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Fuchs's Heterochromic Cyclitis and Posterior Capsulotomy

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Fuchs's Heterochromic Cyclitis and Posterior Capsulotomy Br J Ophthalmol: first published as 10.1136/bjo.69.6.449 on 1 June 1985. Downloaded from British Journal of Ophthalmology, 1985, 69, 449-451 Fuchs's heterochromic cyclitis and posterior capsulotomy THOMAS J ROUSSEL AND DOUGLAS J COSTER From the Department of Ophthalmology, Flinders Medical Centre, Bedford Park, South Australia 5042 SUMMARY We report a case of intractable glaucoma following an uncomplicated secondary posterior capsulotomy in a 48-year-old male with Fuchs's heterochromic cyclitis. The patient had been free of inflammation and glaucoma since cataract extraction 27 years previously. We also report the results of phenotypic analysis of lymphocytes removed from the anterior chamber. The prognosis for successful intraocular procedures complaint of poor visual acuity in the right eye. A in eyes with Fuchs's heterochromic cyclitis has been right extracapsular lens extraction had been done in variously reported. Franceschetti stated that the that eye 27 years previously. Although there was prognosis for cataract extraction in complicated good corrected vision at that time, his right visual heterochromia is excellent, perhaps even better than acuity had decreased over several years prior to 1983. in normal eyes.' Smith and O'Connor reported There had been no episodes of intraocular inflamma- minimal complications in 29 lens extractions in tion or raised pressure since the time of cataract patients with Fuchs's syndrome.2 Conversely, Ward extraction. and Hart considered secondary glaucoma to be the Visual acuity was 6/60 in the right eye and 6/5 in the most serious and most common condition associated left eye. There was mild heterochromia, the right iris http://bjo.bmj.com/ with cataract extraction in this entity.3 Norn reported being lighter. The right cornea was clear except for a postoperative glaucoma in seven of 19 (36%) patients few fine, white endothelial deposits, and there were undergoing cataract extraction for Fuchs's syn- no signs of intraocular inflammation. The posterior drome,4 and Huber described an abrupt rise in capsule was moderately opacified, and there were intraocular pressure following anterior chamber multiple condensations in the right anterior vitreous. puncture in patients with this syndrome.5 Iris transillumination defects were noted in the right We describe a protracted rise in intraocular eye, and its iris vasculature was clearly visualised pressure following posterior capsulotomy in an eye owing to atrophic changes of the iris stroma. Intra- on September 25, 2021 by guest. Protected copyright. with Fuchs's syndrome. The eye had been free of ocular pressure was 12 mmHg by applanation, and inflammation for 27 years after extracapsular cataract the retinal examination was unremarkable. The left surgery. The glaucoma was relentless and progres- eye was normal. sive despite medical and surgical management. We On 9 May 1983 we performed an uncomplicated report this case to remind clinicians of the post- posterior capsulotomy through a clear corneal operative difficulties which can be encountered with incision near the limbus. A trickle of blood, which this disease, to point out that posterior capsulotomy appeared to originate from the angle opposite the site may not always be a trivial procedure in such cases, of entry, was noted during the procedure. and to report a technique for studying the immuno- On the first postoperative day there was diffuse cytology of inflammatory cells in the anterior microcystic oedema of the corneal epithelium, a chamber. moderate aqueous inflammatory response, and a small hyphaema. Intraocular pressure by applana- Case report tion was 60 mmHg. The raised pressure responded initially to acetazolamide, timolol, and atropine, so A 48-year-old white male reported to Flinders that on the following day the intraocular pressure was Medical Centre Eye Clinic on 5 April 1983 with a 20 mmHg, but still with moderate inflammatory signs in the aqueous. Correspondence to Dr T J Roussel. A diagnostic anterior chamber paracentesis was 449 Br J Ophthalmol: first published as 10.1136/bjo.69.6.449 on 1 June 1985. Downloaded from 450 Thomas J Roussel and Douglas J Coster performed in an attempt to establish whether the Table 1 Comparison oflymphocyte surface antigens inflammation was a response to previously seques- found in anterior chamber andperipheral blood tered lens remnants or to reactivation of the underly- ing disease. The patient was then started on dexa- Antibody specificity % Positive cells methasone phosphate 0-1% four times daily in Anterior Peripheral addition to the acetazolamide and timolol. Signs of chamber blood intraocular inflammation remained unchanged on pan T 100 67 this regimen, but the intraocular pressure slowly Ia 8 19 rose, so that by the tenth postoperative day it was T8s 1 24 consistently between 30 and 40 mmHg, and by the twentieth day it was fluctuating between 40 and 45 mmHg. At this point the patient developed aceta- than 10 mmHg until three weeks