Phacogenic uveitis (phacoanafilaxia): causes, symptoms, diagnosis, treatment
Last reviewed: 23.04.2024
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Phacogenic uveitis, phacoanafilactic uveitis, is a rare granulomatous inflammatory process that develops when the tolerance of the immune system to lens proteins is impaired, usually accompanied by hypotension. Phacogenic uveitis is often observed:
- after extraction of a cataract;
- traumatic rupture of the capsule of the lens;
- extraction of cataracts on one and the subsequent extraction of cataracts or the release of lens material in mature cataracts on the other eye.
[Pathophysiology of phacogenic uveitis
It was suggested that phacogenic uveitis is a disease that develops with immune rejection of previously sequestered lens proteins. However, the proteins of the lens were also found in the intraocular fluid of healthy eyes. Currently, it is believed that with phacogenous uveitis, the tolerance of the immune system to lens proteins is impaired, since phacogenous uveitis does not always develop when the lens capsule ruptures. Cousins and Kraus-Mackiw suggest that phacogenic uveitis is a range of diseases with autoimmune, infectious and toxic mechanisms of development. In humans, the autoimmune theory was not proven, but in a rat experiment, the phacogenic granulomatous endophthalmitis was very similar to phacogenic uveitis. In animals sensitive to lens homogenate, with its surgical damage, uveitis developed histologically similar to phacogenic uveitis. With an infectious mechanism, the inflammatory response develops to inactive bacteria, for example, Propionibacterium acnes, found in the lens, or when the bacteria provoke a violation of the immune tolerance of the eye. According to the theory of the toxicity of the lens, with an inflammatory reaction without prior immunization, the lens material exerts a direct inducing action. These three theories may possibly explain the development of phacogenic uveitis, but none of them has been proven. Unfortunately, phacogenic uveitis is often diagnosed after enucleation, when studying the histological material, when the zone granulomatous inflammation is determined with three cell populations found around the lens substance:
- zone 1 - neutrophils, tightly surrounding and infiltrating the lens;
- zone 2 - monocytes, macrophages, epithelioid cells and giant cells surrounding neutrophils;
- zone 3 is a nonspecific infiltrate from mononuclear cells.
Symptoms of phacogenic uveitis
Patients complain of pain, decreased vision and redness of the eye.
Clinical examination
The onset of the disease is different, for most cases, flaccid inflammation of the anterior segment of the eye, especially after surgical extraction of cataract, is characteristic. The remaining substance of the lens dissolves. And the inflammation stops. Panoveitis with hypopion is a more serious manifestation of the disease, which is difficult to differentiate from endophthalmitis. In the anamnesis, there is usually an indication of the remaining fragments of the lens in the vitreous body. The granulomatous inflammatory reaction develops within a few days or months after the destruction of the lens. Phacogenous uveitis, as a rule, is accompanied by hypotension, sometimes increased intraocular pressure, and an increase in intraocular pressure is possible. Precipitates are visible on the cornea, synechiae cause a pupillary block or open-angle glaucoma.
Special tests
Aspirated intraocular fluid or vitreous with negative bacterial cultures help differentiate phacogenic uveitis from bacterial endophthalmitis. The results of cytology rarely matter. Using ultrasound, after a surgical removal of cataracts or trauma, large fragments of the lens in the vitreous cavity are determined.
Treatment of phacogenic uveitis
Continuously flowing uveitis in the absence of treatment leads to phthisis. The process is limited by the use of glucocorticoids topically and inwardly or by administration under the tenon membrane. The final treatment is the removal of lens fragments, optimally, with pars plana vitrectomy . Earlier the prognosis in severe cases of phacogenic uveitis was unfavorable, but at present with modern surgical techniques and equipment the possibility of maintaining a good visual acuity is higher.