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Phacoanaphylaxis Treatment & Management

  • Author: Robert H Graham, MD; Chief Editor: Hampton Roy, Sr, MD  more...
 
Updated: Jun 14, 2016
 

Medical Care

Treatment of phacoanaphylaxis may be medical or surgical. Medical therapy of phacoanaphylactic uveitis includes topical corticosteroids and may include cycloplegics and medication for elevated intraocular pressure as needed. Treatment should be tailored to the individual patient and adjusted according to response. Patient age, immune status, and tolerance for adverse effects always must be taken into account.

Cycloplegics

Topical cycloplegics break or prevent the formation of posterior synechiae, stabilize the blood-aqueous barrier leading to reduced leakage of plasma proteins, increase uveoscleral outflow, and provide mild relief of ciliary spasm pain. The stronger the inflammatory reaction, the more frequently applied or stronger the cycloplegic.

Corticosteroids

Corticosteroids block the formation of arachidonic acid from cell membrane precursors by inhibiting the action of phospholipase-A2, cyclooxygenase, and lipoxygenase. Thus, arachidonic acid is the premier precursor of potent inflammatory mediators, such as prostaglandins, thromboxane, and leukotrienes. Corticosteroids frequently are used in uveitis therapy. Topical steroid drops are given in dosages ranging from once daily to hourly. They also can be given in an ointment form. Periocular corticosteroids generally are given as depot-steroid injections when a more prolonged effect is needed or when a patient is noncompliant or poorly responsive to topical administration.

Nonsteroidal anti-inflammatory agents

Nonsteroidal anti-inflammatory agents typically block the formation of cyclooxygenase. They are useful in the management of cystoid macular edema and anterior segment inflammation. Their anesthetic properties increase patient comfort. They can be used in conjunction with corticosteroids.

Intraocular pressure–lowering agents

When phacoanaphylaxis is associated with high intraocular pressure (see the image below), aqueous suppressants are indicated. Beta-blockers, alpha-agonists, and carbonic anhydrase inhibitors are used to lower the pressure.

Patient with persistently elevated intraocular pre Patient with persistently elevated intraocular pressure after cataract surgery was found to have retained lens material and low-grade inflammation. Eye is white and quiet with anterior chamber lens.
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Surgical Care

If persistent or uncontrolled inflammation or elevated intraocular pressure is not responsive to medical therapy or if such a large amount of exposed lens material is present that medical therapy is likely to fail, then surgical removal of the exposed lens material is indicated (see the image below).

Typical clinical picture of retained lens material Typical clinical picture of retained lens material following cataract surgery. White cortical material is easily visible in the pupillary space.

The most common situation leading to this is posterior capsular rupture with the loss of lens fragments into the vitreous cavity during phacoemulsification (see the images below). Removal of retained lens fragments by pars plana vitrectomy may restore good visual function and reverse many complications in these patients.[66, 67, 68, 69, 70, 71, 72]

Patient with persistently elevated intraocular pre Patient with persistently elevated intraocular pressure after cataract surgery was found to have retained lens material and low-grade inflammation. Retained lens material is visible in retroillumination on downgaze.
Typical appearance of retained lens fragments in p Typical appearance of retained lens fragments in posterior vitreous cavity. Lens material is a whitish substance that obscures fundus details.
Another view of a retained lens fragment, noted in Another view of a retained lens fragment, noted inferiorly.

Surgical removal of retained lens material may be necessary depending upon the degree of inflammation, the size of the retained lens particle, and the presence of increased intraocular pressure. Observation is indicated when the lens fragments are small and the inflammation can be controlled.

Several studies demonstrate no advantage to early surgery; therefore, the cataract surgeon may treat patients with retained lens fragments conservatively, and then refer the patient to a vitrectomy surgeon after an appropriate period of observation and medical therapy, unless the patient develops retinal detachment, highly elevated intraocular pressure, or some other condition in which posterior segment surgery is indicated more urgently.[74]

A review by Schaal et al found that about one third of patients with retained lens fragments may be managed conservatively (ie, medical therapy alone) with good results; however, vitrectomy and lensectomy with removal of the offending lens particles were indicated in those patients not responding to topical and systemic medications.[71] Moreover, Schaal et al found that surgery could be successfully delayed in many patients.[71]

Various techniques have been reported for use by the cataract surgeon at the time of lens fragment loss.[75, 76, 66, 77, 78] However, no apparent advantage exists for immediate removal of retained lens fragments, and such attempts are to be discouraged.

A complete limbal vitrectomy should be performed before any lens placement, and the absence of vitreous to the wound or other anterior structures should be confirmed at the time of wound closure. The recommendation from most retina surgeons is to place the IOL in the posterior chamber if there is adequate capsular support and to place anterior chamber lenses if there is inadequate capsular support at the time of the cataract surgery. If the eye is left aphakic at the time of the cataract surgery, secondary IOL insertion is possible at the time of pars plana vitrectomy. Sutured IOL with transscleral fixation may increase the risk of retinal detachment, endophthalmitis, and cystoid macular edema.

