This information is an excert from an article From the Ocular Immunology and Uveitis foundation (http://www.uveitis.org) and is used with the permission of C Stephen Foster MD.
Phacogenic Uveitis
(Lens- induced Uveitis)
Etiology
Unknown; possibly an autoimmune disorder
Tolerance for lens tissue is lost after trauma to the lens capsule, with consequent development of auto-antibodies and a possible granulomatous reaction with autoreactive T-cells
Triggering factors:
Perforating injury
Retained lens material after cataract extraction
Microtrauma of the capsule in mature cataract or after glaucoma surgery
Associated systemic conditions – none
Clinical Features
Anterior Uveitis;
Granulomatous or non-granulomatous, (severity)
Can reportedly develop between 24 hours and 40 years after the causative event
A massive # of KPs, small and white in early stage, coalescing into large "Mutton fat" KPs
A thick A.C. exudate, opaque lens and rapid development of PS, abundant protein thick flare, cells and in some cases particulate lens material
The AC cells are characterized by being giant macrophages, full of phagocytosed lens material
Hypopyon or pseudohypopyon formation, made of lens material
Figure 1. Multinucleated giant cell surrounded by epithelioid cells on the anterior lens surface.
Differential Diagnosis
I- Sympathetic ophthalmia
II- Other causes of Anterior uveitis
III- Post-operative endophthalmitis, caused by Propionibacterium acnes; demonstration of the pathogen is helpful
Phacogenic Uveitis Sympathetic Ophthalmia
initially unilateral bilateral
anterior anterior and posterior
usually but not always penetrating trauma always penetrating trauma
usually lens fragments in AC no lens fragments in AC and few cells in AC
no relapses after lens removal Relapses characteristic
antigen: lens protein antigen:retinal photoreceptor protein
Propionibacterium Acnes Endophthalmitis
Chronic postoperative endophthalmitis
usually 3 months or more after extracapsular extraction
Granulomatous ( mutton fat KPs ), small hypopyon, mild vitritis, plaques on posterior capsule characteristic and may be residual lens material in capsular bag
Propionibacterium Acnes requires up to 2 weeks of incubation, samples of vitreous and post capsule should be obtained
Other causes of chronic post-operative endophthalmitis are S. Epidermidis ( between 2-6 weeks ) and fungal ( usually Candida 1-3 months )
In postop endophthalmitis with mild anterior uveitis and unclear etiology, treatment initially is frequent topical steroid; If no improvement, then AC and vitreous paracentesis, Gram and Giemsa stains, fungal, aerobic and anaerobic cultures.
Other causes of anterior uveitis
1- HLA - B27 associated uveitis
2- JRA - associated iritis
3- Fuchs` heterochromic iridocyclitis
4- Herpetic iridocyclitis
5- Syphilis
6- Tuberculosis
7- Intraocular lens induced uveitis ( Uveitis Glaucoma Hyphema syndrome )
8- Posner - Schlossman syndrome
9- Traumatic iridocyclitis
10- Idiopathic anterior uveitis
Characteristic features of each of these causes of anterior uveitis
1- HLA - B27 associated uveitis
About 50% of patients with anterior uveitis
more than half of these will have some type of spondyloarthropathy such as AS, Reiters and psoriatic arthropathy. Inflammatory bowel diseese may also be associated
more commonly males in the second or third decade
severe nongranulomatous often with a fibrinous exudate, hypopyon and posterior synechiae
recurrences more common but the initial episode is the most severe
2- JRA - associated iritis
most common disorder associated with uveitis in the pediatric age group
more common in the pauciarticular( less than 5 joints)
20 - 40% of the early onset, pauciarticular develop ch iridocyclitis and up to 60% of those are ANA positive ( 2 substrates )
10 - 20 % of late onset pauciarticular develop ch iridocyclitis and 75% of those are HLA - B27 +ve. RF is negative in both groups
bilateral nongranulomatous ch anterior uveitis associated with white quiet eye esp in early onset
Band shaped keratopathy and cataract
3 - Fuchs` heterochromic iridocyclitis
2 - 5% of all cases of anterior uveitis and may represent an autoimmune reaction against iris pigment
usually ,but not always, in the lighter colored eye ; 7 - 15% have bilateral disease without heterochromia. Paradoxical cases with inflammation in the darker colored eyes occur.
Patients usually present with complications (cataract and glaucoma) because typical symptoms of ant uveitis are usually absent
stellate KPs throughout the cornea and iris stromal atrophy
often unresponsive to steroid; try intensive topical for one week but taper if no response
4 - Herpetic iridocyclitis
stromal or epithelial corneal involvement usually, but not always, precedes
it can be acute, recurrent or chronic
Iris atrophy with transillumination defects charecteristic
one of the causes of sclerouveitis
initially nongranulomatous but may become granulomatous with chronicity
5 - Syphilitic iridocyclitis
secondary stage and late latent acquired syphilis
granulomatous or nongranulomatous
dilated capillary loops within the iris, called roseata, appear as red nodules
posterior segment involvement
Treatable disease
FTA-ABS or MHA-TP to confirm
Diagnosis
6 - Tuberculous iridocyclitis
the incidence is again rising ( AIDS )
granulomatous inflammation
PPD skin test and CXR in suspected cases
Syphilis and sarcoidosis should be ruled out
7 - Intraocular lens induced iridocyclitis
more common with AC lenses but can occur with PC lenses
persistent postop inflammation
rule out infection and remnants of cortical material; Aqueous and vitreous aspirates
removal of the intraocular lens is often needed
8 - Posner - Schlossman Syndrome
unilateral elevation of pressure ( up to 40 - 60 mm Hg ) and anterior uveitis
mild corneal edema and mild mydriasis
fine KPs and mild cellular reaction in AC
benign, and self-limiting course
during the attack topical beta blocker or mild miotic, topical steroids 2 - 4 times daily
Treatment of Phacogenic Uveitis
Good response to treatment with a favorable
Prognosis
Topical mydriatic and steriod drops and if necessary systemic NSAID, eg. ASA or Indomethacin
The cause should be removed: as much of the lens material as possible should be removed from the eye
If it follows extra-capsular extraction, treatment should continue until all lens material is absorbed; lens material that is not absorbed must be removed surgically
Forms of anterior uveitis
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Forms of anterior uveitis
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