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BRIEF COMMUNICATION
Year : 2015  |  Volume : 3  |  Issue : 2  |  Page : 100-102

An unsuspected case of lens-induced uveitis: A case report


Department of Pathology, Employees' State Insurance Corporation, Medical College and Post Graduate Institute of Medical Science and Research, Bangalore, Karnataka, India

Date of Submission16-Apr-2014
Date of Acceptance04-Nov-2014
Date of Web Publication7-May-2015

Correspondence Address:
Sudha M Rao
Department of Pathology, Employee's State Insurance Corporation, Medical College and Post Graduate Institute of Medical Science and Research, Bangalore, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2320-3897.156602

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  Abstract 

We report here a case of unsuspected lens-induced uveitis occurring after small incision cataract surgery (SICS) in a 47-year-old man as a result of retained lens fragment, resulting in a painful blind eye over a period of 1 year. This was not recognized post-operatively on account of a hyphema that developed in the post-operative period. The true nature of the condition became apparent only on histopathological examination of the enucleated eye ball. The gross examination showed that a part of the cataractous lens along with some of its capsule was retained. The intra-ocular lens (IOL) was displaced and an exudate filled the cavity. Microscopy revealed the retained lens fragment, an acute-on-chronic inflammatory reaction with fibrosis in the interior of the eyeball.

Keywords: Displaced intraocular, lens-induced uveitis, retained lens fragment, small incision cataract surgery


How to cite this article:
Rao SM, Murthy SV, Geethamala K. An unsuspected case of lens-induced uveitis: A case report. J Clin Ophthalmol Res 2015;3:100-2

How to cite this URL:
Rao SM, Murthy SV, Geethamala K. An unsuspected case of lens-induced uveitis: A case report. J Clin Ophthalmol Res [serial online] 2015 [cited 2020 Aug 5];3:100-2. Available from: http://www.jcor.in/text.asp?2015/3/2/100/156602

Lens-induced uveitis occurs as an inflammatory or immune response to lens protein material or its capsular remnants. It can result from a leakage of lens protein in a hypermature cataract or after trauma or after inadvertent retention of lens fragments following cataract surgery. [1] This condition may be difficult to recognize clinically due to formation of a hyphema. In the present era of Phaco-emulsification also, retained lens fragments eliciting a chronic uveitis is reported as a well-known complication. [2] A high index of suspicion, early recognition by a cytological study of anterior chamber wash fluid and prompt treatment can save the eye and preserve vision. [3]


  Case Report Top


A 47-year-old male patient presented himself at our hospital with a painful blind eye for which enucleation and orbital implant was done. The removed eyeball was sent for histopathological examination.

About a year ago, the patient had undergone small incision cataract surgery, along with anterior vitrectomy, iridectomy, and intraocular lens (IOL) insertion at an outside eye hospital. Following this, he did not recover good vision. On follow-up during subsequent visits, he was reported to have developed a hyphema for which he underwent anterior chamber wash and steroids, but still did not improve. On the other hand, he also developed retinal detachment and displacement of the IOL. He refused to undergo any further surgery on account of being given a guarded prognosis. By the end of the year, he had a painful blind eye, with which he presented to the ophthalmology department of our hospital and underwent enucleation and insertion of orbital prosthesis.

On gross examination, the eyeball was intact, the cornea collapsed, and blood clot was seen within the cavity. Sections were submitted for histopathological examination.

Microscopic sections studied from the eye ball showed an ulcerated cornea with hyalinization of corneal lamellae, destruction of the epithelial and endothelial layers with neo-vascularization. Pigment deposition was seen on the posterior surface of the cornea. The anterior chamber was also disrupted and a fragment of the cataractous lens was retained along with some part of the capsule [Figure 1]a-d. The vitreous was closely associated to this lens with an organized inflammatory reaction. The fibrinoid material and inflammatory cell infiltrate was seen involving the iris and ciliary body [Figure 2]a. A detached retina was also observed as a result of fibrosis and inflammation. In addition, a giant cell reaction was evident around a broken fragment of the dislocated IOL [Figure 2]b.
Figure 1: (a) Photograph showing part of the retained cataractous lens (arrow) and its capsule (H&E 10×), (b) Intense inflammatory reation (H&E 10×), © Epitheliod cells and multi-nucleated giant cells (H&E, 10x), (d) Iris and ciliary body with infiltration by neutrophils, eosinophils, and macrophages(H&E, 10×)

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Figure 2: (a) Photomicrograph showing iris and ciliary body with infiltration by neutrophils, eosinophils, and macrophages (H&E, 40×) (b) Ciliary body with inflammatory cell reaction to a fragment of intra-ocular lens (IOL) (arrow) (H&E,10×)

