|Year : 1970 | Volume
| Issue : 4 | Page : 185-186
Bilateral phaco-anaphylaxis after couching
OP Ahuja, MS Kaothalkar
Muslim University Institute of Ophthalmology, Gandhi Eye Hospital, Aligarh, India
O P Ahuja
Muslim University Institute of Ophthalmology, Gandhi Eye Hospital, Aligarh
Source of Support: None, Conflict of Interest: None
|How to cite this article:
Ahuja O P, Kaothalkar M S. Bilateral phaco-anaphylaxis after couching. Indian J Ophthalmol 1970;18:185-6
Lens-induced uveitis is a well recognized phenomenon. One of the clinical manifestations of such a reaction, e.g. development of lens-induced uveitis in the unoperated eye following an extra capsular lens extraction in the contra-lateral eye, was first recognized by Straub. Courtney reported seven cases of lens-induced uveitis in unoperated eves in similar circumstances. Similar cases have been reported by other workers and the term 'Bilateral Phaco-anaphylaxis' has been assigned to these.
The present case report is of interest in view of the reaction developing after a couching operation. To date, authors have not seen a report of bilateral phaco-anaphylaxis following this procedure.
| Case Report
A sixty-year-old male was admitted to this hospital in December 1965, with the complaints of rapid appearance of pain, redness and marked loss of vision in the left eye for 20 days. There was a history of couching operation in the right eye, performed five months earlier. Following the operation, the eye remained red and painful for a few weeks, and the vision was completely lost. Since then there had been occasional redness and pain in that eye with intervals of quiet eye.
On examination, right eye (couched) showed a mild conjunctival congestion with slightly hazy cornea, deep anterior chamber, deformed pupil and a few organized exudates in the pupillary area. The couched lens could be made out in the lower part of vitreous which was also hazy due to opacities. Digitally, the ocular tension was markedly low and perception of light was absent.
Left eye (unoperated) had an intense conjunctival and ciliary congestion. Cornea was slightly hazy due to corneal oedema, moderate and large sized keratic precipitates were present. The anterior chamber was shallow with an intense aqueous flare. Iris showed marked oedema, and pupil was occluded with exudates.
Because of the history of trauma to the lens of the contra-lateral eye, development of acute anterior uveitis with large keratic precipitates (mixed uveitis), a presumptive diagnosis of phacoanaphylaxis was made. Skin reaction of the patient to an intra-dermal injection of 0.1., cc of stock lens antigen showed an erythema of i6 mm. with moderate amount of induration, after 48 hours. Similarly, patient's serum was tested for anti-lens antibodies by immunological technique of Oudin on sixth day. Subsequently, similar results were obtained when the patient's skin hypersensitivity and anti-lens antibodies were tested with the antigen prepared from patient's own lens.
The patient was treated with intensive local mydriatics and corticosteroids supplemented with systemic acetazolamide. Surgical intervention was planned to perform a lens extraction in the left eye. A large sector iridectomy was performed and an extracapsular lens extraction was made. As the capsule was found to be ruptured, an intracapsular extraction was not possible. The anterior chamber was thoroughly washed with sterile normal saline.
Post-operatively, there was a severe uveitis which was controlled in three weeks after liberal use of local as well as systemic corticosteroids. At the time of discharge, though the eye was quiet, the iris coloboma was partially occluded with exudates. Visual acuity was only Hand Movements. He was advised to use atropine and corticorteroids locally. Six weeks after discharge, the patient came for a check-up. The eye was quiet and visual acuity improved to a/6o with correction. Anterior vitreous was hazy showing multiple dot-like pigmented and non-pigmented opacities. Fundus details were not clearly visible.
Histopathology of the piece of iris removed at operation, showed dilatation and congestion of iris vessels with round cell infiltration of the otroma. The cellular infiltration consisted predominantly of plasma cells, suggestive of immune reaction.
Couching procedure for cataract is still practised at several places in rural India. Sood and Retnaraj  reported a series of 115 cases encountered in the hospital in about two years time. Secondary glaucoma and iritis (in the same eye) were found to be the commonest complications. No case of bilateral phaco-anaphylaxis was seen.
In the present case the clinical picture was suggestive of bilateral phaco-anaphylaxis and the diagnosis was supported by immunological tests. Histopathology of iris was also consistent with the diagnosis. It is our contention that at the time of couching, the lens was injured and the escaped lens proteins sensitized the uveal tissue of both eyes. A spontaneous small rupture in the capsule of the other eye triggered the antigen-antibody reaction responsible for the picture described.
A clinical diagnosis of bilateral phacoanaphylaxis was made in a case following a couching operation. The diagnosis was supported by immunologic tests and histopathology.
The possible sequence of events in the case has been suggested.
This is the first case reported in literature showing a bilateral phaco-anaphylaxis following couching.
Courtney, R. H. (1942) - quoted by Harrington, O. D., (1944) Amer. J. Ophth. 27 93.
Oudin, J. (1947)-Bull, Soc. Chim. Biol. (Paris). 29: 140.
Sood, N. N. and Ratnaraj, A. (1968) - Amer. J. Ophth. 66: 687.
Straud, M. (1916) - quoted by Woods, A. C. (1959): Amer. J Ophthal. 48: 463.