Phacoanaphylaxis Workup

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

Laboratory Studies

Aqueous paracentesis in subtle or early cases may reveal inflammatory cells and particulate lens proteins without bacteria. This procedure is performed more efficiently at the time of anterior chamber washout and vitrectomy to remove the inciting lenticular antigens. In cases of suspected bacterial endophthalmitis, intraoperative aqueous and vitreous specimens may establish the diagnosis of phacoanaphylaxis in the absence of positive cultures.

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Imaging Studies

Echography

If the media opacity prevents an appropriate fundus examination, echography with A-scan and B-scan may be helpful when evaluating the posterior pole. [63]

Suspicion for acute endophthalmitis, intraocular foreign body, dropped lens nucleus, thickening of the choroid, retinal detachment, and choroidal effusion are all indications for echography if the anterior segment changes hinder examination of the posterior segment.

The shape, position, and thickness of the traumatized lens; the presence of focal echogenic areas; and, sometimes, even the entrance and exit wounds are recognizable by ultrasound. It is clinically important to diagnose the isolated rupture of the posterior capsule of the lens by echography. Such ruptures are characterized by the irregular extension of the highly reflective posterior capsule toward the vitreous with significantly increased thickness of the lens.

Ultrasound biomicroscopy

Ultrasound biomicroscopy (UBM) may have an important role in the evaluation of lens-induced uveitis after extracapsular cataract extraction, revealing hidden lens particles in the posterior chamber causing inflammation as well as lens-particles creating secondary glaucoma. [64, 65]

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Histologic Findings

Histopathology of phacoanaphylactic endophthalmitis is characterized by a zonal granulomatous inflammatory reaction consisting of polymorphonuclear neutrophils, numerous epithelioid cells, and occasional giant cells. The inflammatory reaction is around the lens material or lens capsule (see the images below). Associated cells include eosinophils, plasma cells, and histiocytes containing phagocytized lens material.

Gross photomicrograph for eye enucleated with pene Gross photomicrograph for eye enucleated with penetrating injury.
Gross photomicrograph for eye enucleated with pene 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 rea Low (X25) photomicrograph of phacoanaphylactic reaction to lens protein in eye enucleated with penetrating injury. Note polymorphonuclear leucocytes around lens protein (hematoxylin and eosin).

Minimal histopathologic diagnostic criteria include neutrophil-associated lens damage accompanied by a granulomatous response associated with the lens material. A paucity of neutrophils may be present in late cases. Isolated giant cells without neutrophils and associated lens damage may create difficulty in distinguishing phacoanaphylactic endophthalmitis from a foreign body granuloma since lens material or the Descemet membrane may induce giant cells.

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