Surgery for Diagnostic Reasons in Patients With Long–Lasting Intraocular Inflammation

Abstract

Abstract: : Purpose: To determine the value of invasive diagnostic strategies used in chronic and long–lasting uveitis. Methods: From January 2001 to January 2003, diagnostic pars plana vitrectomy, retinal biopsy and enucleation were performed in patients presenting with a suspicion of pseudo–uveitis of tumoral or infectious origin. Vitreous or retinal biopsy specimens were stained conventionally and prepared for immunocytology. Ocular fluids were analyzed for viral or bacterial infections. The level of interleukine–10 was evaluated in the vitreous. Molecular analysis was performed to detect immunoglobulin gene rearrangements. Corresponding clinical records were compared with the final diagnosis. Results: Pars plana vitrectomy and retinal biopsy were performed respectively in 56 and 6 cases of chronic uveitis, refractory to corticosteroids and immunosuppressors. Mean age was 69 years (range 32–84 y). A diagnostic orientation was obtained in 31 cases (50%) after vitrectomy or retinal biopsy, including primary intraocular lymphoma (24.2%), fungal endophthalmitis (8%), HSV–2 and VZV–associated acute retinal necrosis syndrome (6.5%), extensive retinochoroidal toxoplasmosis (4.9%), Whipple’s disease (3.2%), sarcoidosis (1.7%) and tuberculosis (1.7%). Therefore specific treatment was initiated in 30 cases. Primary intraocular lymphoma were diffuse large B–cell lymphoma in 13 cases and T–cell lymphoma in 2 cases. The level of IL–10 was elevated in all cases of B–cell lymphoma. Detection of clonality by PCR techniques definitively confirmed the diagnosis of intraocular lymphoma in 9 cases. Enucleation confirmed the diagnosis of Langerhans cell histiocytosis in one case. Reactive cellular infiltrates were identified in 43.4% of patients and 4 specimens were considered "insufficient for diagnosis". Post–operative cataract and retinal detachment were noted respectively in 14 and 2 cases Conclusions: Invasive diagnostic strategies should be considered when malignant or atypical infectious conditions are highly suspected. Results are obtained rapidly and lead to an adapted therapeutic management.

Keywords: vitreoretinal surgery • inflammation • clinical laboratory testing