|Year : 1990 | Volume
| Issue : 1 | Page : 20-23
Study of aqueous humour in anterior uveitis
Jairaj Kalsy1, Harish Raichrur2, AD Patwardhan2
1 National Institute of Virology, Pune, India
2 Sassoon General Hospital, Pune, India
National Institute of Virology, 20 A, Dr. Ambedkar Road, Pune-411 001
Source of Support: None, Conflict of Interest: None
Aetiological diagnosis of anterior uveitis was made clinically and substantiated with relevant investigations. Aqueous humour obtained under aseptic conditions, was analyzed for the cells study, culture and protein profile, using polyacrylamide gel electrophoresis. The results were analysed with the help of known clinical facts. Culture and smears were invariably negative, while the lymphocytes were present in varying numbers, polymorphs and macrophages afforded a useful clue for confirmatory diagnosis. The electrophoretic pattern of the proteins was related to the duration of the disease and was same in a group while it was distinctive among different groups of anterior uveitis.
|How to cite this article:|
Kalsy J, Raichrur H, Patwardhan A D. Study of aqueous humour in anterior uveitis. Indian J Ophthalmol 1990;38:20-3
| Introduction|| |
The cases of anterior uveitis are non descript and non specific in their clinical character. Anterior uveitis due to tissue invasion by leptospira, present manifestations of nongranulomatous uveitis while phako-anaphylactic uveitis is considered a hypersensitivity reaction. All these factors go to make this habitually chronic and recurrent anterior uveitis of unknown aetiology a frustratingly difficult condition to treat. The presence of a multitude of unsatisfactory classifications of anterior uveitis and the vast array of investigations including a hemogram atone end and fluorescein antibody test for toxoplasmosis at the other end, not only consume a lot of valuable time but also irritate and harass the patients and ultimately the case sheets show the familiar diagnosis of anterior uveitis of unknown aetiology.
The anterior uvea bathes in the surrounding aqueous and hence will 'surely be affected by it's pathology. The extreme difficulty of obtaining a biopsy specimen and the comparative ease of acquiring the aqueous by an innocuous procedure can give us an important clue to the aetiology of anterior uveitis. By studying the constituents of aqueous in cases of anterior uveitis of presumed aetiology, the pattern of the constituents of the aqueous will help us in understanding the pathogenesis of anterior uveitis better.
In the present study of aqueous humour in case of presumed aetiology of anterior uveitis, the aim is to study and compare the groups of anterior uveitis, regarding protein patterns of aqueous samples on polyacrylamide gel electrophoresis, the study of cells in aqueous and isolation of organisms from aqueous.
This report represents the findings to see if aqueous humour shows similar changes in the presumed groups of anterior uveitis and correlates with the clinical diagnosis and whether the aqueous humour study can be used as a diagnostic tool in bewildering cases of anterior uveitis.
| Materials and methods|| |
1. Case Selection
Cases of iridocyclitis were diagnosed on clinical findings using Hogan's tabulations having symptoms of pain, photophobia and signs like circumciliary congestion, aqueous flare, keratic precipitates etc. Their detailed and past history was taken and they were examined with spot light, corneal loups and slit lamp microscope. Tension and sac syringing was also carried out. Later they were subjected to a routine haemogram, Blood sugar level, blood urea level, eythrocyte sedimentation rate, ENT/dental check up, prostrate in males and genitourinary tract examination in females. Selected cases were taken up for VDRL test, L.E. cell examination, Rheumatoid arthritis factor, tuberculin testing and X-ray chest. On the basis of the above examinations, as well as clinical picture of the patients, they were grouped into the following catagories;
1. Tuberculous iridocyclitis
2. Rheumatoid iridocyclitis
3. Phakotoxic iridocyclitis
4. Traumatic iridocyclitis
5. Iridocyclitis secondary to corneal ulcer
6. Iridocyclitis secondary to septic focus
In all 50 cases of anterior uveitis were studied.
| Paracentesis|| |
It was done in the operation theatre where the eye of the patients was cleaned with savlon, saline and conjucival sac was sterilized with Soframycin drops. The anterior chamber of the eye was punctured with 26 gauge needle fitted on a two cc syringe. After aspiration of aqueous, chloromycetin ointment was applied to the eyes as a proplylactic agent.
