Conrad L. Giles
T. F. Schlaegel Jr.
Whether it is the speed of a struck tennis or golf ball or the velocity of an automobile, we have witnessed a quantum leap in the speed of the environment over the past several years. No proportionate increase in the anatomic orbital protection or blink reflex has accompanied this however. The result, not surprisingly, is a significant increase in ocular and orbital trauma. This chapter deals with the inflammatory implications of trauma to the uveal tract.
Traumatic Anterior Uveitis
Mild contusions can occur without producing permanent structural change, whereas severe contusions result in permanent structural alterations. Flare and cells are seen in the anterior chamber, with the grade for flare usually being greater than the grade for cells. The intraocular pressure usually is low; however, because of a large number of factors, later it may rise above normal. In 15 to 27 cases of traumatic iritis, the intraocular pressure was less than 4 mmHg.1 The contusion disrupts the ciliary body and the secretion of the ciliary epithelium, but the anterior vitreous usually is free of cells. Treatment of the traumatic iritis is by the corticosteroid drops, mydriatics, and cycloplegics tailored to the severity of the process. It frequently is possible to use short-acting cycloplegics agents (tropicamide, cyclopentolate hydrochloride) in this clinical setting. Milder iritis frequently can be managed without treatment. It is possible for trauma to the cornea (from foreign bodies, fingernails, or contact lenses) to break the epithelial barrier and allow ingress of an agent, such as the URI virus.2 Other notable factors in the production of traumatic keratouveitis include bee stings with retained stingers3 and contact with sea matter (jelly-fish stings).4 Whether trauma or some other factor is responsible in the case of soft contact lens induced hypopyon is unknown.5 Rarely bilateral uveitis has been reported to be precipitated in a patient with unilateral nonpenetrating trauma.6
Persistent unilateral iridocyclitis after penetrating injury of the cornea with no radiographic or orbital computer tomography evidence of a foreign body should arouse suspension of foreign material in the angle of the anterior chamber.7 Intralenticular metallic foreign bodies may be well tolerated for years without causing anterior uveitis. This suggests that the management of nonferrous-containing (see siderosis bulbi) intralenticular metallic foreign bodies may be conservatively managed until inflammation or significant cataract formation develops.8 Vegetable matter, oil, glass, stone, and metal may enter the anterior chamber at the time of injury; talcum and lint may be introduced during surgery; and ophthalmic ointments may enter afterward. If the foreign body lodges in the angle, it may not be obvious. Foreign bodies with a specific gravity greater than aqueous sink to the lower recess, whereas oil floats and is obscured by the superior angle shelf. Thus, machine oil may be introduced into the anterior chamber at the time of injury and float to the upper angle. With the patient supine, the globules may float to the posterior center of the cornea. Irrigation with Ringer’s solution through a limbal incision should clear iridocyclitis.9 Foreign material can be in a liquid form, such as the juice from a plant that may pass through the cornea and set up an iridocyclitis.10
Tattooing with cobaltous aluminate11 in three young men resulted in a purulent discharge from the light-blue areas of the tattoo. The skin granulomas persisted, and approximately 6 months later, a uveitis appeared. Treatment consisted of the usual measures plus excision of the draining tattooed areas.
Some postoperative iridocyclitis probably is the result of retained lens cortex (even in the case of an apparent intracapsular extraction). Occasionally, a little cortex may be left under the iris, where it is not visible. Although local administration of corticosteroids and cycloplegics effects cure in the majority of these patients, surgical removal of this hidden retained cortex has been helpful. Other instances of postoperative iridocyclitis may be caused by irritation from other foreign bodies. Cotton usually is well tolerated. Because flare and cells are routine after cataract extraction, one must rely on other signs, such as lid swelling, eye redness, and the development of keratic precipitates.
Ophthalmia nodosa is an inflammation precipitated by hairs of certain insects or vegetable material. It derives its name from the nodular conjunctival reaction that results.
These hairs in the cornea may be seen surrounded by nummular opacities. There is a latent period of a few days to a few months, presumably the period of migration into the eye. Caterpillar hairs have even been reported on top of12 and underneath the retina.13
The recent increasing popularity of tarantulas as pets has resulted in a number of reported cased of Ophthalmia Nodosa.14 The iris reflects an intense inflammation, often with hypopyon and nodules on the iris. A granulomatous reaction, consisting of histiocytes, epithelioid cells, and macrophages, develops around the hair, but this reaction may be suppressed by local administration of steroids. Keratectomy, keratoplasty, iridectomy or occasionally vitrectomy may be indicated to eliminate the offending hairs.15