Incidence of visual improvement in uveitis cases with visual impairment caused by macular edema

Abstract

Purpose: Among cases of visually significant uveitic macular edema (ME), to estimate the incidence of visual improvement and identify predictive factors.

Design: Retrospective cohort study.

Participants: Eyes with uveitis, seen at 5 academic ocular inflammation centers in the United States, for which ME was documented to be currently present and the principal cause of reduced visual acuity (<20/40).

Methods: Data were obtained by standardized chart review.

Main outcome measures: Decrease of ≥ 0.2 base 10 logarithm of visual acuity decimal fraction-equivalent; risk factors for such visual improvement.

Results: We identified 1510 eyes (of 1077 patients) with visual impairment to a level <20/40 attributed to ME. Most patients were female (67%) and white (76%), and had bilateral uveitis (82%). The estimated 6-month incidence of ≥ 2 lines of visual acuity improvement in affected eyes was 52% (95% confidence interval [CI], 49%-55%). Vision reduced by ME was more likely to improve by 2 lines in eyes initially with poor visual acuity (≤ 20/200; adjusted hazard ratio [HR] 1.5; 95% CI, 1.3-1.7), active uveitis (HR, 1.3; 95% CI, 1.1-1.5), and anterior uveitis as opposed to intermediate (HR, 1.2), posterior (HR, 1.3), or panuveitis (HR, 1.4; overall P = 0.02). During follow-up, reductions in anterior chamber or vitreous cellular activity or in vitreous haze each led to significant improvements in visual outcome (P <0.001 for each). Conversely, snowbanking (HR, 0.7; 95% CI, 0.4-0.99), posterior synechiae (HR, 0.8; 95% CI, 0.6-0.9), and hypotony (HR, 0.2; 95% CI, 0.06-0.5) each were associated with lower incidence of visual improvement with respect to eyes lacking each of these attributes at a given visit.

Conclusions: These results suggest that many, but not all, patients with ME causing low vision in a tertiary care setting will enjoy meaningful visual recovery in response to treatment. Evidence of significant ocular damage from inflammation (posterior synechiae and hypotony) portends a lower incidence of visual recovery. Better control of anterior chamber or vitreous activity is associated with a greater incidence of visual improvement, supporting an aggressive anti-inflammatory treatment approach for ME cases with active inflammation.

Figure 1

Kaplan-Meier estimate of the incidence of at least two lines improvement in visual acuity among eyes with macular edema causing a reduction of visual acuity to worse than 20/40 (shaded area denotes the 95% confidence interval [CI]).

Figure 2

Kaplan-Meier estimates of the incidence of at least two lines improvement in visual acuity among eyes with macular edmea causing reduction of visual acuity to worse than 20/40, comparing estimates of vision gain among those with baseline activity, inactivity, or slight activity.

Figure 3

Kaplan-Meier estimates of the incidence of at least two lines improvement in visual acuity among eyes with macular edema causing reduction of visual acuity to worse than 20/40, comparing estimates of vision gain among those with anterior uveitis, intermediate uveitis, posterior uveitis, and panuveitis.

Figure 4

Influence of the change in uveitis activity over six months on the proportion of eyes with macular edema causing visual acuity to worse than 20/40 that gained at least two lines’ improvement in visual acuity by that time. Error bars denote 95% confidence intervals. p<0.01 comparing degrees of step-wise improvements within each category of uveitis activity. CI = confidence interval