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ARTICLE
Year : 1968  |  Volume : 16  |  Issue : 3  |  Page : 139-141

Lens induced uveitis - a case report


Eye Hospital, Sitapur, India

Date of Web Publication24-Dec-2007

Correspondence Address:
Shanno D Sud
Eye Hospital, Sitapur
India
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Source of Support: None, Conflict of Interest: None


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How to cite this article:
Sud SD, Singh M. Lens induced uveitis - a case report. Indian J Ophthalmol 1968;16:139-41

How to cite this URL:
Sud SD, Singh M. Lens induced uveitis - a case report. Indian J Ophthalmol [serial online] 1968 [cited 2020 Jul 5];16:139-41. Available from: http://www.ijo.in/text.asp?1968/16/3/139/37537

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 [6] 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 Top


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.

Differential Diagnosis:

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 Top


COURTNEY [1] 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 [4] ) 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 [2] expressed the danger of leaving a cataract to become hypermature. VERHOEFF AND LEMOINE [9] 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 [5] . RYCHNER [8] got amazed how such eyes clear with removal of the hypermature cataract.

LEIGH [6] 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 Top

1.
COURTNEY, R. H.: Trans. Amer. Ophth. Soc. 40, 355 (1942).  Back to cited text no. 1
    
2.
GIFFORD, H.: Amer. J. Ophth., 17, 289 (1900).  Back to cited text no. 2
    
3.
HISTESTEIN, A.: Trans. Ophth. Soc. U.K., LXXIX, 651, (1959).  Back to cited text no. 3
    
4.
IRVINE, S. R. and IRVINE, A. R.: Lens induced uveitis and glaucoma. Amer. J. Ophth., 35, 177, 370 (1952).  Back to cited text no. 4
    
5.
LEMOINE, A. N. and MACDONALD, A. E. Endophthalmitis. Arch. Ophth. Chicago., 53, 101 (1924).  Back to cited text no. 5
    
6.
LEIGH, A. G. Lens induced uveitis. Trans. Ophth. Soc. U.K., 75, 51 (1955).  Back to cited text no. 6
    
7.
MORGAN, O. G. Some cases of in­flammation in the other eye after cata­ract extraction. Trans. Ophth. Soc. U.K. 67, 369 (1947).  Back to cited text no. 7
    
8.
RYCHENER. R. O.: Secondary glau­coma due to cataract. Amer. J. Ophth., 33, 1166 (1950).  Back to cited text no. 8
    
9.
VERHOEFF. F. M. and LEMOINE, A. N.: Endophthahnitis phaco anaphy­lactica. Tr. Internat Cong. 234 (1922).  Back to cited text no. 9
    




 

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