57-year-old male presents following blunt trauma to right eye presents with pain and decreased visual acuity in the right eye five days after trauma
Remote past ocular history of intra-orbital foreign body (removed) in the right eye
Exam Findings
BCVA OD: HM; OS: 20/30
IOP OD: 48; OS: 14
Pupils: OD: Mydriatic, nonreactive; OS: Round, reactive, no RAPD
SLE OD (Figure 1): 2+ conjunctival injection, diffuse corneal microcystic edema, very deep anterior chamber with 2-3+ flare/haze, mydriatic iris, lens- poor view, cortical changes
SLE OS: Within normal limits
DFE OD: No view; OS: Within normal limits
Gonioscopy OD: No view; OS: Open to CB 360
Figure 1: Slit lamp photo of the right eye showing conjunctival injection, diffuse microcystic corneal edema, a deep anterior chamber with haze and flare and a mydriatic pupil
Differential Diagnosis
Phacoantigenic uveitis
Lens particle glaucoma
Angle recession
Microhyphema
Uveitic glaucoma/trabeculitis
Phacolytic glaucoma
Additional Investigations
CT scan (Figure 2): Lens notably absent within right globe; intact lens in left globe
B-scan ultrasonography (Figure 3): Mobile hyperechoic, ovoid structure within vitreous cavity visible on vertical axial, T3 and T6 views
Figure 2: CT scan of the orbit, axial view. Absent lens material from right globe. Hyperdense foreign object in anterior right orbit is likely residual intraorbital foreign body from prior trauma
Figure 3: B-scan ultrasonography of the right eye, vertical axial view. Hyperechoic, ovoid structure in anterior/inferior portion of the vitreous represents posteriorly dislocated lenticular nucleus
Diagnosis
Phacoantigenic uveitis
Pathophysiology
The lens capsule is violated by trauma, which exposes a large quantity of lens particles to the anterior chamber.
Lens particles are seen as antigens and induce an IgG mediated type III hypersensitivity reaction.
An intraocular granulomatous inflammatory reaction ensues, which obstructs the trabecular meshwork and increases the intraocular pressure.
Treatment
Topical and oral aqueous suppressants
Topical and oral corticosteroids
Cataract extraction (In this case, the patient required a pars plana vitrectomy and lensectomy.)
Prognosis and Future Directions
Prognosis depends on the extent of damage to uveal tissue secondary to granulomatous inflammation as well as glaucomatous damage to the optic nerve from increased intraocular pressure.
References
Ellant JP, Obstbaum SA. Lens-induced glaucoma. Doc Ophthalmol. 1992;81(3):317–38.
Epstein DL. Diagnosis and management of lens-induced glaucoma. Ophthalmology. 1982 Mar;89(3):227–30.
Sowka J. Phacomorphic glaucoma: case and review. Optometry. 2006 Dec;77(12):586–9.
Lee JW, Lai JS, Yick DW, Yuen CY. Argon laser peripheral iridoplasty vs systemic intraocular pressure-lowering medications as immediate management for acute phacomorphic angle closure. Clin Ophthalmol. 2013;7:63–9.
Lee SJ, Lee CK, Kim WS. Long-term therapeutic efficacy of phacoemulsification with intraocular lens implantation in patients with phacomorphic glaucoma. J Cataract Refract Surg. 2010 May;36(5):783–9
Papaconstantinou D, Georgalas I, Kourtis N, Krassas A, Diagourtas A, Koutsandrea C, Georgopoulos G. Lens-induced glaucoma in the elderly. Clin Interv Aging. 2009;4:331–6.
Jarrett WH ll. Dislocation of the lens. Arch Ophthalmol. Sep 1967;78(3):289–296.
Dureau P. Pathophysiology of zonular diseases. Curr Opin Ophthalmol. 2008 Jan;19(1):27–30.
Izquierdo NJ, Traboulsi EI, Enger C, Maumenee IH. Glaucoma in the Marfan syndrome. Trans Am Ophthalmol Soc. 1992;90:111-7; discussion 118–22.
Chu BS. Weill-Marchesani syndrome and secondary glaucoma associated with ectopia lentis. Clin Exp Optom. 2006 Mar;89(2):95–9.
Elkington AR, Freedman SS, Jay B, Wright P. Anterior dislocation of the lens in homocystinuria. Br J Ophthalmol. 1973 May;57(5):325–9.
Flocks M, Littwin CS, Zimmerman LE. Phacolytic glaucoma: a clinicopathological study of 138 cases of glaucoma associated with hypermature cataract. Arch Ophthalmol. 1955;54:37–45.
Yanoff M, Scheie HG. Cytology of human lens aspirate. Its relationship to phacolytic glaucoma and phacoanaphylactic endophthalmitis. Arch Ophthalmol. 1968;80:166–170.
Epstein DL, Jedziniak J, Grant WM. Identification of heavy molecular weight soluble protein in aqueous humor in human phacolytic glaucoma. Invest Ophthalmol Vis Sci. 1978;17:398–402.
Kee C, Lee S. Lens particle glaucoma occurring 15 years after cataract surgery. Korean J Ophthalmol. 2001 Dec;15(2):137–9.
Jain SS, Rao P, Nayak P, Kothari K. Posterior capsular dehiscence following blunt injury causing delayed onset lens particle glaucoma. Indian J Ophthalmol. 2004 Dec;52(4):325–7.
Kim TH, Kim SJ, Kim E, Chung IY, Park JM, Yoo JM, Song JK, Seo SW. Spontaneous anterior lens capsular dehiscence causing lens particle glaucoma. Yonsei Med J. 2009 Jun 30;50(3):452–4.
Marak GE Jr, Font RL, Alepa FP. Experimental lens-induced granulomatous endophthalmitis. Mod Probl Ophthalmol. 1976;16:75–79.
Thach AB, Marak GE Jr, McLean IW, Green WR. Phacoanaphylactic endophthalmitis: a clinicopathologic review. Int Ophthalmol. 1991;15:271–279.
Riise P. Endophthalmitis phacoanaphylactica. Am J Ophthalmol. 1965;60:911–915.
Easom HA, Zimmerman LE. Sympathetic ophthalmia and bilateral phacoanaphylaxis. Arch Ophthalmol. 1964;72:9–15.
Allen JC. Sympathetic uveitis and phacoanaphylaxis. Am J Ophthalmol. 1967;63:280–283.
Ocular Pathology Atlas. American Academy of Ophthalmology website. https://www.aao.org/resident-course/pathology-atlas. Published 2016. Accessed January 4, 2017.
Luna G, Eliassi-Rad B. Lens Induced Glaucomas. http://eyewiki.aao.org/Lens_Induced_Glaucomas
Contact
Benjamin Y. Xu, MD, PhD, Assistant Professor of Clinical Ophthalmology, benjamin.xu@med.usc.edu
Due to ongoing developments with COVID-19, we are only able to see patients with urgent eye problems at this time. If you have any questions or concerns, please call us at 323-442-6335.
