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COMMENTARY
Year : 2023  |  Volume : 3  |  Issue : 1  |  Page : 203-204

Commentary: Herpetic uveitis or leaky lens?


Department of Ophthalmology Advanced Eye Centre, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India

Date of Web Publication20-Jan-2023

Correspondence Address:
Atul Arora
Department of Ophthalmology, Advanced Eye Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh - 160 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_2219_22

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How to cite this article:
Arora A. Commentary: Herpetic uveitis or leaky lens?. Indian J Ophthalmol Case Rep 2023;3:203-4

How to cite this URL:
Arora A. Commentary: Herpetic uveitis or leaky lens?. Indian J Ophthalmol Case Rep [serial online] 2023 [cited 2023 Feb 1];3:203-4. Available from: https://www.ijoreports.in/text.asp?2023/3/1/203/368214



The authors reported a case of hypertensive uveitis in a young male. The patient was diagnosed as phacogenic uveitis and underwent combined cataract surgery with trabeculectomy and had good outcome.[1] I credit the authors for good clinical work-up and management of this case. Additionally, some important points are highlighted detailed here.

Patients with uveitis are intriguing but at the same time may pose a diagnostic challenge in view of overlapping clinical signs and symptoms. A systematic and stepwise approach to history-taking and an observant clinical examination help solve the mystery. A patient and good clinical examination is very useful and can provide important clues that point toward the diagnosis.

Viral anterior uveitis (VAU) produces a myriad of signs and symptoms and it becomes important to meticulously look for specific signs in a patient with hypertensive uveitis. Corneal involvement as active keratitis (epithelial, stromal, interstitial, and disciform), endotheliitis, old corneal scar, and reduced corneal sensation indicate viral etiology. Small-to-mediumsized keratic precipitates (KPs) are common in VAU. Distribution of KPs is usually restricted to the area of the inflamed cornea.[2] Iris atrophy is another important sign associated with VAU.[3],[4] The presence of patchy/sectoral or diffuse iris atrophy is seen in recurrent or chronic anterior uveitis caused by the herpes simplex virus. Segmental/triangular iris atrophy with the base at the iris root is associated with varicella zoster infection. Iris atrophy produces transillumination defects that can be appreciated on retro-illumination of slit lamp. In patients suspected to have VAU, it is important to carefully examine the fundus till periphery with an indirect ophthalmoscope to rule out any retinitis lesion.

Lens-induced uveitis (LIU) refers to ocular inflammation secondary to the lens material.[5] LIU is classified based on the integrity of the lens capsule. The term “phacolytic uveitis” is employed when the lens capsule is intact[6] while the terms “phacogenic uveitis” or “phacoantigenic uveitis” are used when the lens capsule is ruptured. Lens proteins exhibit immune privilege and their presence outside their position of immunological isolation in the lens capsule results in autoimmune response.[7],[8]

In phacolytic uveitis, altered and denatured lens material leaks into the anterior chamber from an intact capsule of hypermature cataracts and clogs the trabecular meshwork where it is engulfed by macrophages.[9] This results in raised intraocular pressure. The inflammation is, however, minimal with no or limited clinical signs.

In phacogenic uveitis on the other hand, release of lens material following traumatic rupture of lens capsule results in severe immune response that may involve a type Ⅱ, type Ⅲ, or type Ⅳ hypersensitivity reaction. The resulting anterior uveitis may be granulomatous or non-granulomatous.[10] Clinical signs on slit-lamp examination include corneal edema, keratic precipitates (KPs) mostly of the “mutton-fat” type, and hypopyon in severe cases. Again, a careful examination would reveal the presence of retained lens fragment in the anterior chamber and breach in integrity of anterior lens capsule, and thereby aid in clinching the diagnosis.

To conclude, there is no substitute to a sound clinical examination, and an observant clinician can pick up important clues on the path to solving diagnostic mystery in a patient with ocular inflammation.



 
  References Top

1.
Mohan M, Natarajan R, Patil TS. Herpetic uveitis or leaky lens? Indian J Ophthalmol Case Rep 2023;3:202-3.  Back to cited text no. 1
  [Full text]  
2.
Babu K, Konana VK, Ganesh SK, Patnaik G, Chan NS, Chee SP, et al. Viral anterior uveitis. Indian J Ophthalmol 2020;68:1764-73.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Tabbara KF, Chavis PS. Herpes simplex anterior uveitis. Int Ophthalmol Clin 1998;38:137-47.  Back to cited text no. 3
    
4.
Tugal-Tutkun I, Otuk-Yasar B, Altinkurt E. Clinical features and prognosis of herpetic anterior uveitis: A retrospective study of 111 cases. Int Ophthalmol 2010;30:559-65.  Back to cited text no. 4
    
5.
Wirostko E, Spalter HF. Lens-induced uveitis. Arch Ophthalmol 1967;78:1-7.  Back to cited text no. 5
    
6.
Basic and Clinical Science Course. Section 9 (2016-2017) Intraocular inflammation and uveitis. American Academy of Ophthalmology Pages 118–119.  Back to cited text no. 6
    
7.
Irvine SR, Irvine AR Jr. Lens-induced uveitis and glaucoma. III. “Phacogenetic glaucoma”: Lens-induced glaucoma; mature or hypermature cataract; open iridocorneal angle. Am J Ophthalmol 1952;35:489-99.  Back to cited text no. 7
    
8.
Halbert SP. Manski W. Biological aspects of autoimmune reactions in the lens. Invest Ophthal 1965;4:516-30.  Back to cited text no. 8
    
9.
Flocks M, Littwin CS, Zimmerman LE. Phacolytic glaucoma; a clinicopathologic study of one hundred thirty-eight cases of glaucoma associated with hypermature cataract. AMA Arch Ophthalmol 1955;54:37-45.  Back to cited text no. 9
    
10.
Marak GE Jr, Font RL, Czawlytko LN, Alepa FP. Experimental lens-induced granulomatous endophthalmitis: Preliminary histopathologic observations. Exp Eye Res 1974;19:311-6.  Back to cited text no. 10
    




 

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