postoperatively, at zolamide intolerance, and the drug was discontinued. which time the intraocular pressure was 40 mmHg, The topical steroid was increased to one drop every and the tube could no longer be visualised in the two hours for 10 days, then discontinued because it chamber angle. had no effect on the inflammatory signs and so as to Further surgery was deferred at the patient's eliminate the prospect of steroid responsiveness. request. The intraocular pressure persisted at around Because of progressive optic nerve head cupping 40 mmHg while on timolol and atropine, and only a and deterioration of the visual field, a trabeculec- small temporal island of visual field remained with tomy was performed on 5 September 1983. The total cupping of the optic nerve head. patient did well for 18 days with a functioning filter and intraocular pressure less than 10 mmHg, but with RESULTS OF ANTERIOR CHAMBER PARACENTESIS continued signs of moderate inflammation in the A small volume of anterior chamber aspirate (0-15 aqueous in spite of the reinstitution of topical dexa- ml) was placed in heparinised tissue culture medium methasone phosphate 0-1% every two hours. and transported to the laboratory for Giemsa Three weeks later the intraocular pressure had cytology and immunoperoxidase staining.7 Examina- risen to 39 mmHg, with no visible conjunctival bleb tion of the Giemsa-stained slide revealed predomi- and no response to ocular massage. While timolol nantly mononuclear cells consisting of 0% neutro- 0-5% and atropine 0-1% drops were administered phils, 24% monocytes, 75% lymphocytes, and 1% twice daily, intraocular pressure remained around 30 immature lymphocytes (Fig. 1). Immunoperoxidase mmHg. Because of progressive changes in nerve staining disclosed that 100% of the lymphocytes were http://bjo.bmj.com/ head and visual field a Molteno tube6 was inserted in positive for a pan T cell marker; 8% were Ta antigen the superotemporal aspect of the chamber angle on positive and only 1% were T-8 antigen positive (Fig. 20 October 1983. Intraocular pressures remained less 2, Table 1). on September 25, 2021 by guest. Protected copyright. Fig. 1 Giemsa-stained mononuclear cellsfrom anterior Fig. 2 Immunoperoxidase stainingfor la antigen. Cell at chamber aspirate. (x437). lower right is Ia antigen positive. (x 1165). Br J Ophthalmol: first published as 10.1136/bjo.69.6.449 on 1 June 1985. Downloaded from Fuchs's heterochromic cyclitis andposterior capsulotomy 451 Discussion for developing increased inflammatory signs and glaucoma following intraocular manipulation. Our The reasons for the postoperative intraocular inflam- experience also underscores the notion that mation and raised intraocular pressure in this patient glaucoma is the most serious complication in this are unclear. The differential diagnosis for the syndrome and that it can be refractory to successful anterior segment inflammation included either a medical and surgical intervention. response to sequestered lens material released at the Immunoperoxidase staining is an appropriate way time of capsulotomy, or early postoperative endoph- of determining the phenotype of inflammatory cells thalmitis, or an exacerbation of the inflammatory in anterior chamber fluid. It is more sensitive than signs that are a part of Fuchs's syndrome. We found immunofluorescence and has the added advantage of the anterior chamber paracentesis valuable in that providing a permanent staining reaction. The tech- the primarily lymphocytic response made the first nique can be used on the small number of cells two possibilities unlikely. The cytological features in retrievable from the anterior chamber. Whether it is this patient are consistent with those described in useful to determine the phenotypes of cells in Fuchs's syndrome by others"' in that the aqueous of anterior uveitis is under investigation. patients with Fuchs's syndrome contains numerous inflammatory cells, primarily of the mononuclear sees. Grateful acknowledgement is made to Keryn Williams, Marion Roberts, Julie Ash, and Heddi Zola for their assistance in preparing Glaucoma, which proved relentless and devastat- this paper. ing in this eye, is reported to occur in from 0 to 56% (average 15%) of eyes with Fuchs's heterochromic cyclitis'2 and represents the most serious complica- References tion of the syndrome. 1 Franceschetti A. Heterochromic cyclitis (Fuchs' syndrome). Am Acute increases of intraocular pressure associated J Ophthalmol 1955; 39: 50-8. with cataract extraction in eyes with this disease have 2 Smith RE, O'Connor R. Cataract extraction in Fuchs sydrome. been reported.3413 Moreover, an increased pressure Arch Ophthalmol 1974; 91: 39-41. following paracentesis was even considered a pro- 3 Ward DM, Hart CT. Complicated cataract extraction in Fuchs's heterochromic uveitis. BrJ Ophthalmol 1967; 51: 530-8. vocative test for glaucoma in heterochromic cyclitis.5 4 Norn MS. Cataract extraction in Fuchs' heterochromia. Acta The glaucoma in eyes with Fuchs's syndrome is Ophthalmol (Kbh) 1968; 46: 685-99. 5 believed to be due to high outflow resistance caused Huber A. Das Glaukom bei komplizierter.
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