Lens-induced uveitis: an update

Ultrasound biomicroscopy qualitative and quantitative signs of phacoantigenic uveitis

BACKGROUND/OBJECTIVE

To describe the ultrasound biomicroscopy (UBM) diagnostic features in patients suspected of experiencing chronic inflammation due to phacoantigenic uveitis SUBJECTS/METHODS: This single-center study enrolled patients referred to the Uveitis Department of Cleveland Clinic Abu Dhabi for chronic anterior uveitis and traumatic cataract. Patients' demographics, causes and dates of the inciting traumatic event, and ophthalmic findings were recorded. 20-MHz UBM assessment of the status of the anterior capsule and the crystalline lens was performed. Then, cataract surgery was performed using a single technique. Comparison of the anterior capsule and lens status by clinical, UBM, and intraoperative evaluation.

RESULTS

Forty eyes with phacoantigenic uveitis were considered. The slit-lamp examination could identify interruption of the anterior capsule in 20% of the eyes and liquefied sinking lens material in 10%. An intra-operative defect in the anterior capsule was documented in 87.5% of eyes. UBM imaging showed anterior capsule irregularity in 63.3% of eyes and confirmed the presence of anterior capsule defects in 47.5% and lens matter herniating into the anterior chamber in 15%. Hypoechogenic lacunae within the cataractous lens were detected in 12.5% of eyes. For UBM, sensitivity and specificity values were 82.86% (95% CI: 66.35-93.44) and 100% (95% CI: 47.82-100), respectively. Positive and negative predictive values for UBM were 100% (95% CI: 88.06-100) and 45.45% (95% CI: 28.69-63.32), respectively. The overall diagnostic accuracy of UBM was 85% [95% CI: 70.16-94.29].

CONCLUSION

Ultrasound Biomicroscopy (UBM) is essential for assessing suspected anterior capsule ruptures in phacoantigenic uveitis cases.

Prospective Cytokine Profiling in Aqueous Humor Reveals a Proinflammatory Microenvironment in Highly Dense Nuclear Cataracts

Purpose

To investigate if the cytokine profile in the aqueous humor (AH) of cataract patients varies according to cataract type and severity.

Methods

This prospective study included 397 eyes of 397 patients (median age, 76 years; range, 30-94 years) who underwent standard small-incision phacoemulsification surgery. Cataracts were graded using the LOCS III system: mild (≤3), moderate (3.5-5), and severe (≥5). Biometric measurements from the IOL master 700 (Zeiss, Oberkochen, Germany) were used to differentiate between thick (>4.5 mm) and thin lenses. Information about age, gender, and self-reported diseases was obtained from patient records. Eleven different proteins were measured in AH using a multiplex cytokine assay (AYOXXA Biosystems, Cologne, Germany), including IL- 6, IL-8, angiopoietin 2, C-reactive protein (CRP), vascular endothelial growth factor A (VEGF-A), platelet-derived growth factor BB, placental growth factor, CXCL12, CXCL13, and CXCL10. Statistical analysis was performed using R and included nonparametrical testing, linear regression, and k-means clustering.

Results

Higher nuclear LOCS grades correlated with increased levels of CCL2 (360 vs. 387 vs. 517 pg/mL, P < 0.001), VEGF-A (270 vs. 292 vs. 390 pg/mL, P = 0.012), IL-8 (3.1 vs. 4.2 vs. 5.7 pg/mL, P = 0.018), and CXCL10 (52 vs. 61 vs. 90 pg/mL, P = 0.003). No associations were observed for cortical and subcapsular cataracts. Thicker lenses were associated with significantly increased levels of CRP, CXCL10, CXCL12, IL-6, IL-8, and VEGF-A.

Conclusions

The cytokine profile of AH varies based on cataract grading and lens thickness. In highly dense nuclear cataracts, CCL2, VEGF-A, IL-8, and CXCL10 were elevated.

