Phacoanaphylactic Endophthalmitis Research Articles

Phacoanaphylactic endophthalmitis as sympathetic ophthalmia after corneoscleral injury

A penetrating corneoscleral injury case with the development of bilateral phacoanaphylactic inflammation of a sympathetic ophthalmia kind in a 59-year-old woman is described. The case reveals a difference between bilateral phacoanaphylactic inflammation and classical sympathetic ophthalmia. Unlike the latter, the clinical case showed on the “healthy” eye a sluggish inflammation of anterior uveitis type with a slowly progressing lens opacity, for which local and systemic corticosteroid therapy proved insufficiently effective. The morphological picture showed that the inflammation was located in the anterior part of the eye around the damaged lens with the formation of a macrophage-neutrophil abscess, which is typical for phacoanaphylactic inflammation, and the absence of granulomatous inflammation in the ciliary body, where plasmacellular infiltration prevailed.Conclusions. Phacoanaphylactic inflammation and sympathetic inflammation are autoimmune in their nature having different autoantigens. In phacoanaphylactic inflammation, autoantigen is the lens protein, while in sympathetic inflammation it is the uveoretinal antigen. The only method of treating phacoanaphylactic inflammation is to remove the cataract-altered lens. Our patient underwent phacoemulsification in her single eye, after which the symptoms of uveitis with hypertension disappeared completely and her vision was restored.

Sympathetic Ophthalmia - a Contribution to Immunology, Clinic and Current Imaging.

Sympathetic ophthalmia (SO) is a rare inflammation of an operated or injured eye that spreads to the fellow eye. It is typically a bilateral granulomatous panuveitis. The traumatized eye is referred to as inciting eye and the fellow eye as sympathizing eye. The pathophysiology of the disease is not entirely understood, but there is strong evidence of an autoimmune genesis. A selective literature search on epidemiology, immunology, clinical features and risk factors of SO was carried out. In addition, our own experience using multimodal imaging for this clinical entity was introduced. In the literature, the incidence after traumatic eye injuries is 0.1 - 3% and approximately 0.01% after intraocular surgery. Among the iatrogenic causes, vitreoretinal surgery has the highest rate of SO, presumably due to disruption of the blood-retinal barrier and involvement of retinal and choroidal tissue, which are susceptible to anterior traction, phthisis and chronic inflammation. In 90% of patients, the disease develops within a year following the eliciting event and is associated with a potentially bilateral risk of blindness. Typical symptoms include bilateral visual impairment with photophobia, dull pain and photopsia. The spectrum of clinical manifestations ranges from granulomatous anterior uveitis and vitritis, to choroiditis, serous retinal detachment and Dalen-Fuchs nodules in the context of posterior involvement. The diagnosis of SO is generally based on clinical presentation and is supported by imaging methods. These primarily comprise fluorescein and indocyanine green angiography, which are increasingly being supplemented by non-invasive methods such as optical coherence tomography. They can provide important information for assessment of severity, differential diagnosis as well as for disease monitoring. The differential diagnosis includes i. a. Vogt-Koyanagi-Harada syndrome, ocular sarcoidosis and the rare phacoanaphylactic endophthalmitis. Immediate systemic high-dose steroid therapy is used as initial treatment. The course of the disease is often relapsing to chronic progressive. Immunomodulators such as ciclosporine A, azathioprine, cyclophosphamide, mycophenolate mofetil, and biologics are increasingly being used and contribute to the significantly better prognosis of the disease. Generally, SO can be triggered by any kind of intraocular intervention. SO remains a threatening clinical diagnosis that poses diagnostic and therapeutic challenges. It can be triggered post-traumatic, but also any intraocular surgery. This should be taken into account when assessing the indication for intraocular eye surgery, especially in eyes with reduced visual outcome.

A case of phacoanaphylactic glaucoma and endophthalmitis caused by intraocular glass foreign bodies for 20 years

A case of phacoanaphylactic glaucoma and endophthalmitis caused by intraocular glass foreign bodies for 20 years

