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Rebound iritis with a well-circumscribed anterior chamber fibrin mass after uncomplicated cataract surgery
Journal of Ophthalmic Inflammation and Infection ( IF 2.9 ) Pub Date : 2021-10-12 , DOI: 10.1186/s12348-021-00270-2
Nilesh Raval 1 , Wen-Jeng Melissa Yao 1 , Gene Kim 1 , Joann J Kang 1
Affiliation  

We report a case of subacute rebound iritis characterized by a globular, pedunculated anterior chamber mass that resolved after topical steroid burst.

A 59-year-old female with no significant past ocular history underwent cataract extraction (CE) with phacoemulsification and posterior chamber intraocular lens (PCIOL) insertion in the right eye (OD). Intraoperatively, a Malyugin ring was deployed due to poor dilation, however the remainder of the surgery was uneventful. On the first postoperative day, 3+ mixed cell and pigment in the anterior chamber (AC) without fibrin reaction was observed, which resolved by the second week with topical steroid administration. The patient was lost to follow up and was non-compliant with her steroid taper.

Eight weeks later, the patient presented with eye pain OD. Visual acuity (VA) was 20/40 and intraocular pressure (IOP) by Goldmann applanation was 6; there was no relative afferent pupillary defect (rAPD) noted. Slit lamp biomicroscopy was remarkable for trace Descemet’s folds (DF), 3+ mixed AC cell and pigment, and a sharply-circumscribed, globular, partially opaque anterior chamber mass with smooth borders and a well-demarcated stalk attached to the surface of the PCIOL (Fig. 1A and B). The PCIOL was well-centered and dilated fundus examination was unremarkable.

Fig. 1
figure1

Sharply-circumscribed, globular, partially opaque mass with a round, smooth border and a well-demarcated stalk attached to the anterior surface of the PCIOL in retro-illumination (A) and direct illumination (B)

Full size image

The patient was started on prednisolone acetate 1% eye drops every two hours and cyclopentolate 1% eye drops twice a day. Examination three days later showed complete resolution of the mass (Fig. 2A and B) and improvement in AC inflammation to 1+ cell. The patient endorsed improvement in her symptoms and was discharged on a tapering regimen of topical steroids but was again lost to follow-up.

Fig. 2
figure2

Complete resolution of the AC mass after three days of topical steroids (A, B)

Full size image

The post-operative anterior segment mass reported above most likely represents a fibrinous exudate secondary to rebound iritis. Rebound and persistent iritis are well-known entities that may occur after cataract surgery. Neatrour et al [1] reported that pupil expansion devices significantly increase the risk of persistent (> 1 month) post-operative iritis.

Fibrinous exudates are occasionally encountered after intraocular surgery, more commonly after pars plana vitrectomy [2,3,4,5]. Fibrin reaction has also been reported after anterior segment surgery involving iris manipulation in patients on long-term miotic therapy and in uveitic patients [4]. Following routine cataract surgery, Miyake et al [6] reported a 4.4% overall incidence of pupillary fibrin membrane formation in Japanese patients, typically around post-operative day five.

The pathophysiology of post-operative fibrin clots is thought to be secondary to a transient lowering of IOP and disruption in the blood-aqueous barrier during CE, resulting in leakage of fibrinogen-rich fluid from arterial plasma into the AC, eliciting a fibrinoid reaction [7,8,9]. If untreated, this fibrin can consolidate and result in a dense pupillary membrane. The low IOP seen in this patient was likely secondary to ciliary body shutdown in the setting of anterior uveitis.

To the best of our knowledge, this is the first report in the ophthalmic literature of a subacute post-operative anterior uveitic mass in such a well-circumscribed configuration that completely resolved after a short course of topical steroids. We surmise that this mass represents a fibrinous exudate in the setting of rebound iritis after cataract surgery involving a pupil expansion device. Ophthalmologists should be aware of this unique presentation after intraocular surgery.

Not applicable.

CE:

Cataract extraction

PCIOL:

Posterior chamber intraocular lens

OD:

Right eye

AC:

Anterior chamber

VA:

Visual acuity

IOP:

Intraocular pressure

rAPD:

relative afferent pupillary defect

DF:

Descemet’s folds

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    Neatrour K, McAlpine A, Owens TB et al (2019) Evaluation of the etiology of persistent iritis after cataract surgery. J Ophthal Inflamm Infect 9(1):4

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    Da Rocha LB, Pichi F, Nucci P, Srivastava SK, Lowder CY (2014) Fibrin reaction after Uveitic cataract surgery: treatment and prevention. Eur J Ophthalmol 24(4):626–628. https://doi.org/10.5301/ejo.5000442

    Article Google Scholar

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We would like to acknowledge Montefiore ophthalmic technicians Kevin Ellerbe and Diana Iglesias for capturing the slit lamp photos presented in this case study.