Mimickers of anterior uveitis, scleritis and misdiagnoses- tips and tricks for the cornea specialist

BACKGROUND

Anterior uveitis, inflammation of the anterior chamber and related structures, is a cohort of diseases that can present to almost any general or sub-specialty Ophthalmology practice. Its features classically involve anterior chamber cell and flare. Below the surface of these two signs exist a panoply of diagnoses. BODY: The purpose of this review is to provide a general framework for diagnoses of anterior uveitis that are often missed as well as non-uveitic pathologies that often mimic anterior uveitis. Diagnostic deviation in either direction can have vision-threatening and rarely life-threatening consequences for patients. Using a comprehensive literature review we have collected a broad spectrum of etiologies of anterior uveitis that are easily missed and non-uveitic pathologies that can masquerade as anterior uveitis.

CONCLUSIONS

We present a focused review on specific misdiagnosed anterior uveitis pathologies and some of the conditions that can masquerade as anterior uveitis and scleritis.

Exogenous Endophthalmitis

PURPOSE

Exogenous endophthalmitis (ExE) results from microbial infection as a complication of ocular surgery, penetrating ocular trauma, and intraocular foreign bodies. We herein review the classification of ExE, etiological agents, differential diagnosis and therapeutic challenges.

METHODS

Narrative Literature Review.

RESULTS

Identification of the causative agent through ocular fluid analysis is central in the diagnostic work-up of ExE. Prompt intravitreal antimicrobial therapy is key to successful management of ExE and vitrectomy is essential in severe cases. In culture-negative cases, and in the presence of specific features, a diagnosis of sterile intraocular inflammation or toxic syndrome should be suspected.

CONCLUSION

Strict adherence to treatment guidelines may improve outcomes of ExE, however the ultimate prognosis, especially in severe cases, may depend more on the virulence of the causative organism and associated ocular complications. Accurate differential diagnosis and effective treatment are crucial elements in the management and prognosis of non-infectious masquerades of ExE.

Polychromatic Aqueous and Vitreous Crystals Due to Phacolytic Glaucoma in a Patient With Marfan Syndrome and Lens Dislocation

Purpose: To describe a patient with Marfan syndrome and crystalline lens luxation who developed phacolytic glaucoma with polychromatic crystals in the anterior chamber and vitreous. Methods: We present a retrospective case report. Results: A 58-year-old man with Marfan syndrome and crystalline lens luxation since childhood presented with 2 days of pain in the left eye. The visual acuity was 20/30 OS with an aphakic contact lens, and the intraocular pressure (IOP) was 31 mm Hg. Polychromatic crystals were evident in the anterior chamber and vitreous. The retina was attached. Despite medical treatment, the IOP remained elevated; therefore, a pars plana vitrectomy and lensectomy were performed. At the last follow-up, the IOP was normal and the retina remained attached. Conclusions: Phacolytic glaucoma can be seen in eyes with a subluxated or luxated mature or hypermature lens. In these rare cases, iridescent crystals can be observed in the aqueous and vitreous. Vitrectomy with lensectomy is the definitive treatment.

Outcomes of manual small incision cataract surgery in hypermature/morgagnian cataract

PURPOSE

To evaluate the visual outcome and complication rate of manual small incision cataract surgery (MSICS) in hypermature morgagnian cataract (HMC).

SETTING

Aravind Eye Hospital, Pondicherry, India.

DESIGN

Retrospective, single center study.

METHODS

Case records of patients diagnosed with HMC and who underwent MSICS from January to December 2019 were retrospectively collected. Data were analyzed for demographic details, preoperative risk factors, intraoperative/postoperative complications, and visual outcome at 1-month follow-up.

RESULTS

105 patients were included in the study. Preoperative risk factors like dense pseudoexfoliation were seen in 6 patients (5.7%), phacolytic glaucoma in 7 patients (6.7%), lens induced uveitis in 5 (4.7%), and phacodonesis in 30 patients (28.5%). Overall intraoperative complication rate was 14.3%, which included posterior capsular rent (n = 4), zonular dialysis (n = 7), and whole bag removal (n = 4). Due to poor posterior capsular bag support, 7 patients (6.6%) did not receive intraocular lens implantation in primary surgery. Both the intraoperative and postoperative complication rate were high in those with risk factors, and this difference was statistically significant ( P < .001 and .0005, respectively). On the first postoperative day, 70 patients (66.7%) had a corrected distance visual acuity (CDVA) better than 20/40, and at 1 month, 98 patients (93.3%) had a CDVA of 20/60 or better of which 89.5% had CDVA of ≥20/40.