| Controls|| |
Aqueous humour from 40 patients with a normal uveal tract who were to undergo cataract extraction were taken as controls for ethical reasons.
| Cell counting|| |
Cell counting was done by mixing a drop of aqueous humour equally with C.S.F diluting fluid (Baker F.J. and Silverton R.E.). The cells were counted in Neubauer's counting chamber. The cell number was expressed as per cubic millimeter.
| Culture studies|| |
The samples were inoculated into glucose broth tubes and were incubated at 35°C for 24 hours to observe turbidity. Simultaneously the blood agar and Mac-conkey plates streaked with samples and incubated at 37°C for 48 hours (R Cruicksahank et al. 1975).
| Protein analysis|| |
The anodic discontinuous/continuous polyacrylamide gel eletrophoresis with slight modifications as per the method of Davis was employed. Vertical slabgels employing 5-7.5% of acrylamide were used. Vertical slab gels along with suitable markers such as lysozyme (14k), trypsinogen (24k), ovalalbumin (67k), cross linked hemoglobin (16k, 32k, 49k,64k,) and purified human Ig (160k) obtained from Sigma Chemical Co. USA were also run as standard. At the end of electophoresis the gels were fixed in 50% tricloroacetic acid and then stained, with 0.1% coomassie brilliant blue in 50% trichloroacetic acid and destained with 7% acetic acid. After development of bands the gels were dried under vaccum for 1 hour in gel drier (Bio-rad). The molecular weight of unknown polypeptide was determined by comparing the RF value with the standards.
| Observations|| |
The observations found in this study have been tabulated in the following tables.
| Results and discussions|| |
Out of fifty cases of anterior uveitis twenty seven were males and twenty three females. [Table - 1]. Incidence of traumatic and tubercular anterior uveitis was more in males while rheumatoid anterior uveitis was found only in females. There was nearly equal distribution in the remaining categories. Acute anterior uveitis is commoner in males while chronic anterior uveitis is commoner in females . [Table - 1] represents the sex incidence and [Table - 2], represents the duration of the disease among various groups of anterior uveitis. Out of nine cases of traumatic anterior uveitis polymorphs were present in six cases with a mean value of 3.22 per case, lymphocytes in six cases with mean value of 5.89 per case and no macrophages were detected in this group [Table - 3]. In rheumatoid anterior uveitis group, polymorphs were absent in all the cases while lymphocytes were present in all the case with a mean value of 25.5 per case and macrophages were present only in one case which is statistically insignificant. Out of nine cases of anterior uveitis secondary to corneal ulcer, polymorphs were seen in one acute case which is statistically insignificant. Lymphocytes were present with a mean value of 47.2 per case and were present in all cases. Macrophages were found in statistically insignificant number, in five of the cases. In anterior uveitis secondary to the septic focus group, polymorphs were present in five out of twelve cases with a mean value of 8.08 per case, lymphocytes in eleven out of twelve cases with a mean value of 23.41 per case and macrophages were spotted in four cases with a mean value of 5.83 per case. Out of nine cases of anterior uveitis secondary to corneal ulcer, polymorphs were seen in one acute case but they were not significant statistically. Lymphocytes were found in all cases with mean value of 47.2 per case. Macrophages were found in five cases with a mean value of 5.56 per case. In anterior uveitis secondary to septic focus, lymphocystes were seen in eleven out of twelve cases with a mean value of 23.41 per case. Macrophages were present in four cases with mean falue of 5.83 per case. In tuberculous anterior uveitis group, polymorphs were absent in all the six cases while lymphocytes were present in all cases with a mean value of 63.3 per case. Macrophages were found in 3 cases only. In phakotoxic group of anterior uveitis lymphocytes were present in large numbers (57.2 mean value), polymorphs being absent in all cases. Macrophages were present in three acute cases in statistically significant amount (3.8 mean value).
