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Phacoantigenic Response to Ruptured Lens Capsule: Clinicopathologic Case. Emily Deschler, MD Charleen Chu, MD, PhD March 2011. Brief History and Course. 58 year-old woman Blind left eye since teens – unknown etiology No history of trauma - PowerPoint PPT Presentation
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Phacoantigenic Response to Ruptured Lens Capsule: Clinicopathologic Case
Emily Deschler, MD
Charleen Chu, MD, PhD
March 2011
Brief History and Course
• 58 year-old woman
• Blind left eye since teens – unknown etiology
• No history of trauma
• Referred to glaucoma service when left eye became painful
Initial Physical Exam
• Vision:– Right eye: 20/20– Left eye: NLP
• IOP:– Right eye: 11– Left eye: 16
• Pupil:– Right eye: 4-3– Left eye: Irregular
• Anterior segment– Right eye: Shallow anterior
chamber with patent PI– Left eye: injected
conjunctiva, cornea with PEE, shallow anterior chamber with patent PI x2, iris with florid rubeosis, posterior synechiae, mature cataract
• Fundus:– Right eye: Normal, c/d 0.6
with healthy neuroretinal rim
– Left eye: no view
Brief History and Course
• Symptoms initially attributed to ocular surface disease and treated with artificial tears, topical steroids
• 1 year later, pain continued and patient elected to proceed with enucleation (PHS10-35123)
Calcific Band Keratopathy
• Gross photo of the cornea – entire cornea is
affected – calcification
spans from limbus to limbus
Calcific Band Keratopathy
• Seen clinically as calcific plaques in the interpalpebral zone – deposition of calcium in the epithelial basement
membrane, Bowman’s layer, and anterior stroma.– usually an intervening region of cornea between the
limbus and the calcification that is unaffected• 6 main causes
– chronic ocular disease (usually inflammatory), hypercalcemia, hereditary transmission, elevated serum phosphorus with normal calcium, exposure to mercury, silicone oil in ahakic eye
• Tx: remove overlying epithelium and then apply EDTA
Calcific Band Keratopathy
• H&E– 1. stippled
basophilia of Bowman’s layer, the calcium deposits merge to form a linear array along Bowman’s layer
– 2. keratocyte nuclei
2
1
Neovascularization of the Iris & Hyphema
1. Neovascularization of the iris – at this power cannot see individual vessels, but flattened anterior iris is a clue
2. Hyphema
1
2
Disorders Predisposing to Neovascularization of Iris and Angle
• Systemic vasular disease– Carotid disease– Giant cell arteritis
• Ocular vascular disease– Diabetes– CRVO– Coats– Eales– ROP– Persistent fetal vasculature– Anterior segment ischemia
• Ocular disease– Cronic uveitis– Chronic retinal detachment– Endophthalmitis– Stickler syndrome– Retinoschisis
• Intraocular tumors– Uveal melanoma– Metastatic disease– Retinoblastoma
• Ocular therapy– Radition therapy
Peripheral Anterior Synechia
• Iris stroma obliterates the angle recess
• Mechanisms of PAS formation:
– Contraction of an inflammatory, hemorrhagic or vascular membrane, band or exudate in the angle
– Forward displacement of the iris-lens diaphragm leading to a prolonged shallow/flat anterior chamber
• Extent of PAS may correlate with visual field damage, larger vertical cup-to-disc ratio, and higher untreated intraocular pressure
• Poor prognosis • Treat underlying cause
(ischemic retina with PRP) anti-VEGF, filtering surgery
1. Chronic Iritis 2. Neovascularization of the Iris
• Lymphocytes – small cells with
round, hyperchromatic nuclei and scant cytoplasm
– found in chronic inflammatory process
1
2
Chronic Plasmacytic Cycloiritis
• B lymphocytes may differentiate into plasma cells and produce immunoglobulin
• Eccentric “cartwheel” or “clockface” nuclei
Chronic Choroiditis
• Small blue cells
Phacoantigenic Response to Ruptured Lens Capsule
• Granulomatous reaction
• Macrophages filled with degenerated lens cortical material
Phacoantigenic Response to Ruptured Lens Capsule - PAS
Phacoantigenic vs PhacoanalyticGlaucoma
Phacoantigenic– Sensitized to own lens protein
following surgery or penetrating trauma
– Granulomatous reaction• Clinically
– Moderate anterior chamber reaction with KP on endothelium and lens capsule
– Low grade vitritis– Synechial formation– Not commonly associated with
glaucomatous optic neuropathy
• Treatment– Corticosteroids, aqueous
suppressants, and if unsuccessful, remove residual lens material
Phacolytic– Leakage of lens proteins
through the capsule of a mature or hypermature cataract
– Proteins, phagocytizing, inflammatory debris obstruct the uveal meshwork
• Clinically – Prominent cell and flare with
possible psuedohypopyon in the anterior chamber
– No KP– Morgagnian cataract with
wrinkled anterior lens capsule– Open anterior chamber angle
• Treatment– IOP lowering medications,
ultimately cataract extraction
Discussion: Phacoantigenic response to ruptured lens capsule
• Occurs following surgery or penetrating trauma causing sensitization to one’s own lens protein– Granulomatous reaction– Variable clinical presentation: moderate AC reaction
with KP on corneal endothelium and anterior lens surface (unlike phacolytic) with moderate AC reaction. Low grade vitritis, synechial formation, residual lens material may be in AC
– Not commonly associated with glaucomatous optic neuropathy.
• Treatment– Corticosteroids, aqueous suppressants, and if
unsuccessful, remove residual lens material
Discussion: Phacolytic response to mature cataract
• Proteins, phagocytizing macrophages, and other inflammatory debris obstruct the trabecular meshwork
• Generally an elderly person with a history of poor vision presents with sudden onset pain, conjunctival injection, elevated IOP, corneal edema, prominent cell and flair without KP and open anterior chamber angle
• Cellular debris may be present in the anterior chamber presenting as pseudohypopyon. The anterior capsule may appear wrinkled representing loss of lens material
• Treatment: – IOP lowering medications, ultimately cataract extraction
• Diagnosis:– Phacoantigenic immune response to
ruptured lens capsule
• Additional diagnoses:– Idiopathic chronic panophthalmitis– Neovascularization of the iris– Peripheral anterior synechiae– Calcific band keratopathy
Sources
• Basic Clinical Science Course Section 10: Glaucoma. American Academy of Ophthalmology 2009-2010
• Yanoff, Myron and Fine, Ben. Ocular Pathology. Mosby. 2002