|Year : 1968 | Volume
| Issue : 3 | Page : 139-141
Lens induced uveitis - a case report
Shanno D Sud, M Singh
Eye Hospital, Sitapur, India
|Date of Web Publication||24-Dec-2007|
Shanno D Sud
Eye Hospital, Sitapur
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Sud SD, Singh M. Lens induced uveitis - a case report. Indian J Ophthalmol 1968;16:139-41
Lens induced uveitis is an allergic or toxic inflammatory reaction which may occur in an eye from the release of products of a cataractous lens from the opposite eye which had undergone a successful extra-capsular cataract extraction some time previously.
There are three such recognized types of lens induced uveitis occurring in the second eye.
1. Endophthalmitis Phakoanaphylactica:
Where the uveitis is thought to be an anaphylactic reaction from lens protein acting as antigen when the second eye is operated or traumatized. An acute non-infective inflammatory reaction occurs characterized by massive lardaceous corneal precipitates, marked aqueous flare and secondary glaucoma. Histologically there is a collection of polymorphonuclear leucocytes and neutrophils; occasionally eosinophils and masses of epithelioid cells. The first eye remains quiet throughout. There may be positive skin reaction to lens protein in some cases.
2. Phakotoxic Uveitis:
This condition is due to seeping of the lens material into the anterior chamber producing a well-marked plasma cell and lymphocytes response and no polymorph or epitheloid cells. This condition may also follow an operation or trauma to the second eye, but may also occur in an unoperated eye.
3. Phakogenic or Phakolytic Glaucoma:
This condition occurs often in old patients who have had an extra-capsular cataract extraction in one eye, but the second cataract has been allowed to become hypermature. It is characterized by acute glaucoma, with a deep anterior chamber, open angle and marked aqueous flare. The absence of K.P.'s is a very characteristic finding. Histologically the trabeculae are filled with lens material and phagocytes. The operated eye remains unaffected. In 1947 MORGAN reported 4 cases of Uveitis in the second eye, following an extracapsular cataract extraction on the first eye. LEIGH  described 6 cases of a similar type and he performed intra-capsular cataract extraction on the second eye in 3 cases.
The case which we are going to describe belongs to this third type of Lens Induced Uveitis.
| Case report|| |
Male, aged 60, attended on March 8, 1966, complaining of pain in the left eye of 3 days duration. Before this, vision had been reduced to perception of light by a cataract which had been there for some 15 years. Since the right eye was operated successfully with an extra-capsular extraction performed 15 years back and the corrected visual acuity in that eye was 6/12 all along, he neglected the other eye for operation and allowed the cataract to progress to hypermaturity.
The left eye showed circumcorneal injection with corneal oedema and raised tension (50 mm Hg Schiotz). The anterior chamber was completely filled with a milky fluid but the striking features were complete absence of K.P.'s but a strong chamber flare as revealed by slit lamp. No details of the iris could be seen due to the presence of a thick white fluid in the anterior chamber.
Paracentesis was performed on the same day and aqueous was allowed to escape slowly. The chamber became quite clear after some thick whitish material came out and then the iris and lens could be visible. Atropine was applied and subconjunctival cortisone injection was given. Systemically Diamox 250 mg one tablet three times a day was ordered. Next morning the case was examined which again showed oedematous cornea and some milky fluid in the anterior chamber. Paracentesis was again performed and the same treatment was continued. This relieved the pain of the patient and lowered the tension. The removal of the cataract was planned and it was done on the third day (March 11, 1966). An intra-capsular cataract extraction was done. Subsequent progress was uneventful and at the time of discharge the visual acuity was 6/24. The patient was again seen on 12.4.66 and corrected visual acuity was 6/9 partial.
The condition can easily be confused with sympathetic ophthalmia and many eyes have been removed because this was suspected. In lens induced Uveitis the inflammation is confined to the second eye and is not preceded by any inflammation in the first. In sympathetic ophthalmia both eyes are involved and the exacerbation and remissions are simultaneous in both the eyes.
