Lens-Induced Granulomatous Endophthalmitis

Definition: Lens-induced granulomatous endophthalmitis is also known as phacoanaphylactic endophthalmitis, phacoantigentic and phacoallergic endophthalmitis. A granulomatous reaction to lens fibers that may appear zonal occurs in the setting of trauma and lens capsule rupture.

Incidence/ Prevalence: Very little good data exist on the exact incidence of this disease (see clinical findings).
Etiology: About 80% of cases are related to trauma, including surgical operations. Retained cortical fragments in the capsular bag after cataract operations have been reported to produce this disorder. (Ref 1). Occasionally presumed spontaneous rupture may be the culprit. Experimental studies, immunofluorescence and immunoperoxidase techniques, suggest that the inflammation is mediated by IgG.
Clinical Findings: Less than 5% of cases are diagnosed correctly clinically. The time of injury varied from 2 days to 59 years in one series (Ref 2). However, most sources state that it may occur as soon as 24 hours after surgery. Numerous anterior chamber cells, flare, keratic precipitates, posterior synechiae are often clinical findings. In the clincial photograph the lens is acutely ruptured and lens material (red arrow) rests adjacent to the cornea with pigment and a cellular anterior chamber infiltrate. The choroid is more often involved than clinically realized (Ref 2).

Histopathology: Histologically, lens-induced granulomatous endophthalmitis classically is described as a central nidus of degenerating lens material surrounded by concentric layers of inflammatory cells (zonal granuloma). Multinucleated giant cells (arrow 1) and neutrophils(arrow 2) may be present within the inner layer adjacent to the degenerating lens material. In the photo below multinucleated giant cells (arrow 4) are associated with the central lens fibers. There is usually evidence of lens rupture (arrows 3); the lens capsule is disrupted here. Lymphocytes and histiocytes may make up the intermediate mantle of cells. In chronic cases, there may be fibrosis surrounding the histiocytes (top of photograph).

Cytologic preparations show numerous histiocytes (black arrows) in proximity of degenerate lens material.
Treatment: Cycloplegics, corticosteroids and prompt removal of the lens are the usual therapeutic modalities.
Prognosis: With prompt lens removal the prognosis is largely dependent on other traumatic injuries. However, there may be associated sympathetic ophthalmitis.

References:

1. J Cataract Refract Surg. 2007;33:921-2.

2. Int Ophthalmol. 1991;15:271-9.