Uveitis Precipitated by Nonpenetrating Ocular Trauma James T. Rosenbaum, M.D., James Tammaro, M.D., and Joseph E. Robertson, Jr., M.D. Although penetrating trauma is a well-recognized cause of uveitis, the role of nonpenetrating trauma in initiating uveitis is not defined. We analyzed the records of 496 patients seen at the uveitis clinic at our institution. Twenty-four of these 496 patients (4.80/0) suspected that the cause of their intraocular inflammation was related to previous nonpenetrating trauma. In contrast, only one of 251 patients (0.4%) attending the general ophthalmology clinic for routine care provided a history of recent trauma or attributed the present ocular complaint to trauma (P < .02). Patients with posttraumatic uveitis were usually male (19 of 24,79%), younger (31 ± 16 years) than the average patient examined in the uveitis clinic, and more likely to have unilateral disease. In ten (42%) of the patients the trauma was workrelated. Bilateral inflammation was seen in eight (one third) of the patients and 17 of 28 patients (71 %) had a considerable degree of inflammation posterior to the lens. Many patients had an identifiable cause of uveitis such as ankylosing spondylitis, Reiter's syndrome, sarcoidosis, or acute retinal necrosis; but most patients had no known predisposition. The role of nonpenetrating trauma in initiating uveitis has implications for diagnosis and treatment. is a well-recognized cause of uveitis in the form of sympathetic ophthalmia.' A more common form of uveitis that results from trauma is the self-limited inflammation associated with intraocular surgery such as cataract extraction. Additionally, PENETRATING

TRAUMA

Accepted for publication July 10, 1991. From the Department of Ophthalmology (Drs. Rosenbaum, Tammaro, and Robertson); and the Departments of Medicine and Cell Biology (Dr. Rosenbaum), Oregon Health Sciences University, Portland, Oregon. This study was supported in part by National Institutes of Health grant EY06484. Reprint requests to James T. Rosenbaum, M.D., Oregon Health Sciences University, 3181 S.W. Sam Jackson Park Rd., Portland, OR 97221.

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surgical procedures can markedly exacerbate intraocular inflammation in an eye that has demonstrated previous uveitis.! The role of nonpenetrating trauma in precipitating uveitis is not as well established. Inflammation in other organ systems, however, is frequently triggered by nonpenetrating trauma. Joint inflammation, for example, may be initiated by a contusion-" and skin inflammation may be precipitated by various injuries including sunburn and minor trauma. This latter phenomenon is known as a Koebner reaction and is commonly associated with psoriasis.v" Approximately 25% of patients with psoriasis develop psoriasis in skin subjected to minor irritation.' We analyzed the consecutive records of the uveitis clinic at our institution. Twenty-four of these 496 patients (nearly 5%) attributed their intraocular inflammation to nonpenetrating trauma or had a history of minor trauma usually less than one week before the onset of intraocular inflammation. We analyzed the characteristics of that patient group and compared them to those of the uveitis clinic population as a whole.

Patients and Methods

The characteristics of the uveitis clinic at our institution have been previously described." The patients who are examined are usually referred for additional opinion in regard to diagnosis or treatment. All patients undergo a thorough ophthalmic examination, as well as an examination by an internist or rheumatologist. Our study involved 496 consecutive patients with a diagnosis of uveitis. Patients were examined from Sept. I, 1985, through July 20, 1990. All patients were seen by one of us (I.T.R.). Charts were reviewed for a history of nonpenetrating trauma that the patient believed to be related to the cause of ocular inflammation. To compare the prevalence of trauma among patients with uveitis to the prevalence in another patient group, 251 charts representing pa-