CONCLUSIONS

MSICS for hypermature cataract is relatively safe and yields adequate visual outcome. Preoperative risk factors, in addition to hypermaturity, increase the complication rate.

Corneal edema associated with degenerating Soemmering ring cataract: Clinical-pathologic correlation

Purpose

To report three patients with an uncommon delayed complication of cataract extraction: corneal edema following dispersion of calcific lens particles from a degenerating Soemmering ring cataract.

Observations

We report three patients, 75–92 years old, presenting with corneal edema and dispersed, degenerated calcific lens material in the anterior chamber and vitreous 20–30 years after cataract surgery. In all patients, calcific particles studded the posterior surface of the cornea in a gravity-dependent distribution without apparent inflammation and were associated with localized corneal edema. In one patient, calcific particles were also associated with secondary open angle glaucoma. Deposits originated from the calcified Soemmering ring cataract. Histopathological examination demonstrated extracellular calcific deposits compatible with cataractous lens material on the posterior surface of stripped Descemet membrane of two patients. The deposits were associated with prominent localized loss of corneal endothelium and were not associated with inflammation. Morphologically similar acellular material was identified in the biopsied aqueous and vitreous fluid of one patient. Management included endothelial keratoplasty, anterior chamber lavage, pars plana vitrectomy, aspiration/removal of a portion of Soemmering ring cataract without intraocular lens implant explantation, and the removal of the entire capsular bag/implant complex. Cornea cleared and visual acuity improved in both patients who underwent endothelial keratoplasty. Persistent elevated intraocular pressure led to visual deterioration in one patient with secondary glaucoma.

Conclusions and Importance

Dispersion of calcific Soemmering ring cataract can occur decades following cataract surgery leading to corneal edema, secondary glaucoma, and vitreous opacities. Timely recognition of this phenomenon may prevent ocular morbidity, including corneal edema and glaucoma.

Vitreoretinal surgery in the management of infectious and non-infectious uveitis - a narrative review

PURPOSE

This study aims to conduct a narrative review about the current role of vitreoretinal surgery in the management of infectious and non-infectious uveitis.

METHODS

This review was performed based on a search of the PubMed database or on relevant published papers according to our current knowledge.

RESULTS

A total of 91 articles were identified in the literature review. With the advance of microincision vitrectomy surgery (MIVS), pars plana vitrectomy (PPV) has gained increasing popularity in the management of infectious and non-infectious uveitis. For diagnostic purposes, larger amounts of sample can be obtained by MIVS than traditional vitreous aspiration using needles. For treatment purposes, PPV removes vitreous opacities, decreases inflammatory cytokines and mediators of inflammation, and tackles related complications, including hypotony, epiretinal membrane, macular holes, and retinal detachment. Achieving optimum control of inflammation prior to surgery is important for surgical interventions for non-emergent therapeutic indications and complications of uveitis. Peri-operative inflammation management is essential for decreasing the risk of surgical intervention. An overall complication rate of 42-54% was reported with cataract to be the leading cause of complications.

CONCLUSION

Most reports affirm the role of PPV in the management of infectious and non-infectious uveitis, although the quality of data remains limited by a lack of applying standardized reporting outcomes, limitations in study design, and a paucity of prospective data.

Lens nucleus dislocation in hypermature cataract: Case report and literature review

INTRODUCTION

Hypermature cataract is a form of late-stage cataract progression that can lead to a variety of complications. Spontaneous capsular rupture with lens nucleus displacement in hypermature cataracts has rarely been reported. We describe 2 cases of spontaneous dislocation of the lens nucleus in a hypermature cataract and perform a review of the literature on this complication.

PATIENT CONCERNS

We report 2 rural men aged 50 and 76 years with deteriorating vision.

DIAGNOSIS

The final diagnosis was senile hypermature cataract with dislocation of the lens nucleus in both patients and secondary glaucoma for the second patient.

INTERVENTIONS AND OUTCOMES

During admission, both patients complained of deteriorating vision. Slit-lamp examination showed lens nucleus dislocation into the anterior chamber. The 50-year-old patient exhibited a residual lens capsule and a turbid cortex, with a normal anterior chamber and intraocular pressure. The 76-year-old patient presented a shrunken and ruptured capsule and no cortex in the pupillary area, mild inflammation in the anterior chamber, and high intraocular pressure. Both patients underwent intracapsular cataract extraction combined with anterior vitrectomy and achieved good postoperative recovery.

