British Journal of Ophthalmology, 1979, 63, 145-149

Vascular changes in the iris in chronicanterior uveitisLEILA LAATIKAINENFrom the Department of Ophthalmology, University of Helsinki, Finland

SUMMARY Vascular changes of the iris were studied in 6 patients with chronic anterior uveitis ofvarying aetiology by means of fluorescein angiography. In 1 case the angiographic findings of thesecond eye were compared with the histopathological changes in the fellow eye enucleated earlierbecause of absolute glaucoma. In the milder cases abnormal superficial vessels were seen mainlyin relation to the minor arterial circle of the iris, while in advanced cases a coarse vascular networkcovered the whole surface of the iris. Both mild and severe changes were found to differ from thearborising type of neovascularisation usually seen in vascular eye diseases. Instead, a resemblancein the vascular pattern was found between some of these cases and eyes with chronic capsularglaucoma. In 1 patient clinical rubeosis seemed to be partly due to dilatation of the pre-existingcapillaries rather than true neovascularisation.

Rubeosis iridis is one of the late complications ofmany vascular, neoplastic, and inflammatory eyediseases (Schulze, 1967; Hoskins, 1974). It hastherefore been considered to be a nonspecificreaction of the iris vasculature to a variety ofnoxious stimuli. Histologically no differences havebeen found between the appearance of the rubeosisassociated with chronic anterior uveitis and that ofother eye diseases (Schulze, 1967). Most of thehistological studies, however, have been done oneyes enucleated because of secondary neovascularglaucoma so that they are representative of the verylate stages of rubeosis. Some peculiarities in theangiographic pattern of the iris have been describedin chronic heterochromic iridocyclitis (Cobb andSmith, 1970). In this paper fluorescein angiographicfindings of the iris vasculature in chronic anterioruveitis of varying aetiology are reported, anddifferences in the vascular response of the iris inuveitis and in some other eye diseases are discussed.

Patients and methods

Six patients with cliniical rubeosis due to chronicanterior uveitis were studied. There were 2 caseswith heterochromic iridocyclitis, 2 cases with rheu-matoid arthritis, I case with ankylosing spondylitis

Address for reprints: Leila Laatikainen, MD, UniversityEye Hospital, Haartmaninkatu 4 C, 00290 Helsinki 29,Finland

with bilateral chronic uveitis, and 1 case withphakogenic iridocyclitis due to traumatic cataractand subluxation of the lens. Further details of thepatients are presented in Table 1.The technique used in fluorescein angiography of

the iris was described in detail by Vannas (1969)and is to be reviewed briefly by the author(Laatikainen, to be published).

Results

Two cases, Case 1 with heterochromic iridocyclitis(Figs. Ia, b) and Case 2 with chronic anterior uveitisdue to ankylosing spondylitis (Figs. 2a, b) showedcoarse irregular vessels superficially and related tothe minor arterial circle of the iris. The superficialnetwork, the arterial circle, and the peripupillarycapillaries all leaked fluorescein. In Case 3, withphakogenic uveitis (Figs. 3a, b), dilated and leakingradial vessels and capillary networks were foundmainly around the pupil and in the midstromalportion of the iris. Mild neovascularisation, althoughnot visible in the angiogram, was present in thechamber angle in all these cases. The intraocularpressure was only moderately raised, and it wascontrolled by medical treatment. The radial vesselswere clearly visible, particularly in Case 1, wherethere was iris atrophy, and they filled regularly inall cases.

In Case 4, with chronic anterior uveitis due torheumatoid arthritis (Figs. 4a, b), and in Case 5,

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Table 1 Clinical features of the patients

Case Agel Duration (yr) and type of Visual acuity IOP (mmHg)no. Sex causative eye disease right/left right/left Gonioscopy Treatment of glaucoma

1 59/M 19, Heterochromic iridocyclitis LE 1 0/1-0 15/37 Mild neovascularisation and Pilocarpine, adrenaline,localised anterior synechiae acetazolamide

2 50/M 8, Chronic uveitis BE HM/0-5 30/42 Ditto Adrenaline, acetazolamide

3 52/M 7, Phakogenic iridocyclitis LE 1 0/PL 15/34 Moderate neovascularisation Pilocarpine, acetazolamide,with anterior synechiae cyclocryocoagulation

4 28/M 4, Chronic anterior uveitis BE 1 0/10 30-60/ Fibrovascular anterior Filtrating surgery,30-50 synechiae > 180° cyclocryocoagulation

5 36/M 16, Heterochromic iridocyclitis RE PL/l 0 34-58/16 Broad fibrovascular anteriorsynechiae