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  Discussion Top


Lens fragments may be retained in the anterior or posterior chambers during seemingly uncomplicated cataract surgery. This was more common in the days before the advent of micro-surgery. However, lens-induced uveitis can result during phaco-emulsification also; the lens may be dislocated posteriorly into the vitreous cavity especially after zonular dehiscence or capsular rupture in a hypermature cataract. The degree of intraocular inflammation in such patients is reported to be governed by the size of the retained lens fragment, time since the surgery, individual's immune status, and also the extent of therapeutic manipulations. [2]

The incidence of posterior displaced lens fragments during phacoemulsification is unknown but estimated between 0.3-18% and about 50% of such patients are likely to develop lens-induced uveitis. [2],[3] Phacoanaphylactic endophthalmitis and phacogenic non-granulomatous uveitis account for less than 1% of all cases of uveitis. [1] It is more common in the elderly with a peak incidence in the 6 th to 7 th decades. [2] The uveitis is typically unilateral and involves only the traumatized eye unlike sympathetic ophthalmitis. The most important symptoms being epiphora, photophobia, pain, loss of vision, and redness. Perilimbal or diffuse congestion, lid swelling, corneal haze, keratic precipitates, development of synechiae, papillary membranes, and iris nodules are the important signs. Visual acuity is variable ranging from 20/20 to no light perception. [1]

The term phacoanaphylaxis is now known to be inappropriate, as there is no evidence of an IgE-mediated response. On exposure to lens protein, an immune complex-mediated inflammation is postulated, which can be experimentally transferred by hyperimmune serum. It may be mediated by types II, III, or IV hypersensitivity reactions in individual patients. [1],[4] The condition typically develops within a fortnight after surgery or intra-ocular injury, but can rarely occur several months after disruption of the lens capsule, [5] as in our case.

Histologically, three different pictures with overlapping clinical features have been described, namely:

  1. Acute granulomatous anterior uveitis following surgical or traumatic rupture,
  2. A non-granulomatous chronic uveitis (phaco-toxic) that may be seen after cataract surgery,
  3. Phacolytic glaucoma, usually resulting from a leakage of lens material from a hypermature cataract. [1]


In this case, interestingly, we encountered acute on chronic inflammatory infiltrate, fibrosis around the retained lens fragment, fibrinoid material in the region of the iris, ciliary body, and vitreous along with retinal detachment. Mild cases of lens-induced uveitis respond well to topical corticosteroids or non-steroidal anti-inflammatory medications. In more severe cases or in cases of phacoanaphylactic endophthalmitis, surgical removal of the remaining lens material is required. [6],[7] If untreated, lens-induced or phaco-anaphylactic endophthalmitis may result in chronic cystoid macular edema, cyclitic membrane formation, tractional retinal detachment (as in our case), and phthisis bulbi. [1],[5]


  Conclusion Top


This case is reported with a view to increase awareness of this condition. An early recognition and prompt removal of the offending lens material can save the eye and restore at least partial vision to the patient.

 
  References Top

1.
Forster DJ. Phacoantigenic uveitis. In: Myron Y, Jay SD, editors. Ophthalmology Text Book. 2 nd ed., Vol. 2., Ch. 178. Mosby Elsevier; 2006. p. 1201-4.  Back to cited text no. 1
    
2.
Nussenblatt RB, Whipcup SM. Uveitis, Fundamentals and Clinical Practice. 3rd ed. Ch. 17. USA: Elsevier; 2004. p. 264-9.   Back to cited text no. 2
    
3.
Kalsy J, Raichur H, Patwardhan AD. Study of aqueous humor in anterior uveitis. Indian J Ophthalmol 1990;38:20-3.  Back to cited text no. 3
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4.
Nagano AO, Toshihiro M, Mari Y, Mariko S. A case of lens-induced uveitis caused by lens nucleus remaining in the anterior chamber. J Eye 2005;22:1137-40.  Back to cited text no. 4
    
5.
Murthy S, Sangwan VS. Common Pan Uveitic entities. In: Dutta LC, Dutta NK, editors. Modern Ophthalmology. 3 rd ed. Chap. 163. New Delhi: Jaypee Publications; 2005. p. 1276-98.  Back to cited text no. 5
    
6.
Abrahams IW. Diagnosis and surgical management of phacoanaphylactic uveitis following extracapsular cataract extraction with intraocular lens implantation. J Am Intraoccul Implant Soc 1985;11:444-7.  Back to cited text no. 6
    
7.
Thach AB, Marak GE Jr, McLean IW, Green WR. Phacoanaphylactic endophthalmitis: A clinicopathologic review. Int Opthalmol 1991;15:271-9.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2]


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[Pubmed] | [DOI]



 

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