Another condition to be kept in mind is incidental uveitis in the second eye,
| Discussion and review of literature|| |
COURTNEY  describes the most marked feature of endophthalmitis accompanying absorption of the crystalline lens as raised tension; all his cases presented inflammatory reaction in the second eye following cataract extraction in the first eye after an interval varying from 3 months to 3 years; in some of these, a spontaneous rupture of the lens capsule in the second eye was supposed to have occurred, or alternatively it was suggested that autolysed lens matter might have passed through the intact lens capsule. He concludes that if one is satisfied that the endophthalmitis is due to absorption of lens protein in the second eye after extra-capsular extraction of cataract in the first, the proper treatment, however intense the inflammaion, would be removal of all lens matter from the inflammed eye.
It is essential to discover what support there is for the separation of the phenomena of the ocular response to lens proteins into three categories: Phako-anaphylactic, toxic and phakogenetic. Spontaneous rupture of the lens capsule (microscopic dehiscences of the capsule) (IRVIN AND IRVIN  ) and transudation of autolysed lens matter through an intact capsule increases the difficulty of classification. The clinical finding should be correlated with the histological appearances, and particularly the reaction of the lens matter with specific cells should be studied before we come to a conclusion. GIFFORD  expressed the danger of leaving a cataract to become hypermature. VERHOEFF AND LEMOINE  agreed that hypermature cataract was toxic and also proved that this could also be an anaphylactic reaction to lens proteins. This was confirmed by LEMOINE AND MACDONALD  . RYCHNER  got amazed how such eyes clear with removal of the hypermature cataract.
LEIGH  in his paper on "Lens Induced Uveitis" advocates quick removal of the lens. The basis of this inflammation is a hypersensitivity of the ocular tissues to the products of cataractous lens. The inflammation is localized to the anterior part of the Uvea. The first eye remains quiet throughout which differentiates it from sympathetic ophthalmia. As soon as diagnosis is made cataract should be removed preferably by the intra-capsular method.
In the case reported above the important features are the length of time between extra-capsular operation in the right eye (15 years) and the Uveitis reaction in the left eye.
The point of incidental uveitis was also kept in mind while diagnosing the case, but as aforesaid the anterior chamber was full of white lens material so much so that no details of iris could be seen except a strong aqueous flare on the slit lamp. The tension was also raised (50 mm. Schiotz) and there was ciliary congestion but no K.P.'s were found. When the anterior chamber puncture was done nothing but white fluid came out. Then the pupil which was round, the iris and the cataract could be seen. The fundus was not visible due to hypermature lens. After intra-capsular cataract extraction the fundus appeared quite normal viz. no macular oedema, vitreous opacity or anterior choroiditis etc.
| References|| |
COURTNEY, R. H.: Trans. Amer. Ophth. Soc. 40, 355 (1942).
GIFFORD, H.: Amer. J. Ophth., 17, 289 (1900).
HISTESTEIN, A.: Trans. Ophth. Soc. U.K., LXXIX, 651, (1959).
IRVINE, S. R. and IRVINE, A. R.: Lens induced uveitis and glaucoma. Amer. J. Ophth., 35, 177, 370 (1952).
LEMOINE, A. N. and MACDONALD, A. E. Endophthalmitis. Arch. Ophth. Chicago., 53, 101 (1924).
LEIGH, A. G. Lens induced uveitis. Trans. Ophth. Soc. U.K., 75, 51 (1955).
MORGAN, O. G. Some cases of inflammation in the other eye after cataract extraction. Trans. Ophth. Soc. U.K. 67, 369 (1947).
RYCHENER. R. O.: Secondary glaucoma due to cataract. Amer. J. Ophth., 33, 1166 (1950).
VERHOEFF. F. M. and LEMOINE, A. N.: Endophthahnitis phaco anaphylactica. Tr. Internat Cong. 234 (1922).