BASICS

DESCRIPTION

A zonular granulomatous-type of inflammation that centers on retained lens material in the involved eye or in the fellow eye.

EPIDEMIOLOGY

• Seen in eyes with traumatic disruption of the lens or that have undergone extracapsular cataract extraction

• Usually seen in the 6th or 7th decade coinciding with the average age of cataract extraction

• Slightly higher male prevalence

GENERAL PREVENTION

Meticulous removal of lens material during cataract extraction

PATHOPHYSIOLOGY

• Disruption of the lens capsule, either traumatic or surgical

• A period of time, wherein there is a sensitization to lens protein that occurs

• A chronic and persistent inflammation then ensues

ETIOLOGY

• Autologous lens protein has been shown to be antigenic.

• Sensitization occurs only when there is a violation of the lens capsule.

COMMONLY ASSOCIATED CONDITIONS

• Glaucoma is related to the accumulation of leukocytes, epithelioid, and giant cells in the trabecular meshwork.

• Lens protein and lens particles may also be found in the trabecular meshwork and may additionally account for the associated glaucoma.

DIAGNOSIS

HISTORY

Prior cataract surgery, lens trauma, or rarely spontaneous rupture of the lens capsule with prolonged period of low-level persistent inflammation.

PHYSICAL EXAM

• Inflammation with associated photophobia and ciliary’s injection

• Anterior chamber cell and flare

• The aqueous may contain lens fragments.

• Often mutton-fat keratic precipitates and posterior synechia are present.

DIAGNOSTIC TESTS & INTERPRETATION

Lab

Initial lab tests

Aqueous or vitreous aspiration for histologic examination

Imaging

Initial approach

• B-scan ultrasound to look for retained lens fragments

• Aggressive control of inflammation and intraocular pressure (IOP)

Follow-up & special considerations

Frequent follow-up until definitive treatment is implemented, which involves removal of retained lens material

Diagnostic Procedures/Other

• Histological examination of the surgically removed lens material

• Microscopic examination of aqueous and/or vitreous

Pathological Findings

Polymorphonuclear leukocytes, epithelioid cells, and giant cells in a zonular pattern surrounding a portion of lens material

DIFFERENTIAL DIAGNOSIS

• Phacolytic glaucoma

• Lens particle glaucoma

• Toxic reaction to materials introduced at surgery

• Exacerbation of prior uveitis

• Infection with low virulence organisms, that is, propionibacterium

• Sympathetic ophthalmia

TREATMENT

MEDICATION

First Line

• Topical steroid therapy to reduce inflammation

• Antiglaucoma therapy to control IOP: with hyperosmotics, topical carbonic anhydrase inhibitors, topical beta-blockers and alpha-2 agonists.

ADDITIONAL TREATMENT

Issues for Referral

• If the retained lens material or the traumatic disruption of the lens capsule involves the anterior segment then the anterior segment surgeon should remove the inciting lens material.

• Often the retained lens material is in the vitreous and consultation or referral to a retina surgeon for appropriate removal is suggested.

Additional Therapies

• Once the lens material is removed, the uveitis is usually easier to control and steroid therapy should be tapered.

• IOP control must be monitored as there may be secondary angle closure glaucoma due to synechia formation.

SURGERY/OTHER PROCEDURES

• Surgical removal of retained lens material

• If the IOP remains elevated after surgical removal of lens and if either the secondary open-angle or angle closure glaucoma is uncontrolled then glaucoma filtering surgery is indicated.

IN-PATIENT CONSIDERATIONS

Initial Stabilization

Admission and intravenous mannitol may be necessary to control IOP until definitive surgery.

Discharge Criteria

Once the IOP is controlled the patient may be discharged with close follow-up appointments.

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

Very close follow-up during the initial postoperative period is warranted to manage the uveitis and IOP.

Patient Monitoring

• Once the IOP and uveitis are controlled lifelong IOP monitoring and treatment are necessary for the secondary open- or closed-angle glaucoma.

• 3–6 month intervals depending on the severity of disease

PATIENT EDUCATION

The physiology of glaucoma and the importance of adherence to medication should be discussed.

PROGNOSIS

The prognosis depends on the severity of the disease upon presentation and the prompt treatment of the uveitis and glaucoma.

COMPLICATIONS

• Vision loss secondary to glaucoma or uveitis, that is, cystoid macular edema

• Surgical complication of vitrectomy or additional anterior segment removal of lens material

• Surgical complications of glaucoma filtering surgery

ADDITIONAL READING

• Allingham RR, Damji KF, Freedman S, et al. Shields textbook of glaucoma, 5th ed. 2004, Philadelphia: Lippincott Williams & Wilkins.

• Marak GE Jr. Phacoanaphylactic endophlamitis. Surv Ophthalmol 1992;36:5325–5340.

• Epstein DL. Diagnosis and management of lens-induced glaucoma. Am Acad Ophthalmol 1982;89(3):227–230.

CODES

ICD9

• 365.59 Glaucoma associated with other lens disorders

• 365.62 Glaucoma associated with ocular inflammations

CLINICAL PEARLS

Suspect in patients with persistent low level uveitis after cataract extraction

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