Man With Vision Loss and Eye Pain

A 51-year-old man presented to the emergency department, complaining of vision loss and ocular pain 10 days after he received vitrectomy for nonclearing vitreous hemorrhage in his left eye. On ophthalmology consultation, his visual acuity was hand motions and intraocular pressure was 40 mm Hg in the left eye. Slit-lamp biomicroscopic examination (Figure 1) and ocular ultrasonography (Figure 2) were conducted. Aqueous humor and vitreous cultures were performed.Figure 2Ocular ultrasonographic image showing an ovoid lesion (asterisk) with moderate internal reflectivity.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Phacoantigenic uveitis (phacoanaphylactic endophthalmitis) with glaucoma and dislocated lens. Slit-lamp biomicroscopic examination (Figure 1) showed ciliary congestion, corneal edema, and fluffy lenticular materials (white arrow) on the top of blood-tinged hypopyon (black arrow). Ocular ultrasonography (Figure 2) revealed vitreous opacity and dislocated lens (asterisk). Pars plana vitrectomy and lensectomy were performed. During the surgery, the dislocated lens was identified in the vitreous cavity, without obvious signs of infectious endophthalmitis. No growth of organisms was identified in vitreous and aqueous samples. Three months after surgery, his final vision was 4/200 because of myopic maculopathy. Phacoantigenic uveitis typically develops 1 to 14 days after traumatic or surgical perforation of the lens capsule and is characterized by a granulomatous antigenic reaction to lens protein.1Marak Jr., G.E. Phacoanaphylactic endophthalmitis.Surv Ophthalmol. 1992; 36: 325-339Abstract Full Text PDF PubMed Scopus (56) Google Scholar Clinically, phacoantigenic uveitis can be difficult to distinguish from other forms of postoperative uveitis or endophthalmitis. Findings can range from mild anterior uveitis to fulminant endophthalmitis with hypopyon. Initial therapy is to control the intraocular pressure with intraocular pressure-decreasing medications and to reduce the inflammation with topical steroids. When phacoantigenic uveitis follows lens trauma, as with our patient, surgery is required for definitive treatment.

Blindness of Johann Sebastian Bach

Johann Sebastian Bach (1685-1750) was one of the greatest composers of all time. Apart from performing as a brilliant organist, he composed over 1.100 works in almost every musical genre. He was known as a hardworking, deeply Christian person, who had to support his family of 20 children and many students staying at his home. At the age of 64 years, his vision started to decline. Old biographies claim that it was the result of overstressing his vision in poor illumination. By persuasion of his friends, he had his both eyes operated by a travelling British eye surgeon. A cataract couching was performed. After surgery, Bach was totally blind and unable to play an organ, compose or direct choirs and orchestras. He was confined to bed and suffering from immense pain of the eyes and the body. He died <4 months after surgery. In this paper, as the plausible diagnosis, intractable glaucoma because of pupillary block or secondary to phacoanaphylactic endophthalmitis is suggested.

Tamsulosin and the Intraoperative Floppy Iris Syndrome

THE INTRAOPERATIVE FLOPPY IRIS SYNDROME (IFIS) was first described by Chang and Campbell in 2005. These authors and others observed that there was a tendency for poor pupillary dilation and the intraoperative triad of the billowing of a flaccid iris, the propensity for iris prolapse, and progressive intraoperative pupillary constriction. In the current technique ophthalmologists perform cataract surgery through a 2.5-mm incision. A widely dilated pupil is essential for complication-free surgery. Billowing of the iris into the surgical field and poor pupillary constriction are potentially catastrophic barriers to successful surgery. Intraoperative floppy iris syndrome is encountered mainly in cataract surgery and in prospective studies has been found to occur in 2% to 3% of all cataract operations and to a lesser extent in glaucoma surgery. The strong association of IFIS with systemic (oral) administration of the 1aselective adrenergic antagonist tamsulosin, the commonly prescribed medication for treatment of benign prostatic hyperplasia, has been noted. In a prospective study involving 167 cataract operations, nearly 90% of the eyes of patients taking tamsulosin were diagnosed with IFIS. Indeed, all drugs of this class of 1antagonists are associated with the development of IFIS, although drugs with an affinity for 1a-receptors (tamsulosin and silodosin) are more commonly associated with IFIS. 1-Receptors are present in the dilator muscle and in the smooth muscle of the arteriolar wall in the iris. Intraoperative floppy iris syndrome has also been associated with the administration of finasteride and duasteride and saw palmetto. Women are not immune to the syndrome because tamsulosin is used in the treatment of obstruction due to renal calculi. The IFIS is not associated with iris color, diabetes mellitus, or pseudoexfoliation. Successful full dilation of the pupil is proportional to the amount of pigment present (eg, blue irides will dilate more rapidly and more fully than heavily pigmented brown irides). However, IFIS is associated with increased intraoperative risk and complications, such as iris prolapse, pupillary miosis, iris trauma, iris aspiration, iridodialysis, hyphema, posterior lens capsular rupture, and vitreous loss. Posterior capsular rupture may lead to dislocation of lens fragments into the vitreous body and vitreous loss, setting the stage for secondary complications such as retinal detachment and severe postoperative inflammation (phacoanaphylactic endophthalmitis). These untoward events are associated with the necessity of performing additional surgical procedures in the early postoperative period. Until now, however, those in the ophthalmologic community have not had good evidence about how great the risk of tamsulosinassociated IFIS might be and whether the risk is modifiable through cessation of the drugs. In this issue of JAMA, Bell and colleagues report the results of a nested case-control analysis of a populationbased retrospective cohort study using linked health care databases from Ontario, Canada. Among men aged 66 years or older who had cataract surgery between 2002 and 2007, 3550 patients (3.7%) had recent exposure to tamsulosin and 7426 (7.7%) had recent exposure to other -blockers. Serious ophthalmologic adverse events occurred in 284 patients (0.3%) and were significantly more common among patients with recent tamsulosin exposure (adjusted odds ratio, 2.33; 95% confidence interval, 1.22-4.43). These findings regarding the serious consequences of tamsulosin-related IFIS in the 14-day period following cataract surgery are most certainly the consequence of posterior capsular rupture, loss of lens fragments into the vitreous body, and vitreous loss. Retinal detachment is a potential consequence of these events and one of the more serious complications of IFIS. The presence of retained lens material in the vitreous body is a strong irritant and may lead to phacoanaphylactic endophthalmitis. It is not surprising that cytological study of vitreous material removed at the time of surgery for retinal detachment or retained lens material or both is invariably associated with the preoperative administration of tamsulosin and an attendant IFIS at the time of cataract surgery. The presence of 1-adrenoreceptor subtypes in the iris dilator muscle has been previously demonstrated. Through careful studies of these receptors, our group has proposed