This research is supported by gifts from Lewis Henkind, as well as the Irving and Branna Sisenwein Endowment Fund to the Department of Ophthalmology, Montefiore Medical Center.

Affiliations

  1. Department of Ophthalmology, Albert Einstein College of Medicine, Montefiore Medical Center, 3332 Rochambeau Ave, 3rd Floor, Bronx, NY, 10467, USA

    Nilesh Raval, Wen-Jeng (Melissa) Yao, Gene Kim & Joann J. Kang

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Contributions

WY evaluated the patient during the initial post-operative visits. NR and JK worked together to diagnose and provide treatment for the patient during the acute phase. NR compiled the images and was primary author of the case report. GK provided additional consultation during the write-up. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Nilesh Raval.

Ethics approval and consent to participate

Not applicable.

Consent for publication

Written informed consent for publication of their clinical details and/or clinical images was obtained from the patient. A copy of the consent form is available for review by the Editor of this journal.

Competing interests

The authors declare that they have no competing interests.

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Raval, N., Yao, WJ.(., Kim, G. et al. Rebound iritis with a well-circumscribed anterior chamber fibrin mass after uncomplicated cataract surgery. J Ophthal Inflamm Infect 11, 39 (2021). https://doi.org/10.1186/s12348-021-00270-2

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中文翻译：
无并发症的白内障手术后伴有界限清楚的前房纤维蛋白团块的反弹性虹膜炎

我们报告了一例亚急性反跳性虹膜炎，其特征是球状、带蒂的前房肿块，在局部类固醇爆发后消退。

一名 59 岁女性，既往无明显眼病史，右眼 (OD) 接受白内障摘除术 (CE)，超声乳化术和后房人工晶状体 (PCIOL) 植入术。术中，由于扩张不良而部署了 Malyugin 环，但手术的其余部分平安无事。术后第一天，前房 (AC) 中观察到 3+ 混合细胞和色素，无纤维蛋白反应，在第二周局部使用类固醇后消退。患者失访并且不符合她的类固醇逐渐减量。

八周后，患者出现眼痛 OD。视力（VA）为 20/40，Goldmann 压平眼压（IOP）为 6；没有注意到相对传入性瞳孔缺陷（rAPD）。裂隙灯活体显微镜检查显示出微量的 Descemet 皱襞 (DF)、3+ 混合 AC 细胞和色素，以及边界清晰、球状、部分不透明的前房团块，边界光滑，并且在 PCIOL 表面有一个界限清楚的茎（图 1A 和 B）。PCIOL 居中良好，散瞳眼底检查无异常。

图。1
图1

在逆向照明 ( A ) 和直接照明 ( B ) 中，边界清晰、球状、部分不透明的肿块，具有圆形、光滑的边界和边界清晰的茎，附着在 PCIOL 的前表面

全尺寸图片

患者开始每两小时使用醋酸泼尼松龙 1% 滴眼液，每天两次使用环喷妥酯 1% 滴眼液。三天后的检查显示肿块完全消退（图 2A 和 B）并且 AC 炎症改善为 1+ 细胞。患者认可她的症状有所改善，并通过局部类固醇逐渐减量的方案出院，但再次失访。

图2
图2

局部使用类固醇三天后 AC 肿块完全消退（A，B）

全尺寸图片

上面报告的术后眼前节肿块很可能代表继发于反跳虹膜炎的纤维蛋白渗出物。反弹性和持续性虹膜炎是白内障手术后可能发生的众所周知的实体。Neatrour 等人 [1] 报告说，瞳孔扩张装置显着增加了术后持续（> 1 个月）虹膜炎的风险。

眼内手术后偶尔会出现纤维蛋白渗出液，更常见于平部玻璃体切除术后 [2,3,4,5]。在接受长期缩瞳治疗的患者和葡萄膜炎患者中，也有报道在涉及虹膜操作的眼前节手术后出现纤维蛋白反应 [4]。在常规白内障手术后，Miyake 等人 [6] 报告日本患者瞳孔纤维蛋白膜形成的总体发生率为 4.4%，通常在术后第 5 天左右。

术后纤维蛋白凝块的病理生理被认为是继发于 CE 期间眼压的短暂降低和血水屏障的破坏，导致富含纤维蛋白原的液体从动脉血浆渗漏到 AC，引发纤维蛋白反应。 7,8,9]。如果未经治疗，这种纤维蛋白会巩固并形成致密的瞳孔膜。该患者的低眼压很可能继发于前葡萄膜炎时睫状体关闭。

据我们所知，这是眼科文献中首次报道了亚急性术后前葡萄膜炎肿块，这种肿块边界清晰，在短期局部使用类固醇后完全消退。我们推测，在涉及瞳孔扩张装置的白内障手术后出现反跳性虹膜炎时，该肿块代表了纤维蛋白渗出物。眼科医生应该意识到眼内手术后这种独特的表现。

不适用。

行政长官：

白内障摘除术

PCIOL：

后房人工晶状体

外径：

右眼

交流：

前房

VA：

视力

眼压：

眼压

RAPD：

相对传入性瞳孔缺陷

DF：

Descemet 的褶皱

  1. 1.