In cases of acute anterior uveitis there is vascular and stromal reaction, this leads to exudation of polymorphs in the initial stage and later lymphocytosis'. In this study also lymphocytes are found in nearly all cases and in very large numbers. In traumatic and rheumatoid anterior uveitis groups the number per case was less, about twenty per cubic millimeter per case while in remaining four groups, they were found in very large numbers up to one hundred and fifty per cubic millimeter per case. Macrophages were statistically insignificant in traumatic and rheumatoid anterior uveitis group. Agarwal  has reported mainly polymorphs in cases of non-granulomatus uveitis while lymphocytes from tubercular and syF hilitic iridocyclitis. Misra & Rahi  found polymorphs, eosinophils, macrophages, occasional lymphocytes and plasma cells while studying lens induced uveitis in rabbits. Goldberg  in phakolytic glaucoma found several hundreds of large round macrophages, large number of erythrocytes, only one polymorph and no lymphocytes. This study is contradictory to the findings in phakotoxic groups where macrophages and lymphocyts were found in significant numbers. In this study the presence and number of polymorphs and macrophages give some indication of the aetiological cause.
Amsler screened out the large number of aqueous samples of cases suffering from iritig and found that only four to eight per cent of the culture were positive. Our reports tally with the previous findings. The reason for getting sterile reports is because of the attenuation of the organism by the action of antibodies, leucocytes and macrophages. Our reports are further confirmed by the findings of Hogan  et al who carried out cytological studies of aqueous humour in anterior uveitis with the electron microscope. They did not find any viral or bacterial inclusions in any of the cells. In out studies the conjuctival swabs were taken in all case of uveitis secondary to corneal ulcer and septic focus to correlate and rule out conjunctival contamination. All the reports were sterile. The results of electrophoresis are mentioned in [Table - 3] and a bar diagram shows the protein pattern in various groups. According to the molecular weights polypeptides have been presumed. It is observed that there is a definite rise in proteins in various aetiologies and changes with the duration of the disease is also found. Albumin and al globulins are present in all cases including controls. Gamma globulins are absent in controls but present in all other groups and absent in acute cases, signifying chronicity. a2 globulins are statistically significant in traumatic, corneal ulcer, septic focus and tuberculous anterior uveitis group and absent in rheumatoid and phakotoxic anterior uveitis group. Globulins are present in tuberculous septic focus and corneal ulcer anterior uveitis group and absent in the rest. Lipoproteins are present in phakotoxic, corneal ulcer, septic focus and tuberculous anterior uveitis group where as absent in traumatic and rheumatoid anterior uveitis group. The low molecular weight proteins ranging from 15K-35K were found only in groups of anterior iveitis secondary to corneal ulcers and septic focus. According to Lyle and Lyle  aqueous contains proteolytic enzymes which are derived from.the bacteria or their toxins which convert the large molecular weight albumin and globulins to low molecular weight proteins. Our findings of proteins are in agreement with the results of Saari  et al. Sallmann  while studying the aqueous of inflamed rabbit eyes detected albumin, a,^r globulins and fibrinogen. Bhatnagar and Mamta Singh  found albumin bands in traumatic and lens induced uvei;Is. They also found, al, a2, and four globulins in the above cases which is not consistant with our study. According to Sorsby  after repeated exacerbations, the blood-aqueous barrier is broken and leads to plasmoid aqueous. In our study there is a definite protein profile for a particular aetiology.
As cited above an A.C. puncture for removel of aqueous humour is a very simple and cheap procedure as compared to lumbar puncture. Any clinician would be able to do it. There is a suggestive correlation between the clinical diagnosis and the aqueous humour study. The aqueous humour examination becomes essential in anteior uveitis of non-traumatic origin because anterior uveitis secondary to corneal ulcer or trauma is easier to diagnose. The difference between these two has been made obvious in [Table - 3]. In cases of tubercular or rheumatoid type of anterior uveitis, the investigations required to come to the conclusion of aetiology are time consuming as well as expensive to the patient. Early diagnosis and early treatment of specific nature will relieve the patients of their symptoms early and prevent complications. We feel that aqueous humour studies will help the clinicians in confirming their diagnosis without patients having to undergo a number of investigations. It is felt that these conclusions should be confirmed with a large number of cases for which this study may serve as a pilot project.
| References|| |
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[Figure - 1]
[Table - 1], [Table - 2], [Table - 3]