Sympathetic Ophthalmia Following Vitrectomy for Endophthalmitis After Intravitreal Bevacizumab

Purpose: To describe a case of sympathetic ophthalmia following vitrectomy for endophthalmitis after an intravitreal injection of bevacizumab. Design: Retrospective case report. Methods: An 84-year-old male developed sympathetic ophthalmia 4 months after vitrectomy for endophthalmitis following an intravitreal injection. The inciting blind eye was enucleated. Results: Histopathology demonstrated sympathetic ophthalmia and phacoanaphylactic endophthalmitis. Visual acuity improved from 20/200 to 20/30 in the sympathizing eye with a combination of oral prednisone and azathioprine. Conclusions: Sympathetic ophthalmia can develop following exogenous endophthalmitis but has a good visual prognosis with appropriate treatment.

Phacoanaphylactic endophthalmitis secondary to capsular block syndrome

A 65-year-old white man presented with sudden onset of painless decrease in vision and a red eye 5 days after cataract surgery. The visual acuity was 20/400 with mild injection. Marked iritis was present, and a hypopyon could be seen behind the intraocular lens (IOL) in the capsular bag. The posterior segment was clear. The iritis worsened despite 4 days of hourly topical corticosteroid treatment. Anterior chamber washout was performed, with clearing of the material behind the IOL. The iritis subsided 4 weeks later, and visual acuity recovered to 20/20. Capsular block syndrome can present as phacoanaphylactic endophthalmitis if cortical material is left in the capsular bag, requiring surgical intervention.

Sympathetic Ophthalmia Following Postoperative Bacterial Endophthalmitis: A Clinicopathologic Study

Clinical and histopathologic documentation of sympathetic ophthalmia (SO) development in eyes with postoperative bacterial endophthalmitis. Observational case series; retrospective clinicopathologic study. All patients who presented with a clinical diagnosis of SO during 2002 to 2004 were included in the study. The diagnosis of SO was made on the basis of history of penetrating ocular injury, followed by development of bilateral intraocular inflammation, ultrasonographic detection of bilateral diffuse thickening of the choroid, or both. Patients presenting with the additional finding of hypopyon underwent an anterior chamber tap and vitreous aspirate for microbiologic detection of bacteria and fungi. Eight exciting eyes were enucleated and submitted for histologic examination. Of a total of 26 patients with a clinical diagnosis of SO, four also had bacterial endophthalmitis. Of these, histologic examination of three exciting eyes revealed vitreous abscess and typical features of SO. Of the five remaining enucleated globes, histologic examination showed that two eyes had phacoanaphylactic endophthalmitis, and two others revealed features of SO; the one remaining eye had nongranulomatous diffuse choroiditis. Bacterial endophthalmitis cannot prevent the development of SO. Early diagnosis of coexistent mixed infectious and inflammatory processes, and initiation of antimicrobial treatment directed at the infection followed by immunomodulatory agents to address the autoimmune component may improve the prognosis in such cases.

