitis, posterior uveitis, or
188
Downloaded for hendsun Goh (hendsunh@ymail.com) at Universitas Tarumanagara from ClinicalKey.com by Elsevier on July 31, 2018.
For personal use only. No other uses without permission. Copyright ©2018. Elsevier Inc. All rights reserved.
Sen et al
Cataract Surgery Outcomes in Uveitis
panuveitis show similar improvements in visual acuity after 11. Ram J, Gupta A, Kumar S, et al. Phacoemulsification with
cataract surgery, regardless whether the uveitis was treated intraocular lens implantation in patients with uveitis. J Cataract
with the fluocinolone acetonide implant or with systemic Refract Surg 2010;36:1283–8.
therapy with oral corticosteroids and immunosuppression. 12. Okhravi N, Lightman SL, Towler HM. Assessment of visual
outcome after cataract surgery in patients with uveitis.
Ophthalmology 1999;106:710–22.
References 13. Estafanous MF, Lowder CY, Meisler DM, Chauhan R.
Phacoemulsification cataract extraction and posterior chamber
lens implantation in patients with uveitis. Am J Ophthalmol
1. Jancevski M, Foster CS. Cataracts and uveitis. Curr Opin 2001;131:620–5.
Ophthalmol 2010;21:10–4. 14. Ganesh SK, Babu K, Biswas J. Phacoemulsification with
2. Van Gelder RN, Leveque TK. Cataract surgery in the setting intraocular lens implantation in cases of pars planitis.
of uveitis. Curr Opin Ophthalmol 2009;20:42–5. J Cataract Refract Surg 2004;30:2072–6.
3. Mehta S, Linton MM, Kempen JH. Outcomes of cataract 15. Callanan DG, Jaffe GJ, Martin DF, et al. Treatment of poste-
surgery in patients with uveitis: a systematic review and meta- rior uveitis with a fluocinolone acetonide implant: three-year
analysis. Am J Ophthalmol 2014;158:676–92. clinical trial results. Arch Ophthalmol 2008;1261191–201.
4. Foster CS, Rashid S. Management of coincident cataract and 16. Powe NR, Schein OD, Gieser SC, et al. Synthesis of the
uveitis. Curr Opin Ophthalmol 2003;14:1–6. literature on visual acuity and complications following
5. Meier FM, Tuft SJ, Pavesio CE. Cataract surgery in uveitis. cataract extraction with intraocular lens implantation. Cata-
Ophthalmol Clin North Am 2002;15:365–73. ract Patient Outcome Research Team. Arch Ophthalmol
6. Bélair ML, Kim SJ, Thorne JE, et al. Incidence of cystoid 1994;112:239–52.
macular edema after cataract surgery in patients with and 17. Sheppard JD Jr, Nguyen QD, Usner DW, Comstock TL. Post-
without uveitis using optical coherence tomography. Am J cataract outcomes in patients with noninfectious posterior
Ophthalmol 2009;148:128–35. uveitis treated with the fluocinolone acetonide intravitreal
7. Multicenter Uveitis Steroid Treatment (MUST) Trial Research implant. Clin Ophthalmol 2012;6:79–85.
Group, Kempen JH, Altaweel MM, Holbrook JT, et al. Ran- 18. Dana MR, Merayo-Lloves J, Schaumberg DA, Foster CS.
domized comparison of systemic anti-inflammatory therapy Prognosticators for visual outcome in sarcoid uveitis.
versus fluocinolone acetonide implant for intermediate, pos- Ophthalmology 1996;103:1846–53.
terior, and panuveitis: the multicenter uveitis steroid treatment 19. Sen HN, Vitale S, Gangaputra SS, et al. Periocular cortico-
trial. Ophthalmology 2011;118:1916–26. steroid injections in uveitis: effects and complications.
8. Multicenter Uveitis Steroid Treatment Trial Research Group, Ophthalmology 2014;121:2275–86.
Kempen JH, Altaweel MM, Holbrook JT, et al. The Multi- 20. Maini R, O’Sullivan J, Reddy A, et al. The risk of complica-
center Uveitis Steroid Treatment Trial: rationale, design, and tions of uveitis in a district hospital cohort. Br J Ophthalmol
baseline characteristics. Am J Ophthalmol 2010;149:550–61. 2004;88:512–7.
9. Ferris FL III, Bailey I. Standardizing the measurement of visual 21. Sen HN, Drye LT, Goldstein DA, et al; for the Multicenter
acuity for clinical research studies: guidelines from the Eye Care Uveitis Steroid Treatment (MUST) Trial Research Group.
Technology Forum. Ophthalmology 1996;103:181–2. Hypotony in patients with uveitis: the Multicenter Uveitis
10. Tomlins PJ, Sivaraj RR, Rauz S, et al. Long-term biocom- Steroid Treatment (MUST) trial. Ocul Immunol Inflamm
patibility and visual outcomes of a hydrophilic acrylic intra- 2012;20:104–12.
ocular lens in patients with uveitis. J Cataract Refract Surg 22. Daniel E, Pistilli M, Pujari SS, et al. Risk of hypotony in
2014;40:618–25. noninfectious uveitis. Ophthalmology 2012;119:2377–85.
189
Downloaded for hendsun Goh (hendsunh@ymail.com) at Universitas Tarumanagara from ClinicalKey.com by Elsevier on July 31, 2018.
For personal use only. No other uses without permission. Copyright ©2018. Elsevier Inc. All rights reserved.
Ophthalmology Volume 123, Number 1, January 2016
MD). Bausch & Lomb (Rochester, NY) provided support to the study in the Author Contributions:
form of donation of fluocinolone implants for patients randomized to Conception and design: Kempen, Jabs, Abreu, Louis, Sugar, Sen
implant therapy who were uninsured or otherwise unable to pay for im-
Analysis and interpretation: Kempen, Jabs, Abreu, Louis, Sugar, Sen
plants, or who were located at a site where implants could not be purchased
(e.g., the United Kingdom). Additional support was provided by Research Data collection: Sen, Abreu, Louis, Sugar, Altaweel, Elner, Holbrook, Jabs,
Kim, Kempen
to Prevent Blindness, Inc., New York, NY; the Paul and Evanina Mackall
Foundation (Chicago, IL); and the Lois Pope Life Foundation (Delray Obtained funding: none
Beach, FL). A representative of the National Eye Institute participated in Overall responsibility: Kempen, Jabs, Sen
the conduct of the study, including the study design; collection, manage- Abbreviations and Acronyms:
ment, analysis, and interpretation of the data; and review and approval of CI ¼ confidence interval; IQR ¼ Interquartile range; MUST ¼ Multicenter
this manuscript. The sponsor or funding organization had no role in the
Uveitis Steroid Treatment; OR ¼ odds ratio.
design or conduct of this research.
Correspondence:
H. Nida Sen, MD, MHS, National Eye Institute, National Institutes of
Health, 10 Center Drive, 10N109, Bethesda, MD 20892. E-mail: senh@nei.
nih.gov.
MARIA E. RODRIGUEZ, MD
CHRISTOPHER K. BURRIS, MD
NOAH B. SAIPE, MD
Department of Ophthalmology and Visual Sciences, University of
Wisconsin e Madison, Wisconsin
190
Downloaded for hendsun Goh (hendsunh@ymail.com) at Universitas Tarumanagara from ClinicalKey.com by Elsevier on July 31, 2018.
For personal use only. No other uses without permission. Copyright ©2018. Elsevier Inc. All rights reserved.