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tient visits for routine eye care to the Department of Ophthalmology General Clinic at our institution were reviewed. This control group included 144 patients who wanted a routine refraction or contact-lens examination; 35 patients with an external eye condition such as conjunctivitis; 19 patients with cataract; 18 patients with diabetes; and 35 other patients with miscellaneous conditions including suspected glaucoma, strabismus, macular degeneration, or diplopia. Each physician completed a form that specifically referred to trauma. Patients were excluded if a history related to trauma was not recorded. Twenty-four of the 496 patients (4.8%) with uveitis attributed their eye disease to previous nonpenetrating trauma. Patients whose uveitis developed after penetrating trauma (for example, those with sympathetic ophthalmia or those with inflammation after insertion of an intraocular lens) were not included among these 24. In the control group, 19 of 251 patients (7.6%) provided a history of recent or remote trauma, but only one of 251 (0.4%) patients in the control group ascribed the current ocular complaint to nonpenetrating trauma. This patient had recurrent corneal erosion. The probability of ophthalmic examination necessitated by nonpenetrating trauma was significantly different between the patients with uveitis and the control group (P < .02, by chi-square analysis). Nineteen of the 24 patients with posttraumatic uveitis (79%) were male, whereas only 233 of the 496 patients of the total uveitis clinic population (47%) were male (P < .01, by chi-square analysis). Of the 251 control patients, 105 (42%) were male. The average age of patients with posttraumatic uveitis was 31 :t 16 years (mean :t standard deviation), whereas the average age in the uveitis clinic as a whole was 42 years (P < .01, by Student's t-test). The average age of the control patients in the eye clinic was 43 years. Precipitating trauma included splashes with chemicals; trauma with blunt objects (as with a bat, a tennis ball, or a branch); and pokes, as with a finger. The trauma itself did not usually precipitate ophthalmic examination. In some patients who were being examined years after the onset of uveitis, the duration of time between trauma and the onset of uveitis was difficult to establish; but for most patients, the inflammation usually began within one week of the trauma, and most often within a few days. In ten of the 24 patients (42 %), the trauma was related to

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work. Many patients had a known predisposition to uveitis; two patients had Reiter's syndrome, two patients were HLA-B27 positive, two patients had sarcoidosis, and one patient had ankylosing spondylitis. Of all patients with HLA-B27-associated iritis (patients with Reiter's syndrome, ankylosing spondylitis, or who were HLA-B27 positive, but without joint disease), five of 62 (8%) attributed the eye disease to the trauma. One patient had retinal degeneration and one had suspected interstitial nephritis. One patient developed acute retinal necrosis and a second patient was suspected of having this entity. Sixteen of the 24 patients with posttraumatic uveitis (67%) had unilateral disease, compared with 213 of the 496 patients with uveitis as a whole (43%; P < .02, by chi-square analysis). Seventeen of the 24 patients with posttraumatic uveitis (71 %) had a marked degree of inflammation posterior to the lens, sometimes involving the choroid or retina. This localization of the inflammation did not differ from that of 496 patients of the uveitis clinic population as a whole, of whom approximately 342 patients (69 %) had a marked degree of inflammation posterior to the lens.

Case Reports

Case 1 Hypopyon in an HLA-B27-positive man-An 18-year-old man suffered mild trauma caused by a blunt object to one eye. Five days later, he had a unilateral iridocyclitis in the traumatized eye, associated with the presence of fibrin and hypopyon. The patient had no back or joint complaints, but his family history demonstrated a possibility for ankylosing spondylitis. Endophthalmitis was tentatively diagnosed. However, the patient proved to be HLA-B27 positive and had complete resolution of his inflammation as a result of oral and topical treatment with corticosteroids. Case 2 Bilateral uveitis in a patient with sarcoidosis-A 14-year-old boy was struck by a tennis ball in the left eye. Vision became blurry in the left eye one to three days later and then became blurry in the right eye two weeks later. Subsequent ophthalmic examination showed the presence of anterior chamber cells, vitreous cells and haze, posterior synechiae, and peri-

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phlebitis that was bilateral, but markedly worse in the left eye. Sarcoidosis was diagnosed on the basis of hilar adenopathy, increased angiotensin-converting enzyme concentration in serum, subsequent parotid enlargement, and a skin biopsy showing noncaseating granuloma.

Case 3

Sustained vitreous inflammation-A 37-yearold farm worker developed eye discomfort shortly after being struck by an onion while in the field. Examination four months after the trauma showed a minimal anterior chamber reaction and extensive vitreous cells and debris. Discussion Our study indicated that nearly 5% of patients attending a uveitis referral clinic attributed their inflammation to nonpenetrating trauma. Patients with nonpenetrating trauma were more often male, were more likely to have unilateral disease, and were younger than the majority of patients in the uveitis clinic. In general, ocular trauma is most common in a young male population. Surprisingly, one third of the patients had bilateral disease and most patients had considerable inflammation posterior to the lens. These observations suggest that nonpenetrating trauma may precipitate intraocular inflammation. Several hypotheses could explain this association. In some cases, the inflammation may have preceded the trauma and the trauma merely brought to attention a disease process that had begun insidiously and had therefore been undetected. In other cases, however, the trauma may have had a more causal role. In some instances, an underlying predisposition to inflammation could be identified, but in most cases the inflammation had an idiopathic origin. The process of inflammation has been described as a wound that does not heal. Trauma undoubtedly elicits many of the same mediators such as prostaglandins, cytokines, and growth factors that contribute to inflammation. In contrast to trauma, inflammation involves a positive feedback loop that ordinarily does not terminate without treatment intervention. In a predisposed eye, trauma may initiate this positive feedback loop. Several conditions, the HLA-B27 spectrum of disease, sarcoidosis, and