The contribution of aqueous humor cytology in the differential diagnosis of anterior uvea inflammations

Background:Cytology of the aqueous humor can confirm the diagnosis of many intraocular conditions by revealing inflammatory cells, ghost red cells, lens material, and microorganisms. Purpose:The purpose of this study was to emphasize the contribution of aqueous humor fine needle aspiration cytology in cases where there is a clinical diagnostic dilemma whether an infectious or a noninfectious inflammatory process of the uvea is present. Methods:Collection of 0.15–0.2 ml aqueous humor was carried out with an insulin needle. The aspirated aqueous was then prepared for examination using either the Cytospin or the Thin-Prep technique and smears were stained with modified Papanikolaou and May-Grünwald-Giemsa stains. Results:Cytology of the aqueous humor essentially facilitated the differential diagnosis in 16 cases with an anterior uveal inflammation clinical picture. The cases included phacoanaphylactic endophthalmitis (n = 6), chronic postoperative bacterial endophthalmitis (n = 3), phacolytic glaucoma (n = 2), ghost cell glaucoma (n = 2), metastatic endophthalmitis (n = 1), post-traumatic lenticular abscess (n = 1), and iridocyclitis (n = 1). Treatment of the cases was successful. Conclusions:In selected cases, cytology of the aqueous humor reveals specific, with regard to the clinical entity, cell populations and other elements and thus contributes effectively to the differential diagnosis and therapeutic approach to some anterior uvea inflammations.

Diagnosis of Phacoanaphylactic Endophthalmitis by Fine Needle Aspiration Biopsy

Diagnosis of phacoanaphylactic endophthalmitis (or lens induced uveitis), a rare autoimmune disease, is difficult due to variable clinical presentation. We sought to diagnose a case based on the cytopathology of the anterior chamber aspirate. This is a case report of spontaneous phacoanaphylactic endophthalmitis in a 79-year-old woman with no history of eye trauma or surgery. After clinical examination, diagnostic anterior chamber paracentesis was performed. Cytologic examination of the aspirate revealed polymorphonuclear leukocytes, histiocytes, and plasma cells surrounding amorphous lens material. A mature cataract was removed subsequently, and the eye has remained free of inflammation postoperatively. As the clinical diagnosis of phacoanaphylactic endophthalmitis is often difficult, cytopathology of an anterior chamber aspiration specimen may be useful in diagnosing this rare, treatable condition. As far as we know, this is the first case report of the diagnosis of phacoanaphylactic endophthalmitis solely by anterior chamber fine needle aspiration biopsy.

Intraocular inflammation in transgenic mice expressing a foreign antigen in their lens a preliminary report

Lens-induced uveitis can be elicited in experimental animals by immunization with lens antigens, followed by puncture of the lens capsule. The animal disease, that serves as a model for the human disease (also known as phacoanaphylactic endophthalmitis), has been shown to be mediated by antibodies against the lens antigens. Here the authors report on a new disease model for lens-induced uveitis which is cell-mediated. This experimental disease is induced in transgenic (Tg) mice that express hen egg lysozyme (HEL) in their lens. Eyes of these mice show disrupted lens, but no inflammation. On the other hand, severe inflammation develops in eyes of these Tg mice following intraperitoneal injection of lymphocytes from syngeneic wildtype donors sensitized against HEL. Furthermore, the recipient mice exhibit intense cellular immunity but no antibodies against HEL.

Phacoanaphylactic endophthalmitis: a clinicopathologic review

Lens-induced uveitis or phacoanaphylactic endophthalmitis (PE) is a chronic endophthalmitis with a zonal granulomatous inflammation surrounding a ruptured lens. One hundred forty four cases of PE were retrospectively evaluated clinically and histopathologically. The disease was not well recognized clinically as only six of the cases were given the clinical diagnosis of PE. Most cases (80%) occurred after trauma, surgical or non-surgical. The time after injury varied from two days to fifty nine years. Of those individuals less than 55 years of age who had no history of trauma. 29% were noted by clinical history to have microphthalmia. Although classically the inflammation of PE has been described as being confined to the anterior aspect of the eye, the choroid was involved with an inflammatory reaction in 76% of the cases.

