Lens-related uveitis and glaucoma

When lens proteins penetrate through an intact or damaged capsule into the anterior chamber of the eye or the vitreous cavity, a strong intraocular inflammatory reaction is triggered, which can result in a disruption of the outflow of intraocular fluid with the development of an acute increase in intraocular pressure or glaucoma.

Release of lens proteins usually occurs as a result of accidental or surgical damage to the capsule or is associated with cataract progression. Conditions that cause lens-related uveitis and glaucoma include phacoantigenic uveitis, phacolytic glaucoma, lens mass glaucoma, and phacomorphic glaucoma. Uveitis and glaucoma may also develop as a complication of intraocular lens implantation.

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Epidemiology of lens-related uveitis and glaucoma

The incidence of glaucoma in the various forms of lens-related uveitis is unknown, although the condition has been well studied. One study reported data on patients with phacoanaphylactic uveitis (phacoantigenic uveitis), in which glaucoma was found in 17% of cases.

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Causes of lens-related uveitis and glaucoma

Typically, in lens-related glaucoma, the outflow of intraocular fluid is impaired at the level of the trabecular meshwork. In phacoantigenic uveitis, altered lens proteins cause the development of a granulomatous inflammatory process, which can result in the formation of synechiae and blockage of the trabecular meshwork. In phacolytic glaucoma, the trabecular meshwork is obstructed by lens proteins and protein-filled macrophages, and in glaucoma associated with lens masses, fragments of cortical masses damage the trabecular meshwork of the lens. In phacomorphic glaucoma, unlike other types of lens-related glaucoma, when the anterior chamber angle is open, swelling of the lens leads to the development of pupillary block or anterior displacement of the iris, which leads to the formation of a slit-like anterior chamber and acute angle closure. In pseudophakia, intraocular inflammation may be due to previous uveitis, delayed onset of postoperative endophthalmitis, or irritation of the choroid by the intraocular lens. The development of glaucoma occurs due to damage to the trabecular meshwork, formation of synechiae on the intraocular lens with the development of pupillary block or peripheral anterior synechiae and closure of the anterior chamber angle.

Symptoms of uveitis and glaucoma related to the lens

Phacoantigenic uveitis, phaco-anaphylactic uveitis or phaco-anaphylactic endophthalmitis, develops as a result of the release of lens proteins when its capsule ruptures. The disease develops several days or weeks after traumatic or surgical damage to the lens. When examining the patient, redness and soreness of the eyeball are detected. Rarely, with phacoantigenic uveitis, sympathetic ophthalmia and inflammation of the second eye develop.

Phacolytic glaucoma usually occurs in older patients with mature or hypermature cataracts, resulting from leakage of lens proteins through an intact but permeable capsule. Phacolytic glaucoma usually presents as sudden pain and redness in the visually impaired eye that previously had a cataract.

Glaucoma associated with lens masses (phacotoxic uveitis) occurs with any injury that causes cortical lens masses to enter the anterior chamber. Typically, increased intraocular pressure develops days to weeks after the injury.

In phacomorphic glaucoma, the capsule is usually not damaged, and there is no pronounced inflammatory process in the eye. With low visual acuity due to cataracts, pain and redness associated with the closure of the anterior chamber angle appear.

Uveitis-glaucoma-hyphema syndrome is a common cause of postoperative inflammation and glaucoma in patients who have undergone implantation of first-generation rigid anterior chamber intraocular lenses. The syndrome is associated with incorrect selection of lens size or manufacturing defects in the lens material, which leads to mechanical irritation of the anterior chamber structures. In chronic or severe postoperative inflammation that develops in patients who have undergone posterior chamber implantation of an intraocular lens, pseudophakic inflammatory glaucoma may develop.

Course of the disease

The clinical course of lens-related glaucoma is relatively short due to the high efficiency of surgical methods.

Diagnosis of lens-related uveitis and glaucoma

Ophthalmological examination

On external examination of patients with lens-associated glaucoma and acute uveitis, conjunctival and ciliary injection of the eyeball are detected. There may be signs of damage to the eyeball. With a marked increase in intraocular pressure, corneal edema is noted. The anterior chamber fluid is usually opalescent, contains inflammatory cells, and granulomatous and nongranulomatous precipitates are found on the cornea. White flocculent matter and fragments of cortical lens masses may be present in the intraocular fluid and in the area of the anterior chamber angle. The anterior chamber angle may be open, narrow, or closed. Peripheral anterior and posterior synechiae are often observed. In phacoantigenic uveitis and lens-associated glaucoma, signs of damage to the lens capsule or free lens masses are usually found. In phacolytic or phacomorphic glaucoma, a hypermature or swelling cataract is detected, respectively, and in pseudophakic inflammatory glaucoma, an intraocular lens is detected. When examining the posterior segment of the eye, inflammatory cells and opacities of the vitreous body, lens masses in the vitreous cavity, and other signs of damage to the eyeball can be detected.

Differential diagnostics

Phacoantigenic and lens mass-related glaucoma should be differentiated primarily from posttraumatic and postoperative endophthalmitis. In phacomorphic glaucoma, other causes of anterior chamber angle closure should be excluded.

Laboratory research

The diagnosis of uveitis and glaucoma associated with the lens is made on the basis of clinical data, there is no need for laboratory methods of examination. Histological examination of the lenses of patients suffering from phacoantigenic uveitis reveals zonal granulomatous inflammation localized at the site of lens damage.

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Treatment of uveitis and glaucoma associated with the lens

Radical treatment of uveitis and glaucoma associated with the lens is cataract extraction or removal of the lens mass or intraocular lens. Before surgery, the inflammatory process should be stopped with local glucocorticoids and intraocular pressure should be normalized with antiglaucoma drugs. In phacomorphic glaucoma, if cataract extraction is impossible or surgery needs to be postponed, laser iridotomy should be performed after drug-induced reduction of intraocular pressure.