6 71 /M 29, Recurrent anterior uveitis BE 0 5/-* 40-60/- Angle closed by fibrous Filtrating surgerytissue > 180°

RE = right eye, LE = left eye, BE = both eyes, HM hand movement, PL = perception of light.

with heterochromic iridocyclitis (Figs. 5a, b), thesuperficial vascular network covered most of thesurface of the iris from the angle to the pupillarymargin, showing extensive leakage of the dye in thelate phase of the angiogram. In Case 5 ectropionuveae was found on the temporal side. Some of thenewly formed vessels had spread over the pigmentepithelial seam on to the cataractous lens. In theseeyes the radial vessels were less clearly visiblebecause of a sheet of fibrous tissue covering thesurface of the iris. Broad fibrovascular synechiae

Fig. 1 Case 1, heterochromic iridocyclitis.Fluorescein angiogram of the left iris.Coarse superficial irregular vessels inrelation to the minor arterial circle (a) withleakage (b). Mild leakage around the pupil(b). IOP 37mmHg

were present in the chamber angle, and the intra-ocular pressure was high. In Case 4, 5 antiglauco-matous operations have been performed since thisangiogram, but within a few weeks of operation thefiltration cleft was closed by new fibrous tissue. Inspite of increased intraocular pressure no treatmenthas been required for glaucoma in Case 5, becausethe eye was comfortable but blind.

In Case 6, with recurrent iridocyclitis and sec-ondary glaucoma due to rheumatoid arthritis,dilated capillaries were seen in relation to the radial

Fig. 2 Case 2, chronic anterior uveitis dueto ankylosing spondylitis. Fluoresceinangiogram of the right iris. Coarsesuperficial vessels particularly in relationto the minor arterial circle (a) with mildleakage (b). Lea,kcage around the pupil (b).IOP 42 mmHg

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Vascular changes in the iris in chronic anterior uveitis

Duration and type of causativeOther changes disease

Aphakia for 15 yr

Posterior subcapsular cataract Ankylosing spondylitis for 10 yr

Mature cataract and subluxation of Trauma 47 yr agothe lens

Aphakia RE for 2 yr, LE for 1 yr Juvenile rheumatoid arthritis for16 yr

Mature cataract, ectropion uveae

Mild posterior subcapsular cataract Rheumatoid arthritis for 50 yr

0 Left eye enucleated because of secondary glaucoma 7 yr earlier.

arteries (Fig. 6a). Furthermore these vessels leakedfluorescein (Fig. 6b). On this eye trabeculectomywas performed and iris angiography was repeated1 week later when the intraocular pressure was10 mmHg. This postoperative angiogram (Figs. 6c,d) showed further dilatation and leakage of the deepcapillaries between the radial vessels, but superficialvessels similar to those seen in the previous caseswere not present. In this case the intraocular pres-sure has been controlled since the operation.Histopathological study of the other eye, enucleated

because of absolute glaucoma 7 years earlier,showed peripheral anterior synechiae and mono-nuclear inflammatory cells in the angle (Fig. 7a).In the central part of the iris deposits of denseinflammatory cells with a few small vessels were alsopresent, but dilated capillaries were seen only roundthe pupil (Fig. 7b).

Discussion

The fluorescein angiographic picture of rubeosisiridis seen in the present cases of chronic anterioruveitis differed from that found in various vasculareye diseases (Laatikainen and Blach, 1977;Laatikainen, to be published). In the less advancedcases minute vessels were found crossing the cham-ber angle, and in addition irregular superficialleaking vessels were present in the area of the minorarterial circle of the iris. Similar angiographicchanges were described by Cobb and Smith (1970)in heterochromic iridocyclitis. The present casesshowed that this type of capillary network was notspecific for heterochromic iridocyclitis but thatsimilar vessels could also be found in other types ofchronic anterior uveitis.

Vascular changes described in other anteriorsegment diseases such as pseudoexfoliation of thelens with or without capsular glaucoma have somesimilarities with these cases (Vannas, 1969). In

Fig. 3 Case 3, phakogenic uveitis.Fluorescein angiogram of the left iris.Areas of superficial neovascularisation,particularly in the pupillary part of the iris(a) with leakage (b). IOP 34 mmHg

Fig. 4 Case 4, chronic anterior uveitis dueto rheumatoid arthritis. Fluoresceinangiogram of the right iris. Delicate newlyformed vascular network all over the iris (a)with moderate leakage in the late picture(b). IOP 30 mmHg