Localized endophthalmitis: A newly described cause of the so-called toxic lens syndrome

We report five cases of post-extracapsular cataract extraction infection in which subsequent pathologic analyses identified the organisms and found the infection to be localized or confined to the lens capsular sac. The most common offending organisms were gram-positive pleomorphic bacilli. In one case, we were able to identify the bacteria as Propionibacterium acnes. We designate this condition a localized endophthalmitis. It should be considered any time a persistent, smoldering, postoperative inflammation occurs, and in the differential diagnosis of phacoanaphylactic endophthalmitis. The condition itself is not new, but undoubtedly many such cases have gone unrecognized or have been misdiagnosed as the so-called toxic lens syndrome. In localized endophthalmitis, a clinically visible inflammatory process may occur even when multiple diagnostic taps are negative, although when the cases first appeared, the surgeons were not aware of the entity and anaerobic cultures were not always obtained. A negative tap may be explained by the fact that metabolic products from the organisms are released from the bag into the anterior segment and vitreous. A synergistic reaction may occur between these organisms and retained lens cortical remnants that may cause or exacerbate a hypersensitivity reaction. The condition may be worsened by Nd:YAG capsulotomy. The pathogenesis of localized endophthalmitis has nothing to do with the type of intraocular lens fixation (lens capsular sac or ciliary sulcus); rather, the simple presence of a capsular sac after extracapsular cataract extraction is the prerequisite for the clinical condition.

Modulation of experimental phacoanaphylactic endophthalmitis with the antioxidants sodium benzoate, and 2,3-dihydroxybenzoic acid.

The antioxidants sodium benzoate and 2,3-dihydroxybenzoic acid reduced the inflammatory response in experimental phacoanaphylactic endophthalmitis. The 2,3-dihydroxybenzoic acid was by far the more effective antiphlogistic agent. The molecular mechanisms that may have contributed to the observed difference in antiphlogistic activity are discussed.

Pseudophakic Phacoanaphylactic Endophthalmitis

Two cases of pseudophakic phacoanaphylactic endophthalmitis are reported. Both responded favorably to a total posterior capsulectomy performed in addition to removal of the intraocular lens and remaining cortical material. Current theories on phacoanaphylactic endophthalmitis are discussed. Excision of the entire posterior capsule with anterior capsular flaps and entrapped cortex is emphasized as an integral part of the treatment of this condition.

Antiphlogistic effect of catalase on experimental phacoanaphylactic endophthalmitis.

Oxygen-derived free radicals generated by polymorphonuclear leukocytes have recently been implicated as important pathogenic mediators of tissue damage in immune complex-mediated acute inflammatory reactions. In order to study the role of oxygen radicals in experimentally induced phacoanaphylactic endophthalmitis, rats were immunized with soluble bovine lens protein and, following surgical disruption of the anterior lens capsule, subjected to treatment with catalase. Our data show that phacoanaphylactic endophthalmitis, as determined morphologically and by measurements of retinal edema, choroidal inflammation, retinal hemorrhage and necrotizing vasculitis, is greatly diminished in catalase-treated animals. This protective effect of catalase indicates that hydrogen peroxide (H2O2) and/or conversion products of H2O2 (e.g., hydroxyl radical, hypochlorous acid) may play an important role in the development of experimental phacoanaphylactic endophthalmitis.

Modulation of Lens-Induced Uveitis by Superoxide Dismutase

Recent studies on reactive oxygen metabolites have suggested that these products may be important mediators in the early tissue damage that develops from immunopathologic inflammations. The superoxide anion appears to be the principal product of the respiratory burst. In order to determine the effects of removing superoxide with superoxide dismutase on modulating the inflammation in experimental phacoanaphylactic endophthalmitis, the animals with this experimental disorder were treated with superoxide dismutase. The treatment resulted in significant reduction of choroidal inflammation, retinal edema and vasculitis, suggesting phlogogenic role of superoxide in the ocular immune-complex disease.

Antioxidant modulation of phacoanaphylactic endophthalmitis.

Catalase treatment reduces the expected inflammation in experimental phacoanaphylactic endophthalmitis. Catalase is a scavenger of hydrogen peroxide and presumably protects against the cytolytic effects of reactive oxygen metabolites. Recent work indicates that oxygen-derived free radicals may play a critical role in the early tissue damage in immune complex disease.

Experimental lens-induced granulomatous endophthalmitis in common laboratory animals.

Guinea pigs and mice after immunization with lens proteins were observed to develop a typical form of experimental phacoanaphylactic endophthalmitis after lens injury. Sensitization to lens protein elicited a good antibody response in rabbits, however no disease developed after lens injury. This is another example of frequent discrepancies between autoimmune responses and autoimmune disease and indicates the importance of investigating mechanisms of phlogogenicity in autoimmune disease.