    Neatrour K、McAlpine A、Owens TB 等 (2019) 白内障手术后持续性虹膜炎的病因评估。J Ophthal Inflamm Infect 9(1):4

    文章 谷歌学术

  2. 2.

    Jaffe GJ、Schwartz D、Han DP、Gottlieb M、Hartz A、McCarty D、Mieler WF、Abrams GW (1990) 玻璃体切除术后纤维蛋白形成的危险因素。Am J Ophthalmol 109(6):661–667。https://doi.org/10.1016/S0002-9394(14)72434-1

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    Sebestyen JG (1982) 纤维蛋白样综合征：糖尿病患者玻璃体切除术的严重并发症。安眼科 14(9):853–856

    CAS PubMed 谷歌学者

  4. 4.

    Lesser GR、Osher RH、Whipple D、Abrams GW、Cionni RJ (1993) 使用组织纤溶酶原激活剂治疗白内障手术后的前房纤维蛋白。J 白内障屈光手术 19(2):301–305。https://doi.org/10.1016/S0886-3350(13)80961-3

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    Lewis H、Han D、Williams GA (1987) 玻璃体腔内注气玻璃体切除术后纤维蛋白瞳孔阻滞性青光眼的管理。Am J Ophthalmol 103(2):180–182。https://doi.org/10.1016/S0002-9394(14)74223-0

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    Miyake K、Maekubo K、Miyake Y、Nishi O (1989) 瞳孔纤维蛋白膜：日本后房型晶状体植入术后常见的早期并发症。眼科。96（8）：1228-1233。https://doi.org/10.1016/S0161-6420(89)32746-1

    CAS 文章 PubMed Google Scholar

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    Siatiri H、Beheshtnezhad AH、Asghari H、Siatiri N、Moghimi S、Piri N (2005) 前房内组织纤溶酶原激活剂，以防止先天性白内障手术后严重的纤维蛋白渗出。Br J Ophthalmol 89（11）：1458-1461。https://doi.org/10.1136/bjo.2005.071407

    CAS 文章 PubMed PubMed Central Google Scholar

  8. 8.

    Wu TT, Wang HH (2009) 前房内重组组织纤溶酶原激活剂治疗眼内炎严重纤维蛋白反应。眼睛。23（1）：101-107。https://doi.org/10.1038/sj.eye.6702984

    CAS 文章 PubMed Google Scholar

  9. 9.

    Da Rocha LB、Pichi F、Nucci P、Srivastava SK、Lowder CY（2014 年）葡萄膜炎性白内障手术后的纤维蛋白反应：治疗和预防。欧洲眼科杂志 24(4):626–628。https://doi.org/10.5301/ejo.5000442

    文章 谷歌学术

下载参考

我们要感谢 Montefiore 眼科技术人员 Kevin Ellerbe 和 Diana Iglesias 拍摄了本案例研究中展示的裂隙灯照片。

这项研究得到了 Lewis Henkind 以及 Irving 和 Branna Sisenwein Endowment Fund 捐赠给 Montefiore 医学中心眼科的礼物的支持。

隶属关系

  1. 眼科，阿尔伯特爱因斯坦医学院，Montefiore 医疗中心，3332 Rochambeau Ave，3rd Floor，Bronx，NY，10467，美国

    Nilesh Raval、Wen-Jeng (Melissa) Yao、Gene Kim 和 Joann J. Kang

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  2. Wen-Jeng (Melissa) Yao查看作者出版物

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贡献

WY 在最初的术后访问期间对患者进行了评估。NR 和 JK 共同为患者在急性期进行诊断和治疗。NR 编译了图像并且是病例报告的主要作者。GK 在撰写过程中提供了额外的咨询。所有作者阅读并认可的终稿。

通讯作者

与Nilesh Raval 的通信。

伦理批准和同意参与

不适用。

同意发表

从患者那里获得了公开其临床细节和/或临床图像的书面知情同意书。同意书的副本可供本期刊的编辑审查。

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Raval, N., Yao, WJ.（., Kim, G.等人。无并发症白内障手术后具有界限清楚的前房纤维蛋白团块的反弹虹膜炎。J Ophthal Inflamm Infect 11, 39 (2021) 。https :// doi.org/10.1186/s12348-021-00270-2

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