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Leila Laatikainen

Fig. 5 Case 5, heterochromic iridocyclitis.Fluorescein angiogram of the right eye.Rich superficial vascular network all overthe iris (a) with mild leakage in the latepicture (b). Newly formed vessels cross thepupillary border on to the cataractous lens(a, b). IOP 37 mmHg

Fig. 6 Case 6, recurrent anterior uveitiswith secondary glaucoma due to rheumatoidarthritis, a and b: Fluorescein angiogramof the right iris at the time of increased lOP(40 mmHg) showing arborisations of smalldeep vessels (a) which leak.fluorescein (b).c and d: Postoperative angiogram(IOP 10 mmHg) showing further dilatationand leakage of the iris capillaries (c, d)

c

contrast, in vascular diseases, neovascularisation ofthe iris usually appears as arborisations of vesselscoming from the angle with or without peripupillaryvascular dilatation or neovascularisation, but themidstromal portion is rarely involved early. Earlyleakage of fluorescein from the circular vessels orvessel loops in the area of the minor arterial circleis common both in inflammatory and in vasculardiseases.As the inflammatory process advances, fibro-

vascular tissue may gradually cover most of thesurface of the iris. In these advanced cases a uniformnetwork of larger mesh of neovascularisation wasformed rather than arborisations of vessel trunkssuch as are usually seen in advanced cases ofdiabetics (Laatikainen, to be published) or othervascular iridopathies. Similar changes in chronic

uveitis have recently been reported by Demeler(1978). Thus it seems that, although histologicallyindistinguishable, the vascular changes in the iris inlocalised chronic inflammatory diseases differ intheir evolution from those in vascular diseases ofthe eye. In vascular diseases the pathological processis usually more acute and affects the metabolism ofthe iris tissue more than in chronic inflammations.Therefore the stimulus for the formation of newvessels is more intense, whereas the formation offibrous tissue predominates in inflammatorydiseases.

It is not always possible to differentiate neo-vascularisation from dilated vessels clinically oreven by fluorescein angiography, because both leakfluorescein. Leakage is more profuse if activeinflammation or hypotonia is present, as was seen

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Vascular changes in the iris in chronic anterior uveitis

Fig. 7 Case 6, left eye. Sections fromchamber angle (a) and central part of theiris (b). Anterior synechiae and mononuclearinflammatory cells in the angle (a). Denseinflammatory cell deposits and a few vesselsin the iris stroma (b). Peripupillarycapillaries dilated. Remnants of cycliticmembrane on posterior surface.(Haematoxylin and eosin)

F-vw:Fa,:5:'S < Se~~~~~.~

f %4"-k4s'-'" ''fiev\t 's;-- .A ; t8ti'4ase*s

b

in the post-operative angiogram in Case 6, wheresome of the leaking vessels were probably dilatedcapillaries rather than newly formed vessels. Thisopinion was supported by histological findings inthe other eye, where the chamber angle was closedby anterior synechiae, but the number of vessels inthe iris was small.

In the second eye of this patient filtering surgerywas also more successful than in the other caseswhere neovascularisation was present on the surfaceof the iris. In all the other cases the intraocularpressure at the time of angiography was moderatelyraised. This pressure level may slightly increase theleakage of the superficial networks, because corres-ponding vessels found in capsular glaucoma haveshown less leakage and some of them have evendisappeared after return of the intraocular pressureto normal by surgery (unpublished data).This work was supported by the Paulo Foundation.

References

Cobb, B., and Smith, M. E. (1970). Fluorescein studies ofthe iris in pseudoexfoliation of the lens capsule, hetero-chromic cyclitis and central and branch vein occlusion.Acta XXI Concilium Ophthalmologicum Mexico 1970, Part1, pp. 953-958. Excerpta Medica International CongressSeries No. 222.

Demeler, U. (1978). Irisangiographie bei Rubeosis iridis.Ophthalmologica, 176, 91 -101.

Hoskins, H. D., Jr. (1974). Neovascular glaucoma: Currentconcepts. Transactions of the American Academy ofOphthalmology and Otolaryngology, 78, 330-333.

Laatikainen, L., and Blach, R. K. (1977). Behaviour of theiris vasculature in central retinal vein occlusion. Afluorescein angiographic study of the vascular responseof the retina and the iris. British Journal of Ophthalmology,61, 272-277.

Schulze, R. R. (1967). Rubeosis iridis. American Journal ofOphthalmology, 63, 487-495.

Vannas, A. (1969). Fluorescein angiography of the vesselsof the iris in pseudoexfoliation of the lens capsule, capsularglaucoma and some other forms of glaucoma. ActaOphthalmologica, Suppl. 105.

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