Kim suggests that the final visual acuity is probably more dependent on the extent of manipulations during the initial cataract surgery than the type of IOL placed or subsequent surgery.[68]

Borne et al found perfluorocarbon liquids not to be protective against poor visual outcome.[76] They reported no statistically significant retinal detachment rates in eyes where perfluorocarbon liquid was used compared with eyes in which only vitrectomy was performed to remove retained lens fragments. However, the study conducted by Ross found that patients with retained lens fragments in whom posterior chamber lenses were implanted had a better outcome than patients with anterior chamber lenses, and both groups of pseudophakic patients fared better than aphakic patients. Other studies have failed to find a correlation between IOL placement, type of IOL placed (anterior or posterior chamber IOL), and final visual outcome.

Surgical outcomes

The final visual acuity after vitrectomy for retained lens fragments was 20/40 or better in 60-70% of patients and worse than 20/200 in 10-15% of patients in 2 large retrospective studies.[79]

Postoperative complications related to vitrectomy include corneal edema, glaucoma, persistent uveitis, cystoid macular edema, retinal detachment, and endophthalmitis. The same complications are associated with complicated cataract surgery and may coexist before and after pars plana vitrectomy.

Retinal detachment is the major cause of a poor visual outcome in the management of retained lens fragments. The frequency of retinal detachment is higher in eyes in which ultrasonic phacofragmentation was used (24%) compared to the eyes in which it was not used (12%), although the difference is not statistically significant. The cumulative incidence of retinal detachment is 15-17% when large series of vitrectomy for retained lens fragment are analyzed.

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Activity

In the postoperative period of complicated cataract surgery or pars plana vitrectomy, patients are instructed not to bend over, to avoid extreme physical activities, and to protect the operated eye (eg, glasses, Fox-shield at night) for a minimum of 2 weeks.

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Contributor Information and Disclosures
Author

Robert H Graham, MD Consultant, Department of Ophthalmology, Mayo Clinic, Scottsdale, Arizona

Robert H Graham, MD is a member of the following medical societies: American Academy of Ophthalmology, Arizona Ophthalmological Society, American Medical Association

Disclosure: Partner received salary from Medscape/WebMD for employment.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

R Christopher Walton, MD Professor, Director of Uveitis and Ocular Inflammatory Disease Service, Department of Ophthalmology, University of Tennessee College of Medicine

R Christopher Walton, MD is a member of the following medical societies: American Academy of Ophthalmology, Association for Research in Vision and Ophthalmology, Retina Society, American College of Healthcare Executives, American Uveitis Society

Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy, Sr, MD Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy, Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Additional Contributors

John D Sheppard, Jr, MD, MMSc Professor of Ophthalmology, Microbiology and Molecular Biology, Clinical Director, Thomas R Lee Center for Ocular Pharmacology, Ophthalmology Residency Research Program Director, Eastern Virginia Medical School; President, Virginia Eye Consultants

John D Sheppard, Jr, MD, MMSc is a member of the following medical societies: American Academy of Ophthalmology, American Society for Microbiology, American Society of Cataract and Refractive Surgery, Association for Research in Vision and Ophthalmology, American Uveitis Society

Disclosure: Nothing to disclose.

Acknowledgements

Charles C Barr, MD Retina Service Director, Professor, Department of Ophthalmology, University of Louisville School of Medicine

Disclosure: Nothing to disclose.

Judith Mohay, MD Director of Primary Care Center Eye Clinic, Instructor, Department of Ophthalmology, University of Louisville School of Medicine

Disclosure: Nothing to disclose.

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Gross photomicrograph for eye enucleated with penetrating injury.
Gross photomicrograph for eye enucleated with penetrating injury. Note marked inflammatory reaction consisting of polymorphonuclear cells around lens capsule and lens fibers (hematoxylin and eosin X100).
Low (X25) photomicrograph of phacoanaphylactic reaction to lens protein in eye enucleated with penetrating injury. Note polymorphonuclear leucocytes around lens protein (hematoxylin and eosin).
High (X50) photomicrograph of phacoanaphylactic reaction to lens protein in eye enucleated with penetrating injury. Note polymorphonuclear leucocytes around lens protein (hematoxylin and eosin).
Phacoanaphylactic reaction to penetrating injury of lens. This patient was a 25-year-old woman whose eye was penetrated with a 27-gauge needle during an attempt to anesthetize the eyelid for chalazion removal. One week later, a marked uveitis was present. Notice perforation site and posterior synechiae.
Same patient as in Media file 5. Notice cortical cataract at perforation site.
Typical clinical picture of retained lens material following cataract surgery. White cortical material is easily visible in the pupillary space.
Patient with persistently elevated intraocular pressure after cataract surgery was found to have retained lens material and low-grade inflammation. Eye is white and quiet with anterior chamber lens.
Patient with persistently elevated intraocular pressure after cataract surgery was found to have retained lens material and low-grade inflammation. Retained lens material is visible in retroillumination on downgaze.
Typical appearance of retained lens fragments in posterior vitreous cavity. Lens material is a whitish substance that obscures fundus details.
Another view of a retained lens fragment, noted inferiorly.
 
 
 
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