the viral retinitis known as acute retinal necrosis, seem particularly predisposed to being triggered by trauma. We previously observed trauma as a trigger for iritis associated with HLAB27 8 and trauma has also been observed to initiate HLA-B27-associated joint disease." The relative contribution of trauma in initiating inflammation outside the eye is likewise difficult to ascertain. For example, in rheumatoid arthritis, the role of trauma is debated." At least one study, however, found that 5% of the patients with rheumatoid arthritis had previous trauma," a percentage nearly identical to our observations in regard to uveitis. Finding bilateral inflammation after nonpenetrating trauma is perplexing and suggests coincidence rather than causality. However, sometimes after vitrectomy we have observed an immediate, self-limited inflammation in the contralateral eye. The early onset and brief duration seem to preclude sympathetic ophthalmia and suggest that inflammation in one eye may trigger contralateral inflammation by an unknown reflex arc. These observations have potential implications. From a diagnostic perspective, recognition of the syndrome helps to place the inflammation into an etiologic category that may have implications for treatment and prognosis. For example, the history of Case 1 and the recognition that the patient was HLA-B27 positive convinced us to treat the inflammation rather than to perform a vitrectomy for culturing. Our study indicates that many patients experienced the trauma in the work place. Although we do not suggest that nonpenetrating trauma is the only cause of uveitis in these patients (and dearly some of these patients had a predisposing reason to develop uveitis), our observations strongly suggest that nonpenetrating trauma may be a precipitating factor in the development of intraocular inflammation.

References 1. Lubin, ]. R., Albert, D. M., and Weinstein, M.: Sixty-five years of sympathetic ophthalmia. Ophthalmology 87:109,1980. 2. Foster, C. 5., Fong, C. P., and Singh, G.: Cataract surgery and intraocular lens implantation in patients with uveitis. Ophthalmology 96:281, 1989. 3. Olivieri, I., Gemignani, G., Christou, c., and Giampiero, P.: Trauma and seronegative spondyloarthropathy. Report of two more cases of peripheral

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arthritis precipitated by physical injury. Ann. Rheum. Dis. 48:520, 1989. 4. Wallace, D. J.: The role of stress and trauma in rheumatoid arthritis and systemic lupus erythematosus. Semin. Arthritis Rheum. 16:153, 1987. 5. Farber, E. M., Roth, R. J., Aschheim, E., Eddy, D. D., and Epinette, W. W.: Role of trauma in isomorphic response in psoriasis. Arch. DermatoI. 91 :246, 1965.

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6. Koebner, H.: Zur aetiologie der psorrasis. Viertelijahresschr. DermatoI. Syphilis 8:559, 1877. 7. Rosenbaum, J. T.: Uveitis. An internist's view. Arch. Intern. Med. 149:1173, 1989. 8. - - : Characterization of uveitis associated with spondyloarthritis. J. RheumatoI. 16:792, 1989. 9. Short, C. L., Bauer, W., and Reynolds, W. E.: Rheumatoid Arthritis. Cambridge, Massachusetts, Harvard University Press, 1957, p. 180.

OPHTHALMIC MINIATURE

But the side of the question that I want to bring before you today. .. is related to what is often called the "diaphragm of the eye," that is, the ciliary body with the suspensory ligaments and capsule. This diaphragm is a great protection to the eye, both from the mechanical escape of vitreous, and also from infection. It powerfully strengthens the anterior hyaloid membrane. That is a matter on which any man with large cataract experience can have no question in his mind. I look upon-and always will look upon-the integrity of the vitreous at the close of a cataract operation as a very great asset. Col. R. H. Elliot, Transactions of the International Congress of

Ophthalmology

Washington, 1922, p. 334

Uveitis precipitated by nonpenetrating ocular trauma.

Although penetrating trauma is a well-recognized cause of uveitis, the role of nonpenetrating trauma in initiating uveitis is not defined. We analyzed...
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