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.
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Contact
Benjamin Y. Xu, MD, PhD, Assistant Professor of Clinical Ophthalmology, benjamin.xu@med.usc.edu