CONCLUSION

Lens nucleus dislocation in hypermature cataracts can be seen in clinical practice, particularly in underdeveloped areas. Early recognition and surgery can improve vision.

Hypopyon: Is-it Infective or Noninfective?

Hypopyon usually corresponds to the sedimentation of white blood cells, and it signifies severe intraocular inflammation. This key clinical sign may occur in association with a wide variety of infectious, inflammatory, and neoplastic conditions that may be sight- and, occasionally, life-threatening. A careful history and thorough clinical examination are the cornerstones for orienting the differential diagnosis, identifying the causative agent, and initiating prompt and appropriate treatment. This review outlines the clinical characteristics and management of hypopyon in relation with the underlying causative infectious or noninfectious ocular or systemic diseases.

Posterior lens capsule neovascularization treated with anti-VEGF complicated by phacogenic uveitis

Purpose

To report a case of neovascularization of posterior capsule (NVPC) successfully treated with intravitreal ranibizumab (Lucentis) and neodymium:YAG (Nd:YAG) capsulotomy, followed by phacogenic uveitis.

Observations

We report a systemically otherwise healthy 81-year-old male presenting with unilateral NVPC and iris (NVI) occurring five years after a central retinal vein occlusion. A single intravitreal injection of ranibizumab led to complete regression of NVPC and NVI within three weeks after which a Nd:YAG capsulotomy was performed. Two weeks later, the patient returned with a severe inflammatory reaction diagnosed as phacogenic uveitis and treated with surgical capsular bag/intraocular lens complex removal and peripheral pan-retinal photocoagulation. One-year follow-up demonstrated no recurrence of NVPC. Visual acuity remained at baseline of light perception.

Conclusions

We acknowledge that intravitreal anti-vascular endothelial growth factor treatment with Nd:YAG capsulotomy for NVPC is a rational option, but raise awareness to the rare possibility of phacogenic uveitis.

A Rare Case of Lens-Induced Uveitis with Proliferative Vitreoretinopathy and Massive Encapsulation of Fallen Nuclear Material

We experienced a rare case of lens-induced uveitis (LIU) with severe proliferative vitreoretinopathy (PVR) diagnosed upon finding lens nuclear material encapsulated by intravitreal proliferative tissue. A 60-year-old man was referred to our hospital for the treatment of vision loss caused by unexplained uveitis in the right eye (OD). Seven months previously, a complicated cataract surgery that required unplanned anterior vitrectomy and transscleral suture of intraocular lens was performed on that eye at another clinic. Severe inflammation with dense vitreous opacity occurred in the OD postoperatively. Although topical and oral administration of steroids reduced the inflammation 7 months after the surgery, PVR with tractional retinal detachment was developed in the OD. Pars plana vitrectomy (PPV) was performed for the treatment and diagnosis. PPV revealed the presence of lens nuclear fragments within the vitreous, which was approximately 60% the ordinary nucleus size and was encapsulated by intravitreal proliferative tissue. The nuclear fragments were extracted from a superior corneoscleral flap. Intraocular inflammation was reduced with postoperative topical and oral steroid treatments and the retina remained reattached 1 year after the PPV. In conclusion, uveitis with an episode of a complicated cataract surgery may suggest LIU.

Lens-Induced Uveitis Triggered by Intravitreal Injection 40 Years after Primary Congenital Cataract Surgery with Aphakia

We report a case of a 42-year-old male with a history of bilateral congenital cataract surgery performed at 2 years of age. The patient was left with aphakia, secondary glaucoma, and a history of diabetic macular edema in the setting of diabetes mellitus type 1. The right eye became prephthisical from his congenital surgical repair, and his left eye presented with an acute pseudo-endophthalmitis developing after the seventh intravitreal injection to treat the macular edema. The eye then presented with decrease in vision, periocular injection, and a diffuse inflammatory reaction focused around the anterior residual lens capsule. The patient underwent surgical removal of the residual capsule and primary vitrectomy repair of the eye, achieving a significant improvement in visual symptoms and recovery of visual and anatomic function.