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Editor,—We report a case of unilateral anterior pseudouveitis in a diabetic retinopathic eye, as a manifestation of hyperlipidaemia. High levels of lipids were detected in the aqueous humour and the anterior flare resolved only after successful control of diabetes and hyperlipidaemia was obtained.
A 44 year old man was referred for anterior uveitis not responsive to a 5 day topical steroid therapy. His past medical history was significant for non-insulin dependent diabetes mellitus, systemic hypertension, hyperlipidaemia, and obesity.
At presentation, the patient complained of pain and redness in his left eye. Visual acuity was 20/25 in the right eye and light perception in the left eye. Examination of the right eye disclosed only mild diabetic retinopathy. Slit lamp examination of the left eye showed hyperaemia of the conjunctiva, and an intense milky flare obstructing the view of the iris and the fundus (Fig 1). It was difficult to detect the presence of cells in the anterior chamber because of the flare. There were neither keratic precipitates nor hypopyon or iris neovascularisation. Intraocular pressures in both eyes were within normal limits. B-scan ultrasonography was unremarkable.
Results of laboratory tests showed hyperglycaemia (24 mmol/l), a twofold increase in normal cholesterol levels (15 mmol/l), and a 22-fold increase in normal triglyceride levels (38 mmol/l). Results of laboratory examination including HLA typing, angiotensin converting enzyme, serologies for herpes simplex virus (HSV) and lues, purified protein derivative (PPD) skin test, and chest and sacroiliac x rays, were not contributory. A β and pre-β lipoproteinaemia pattern was established by serum electrophoresis. Analysis of the aqueous humour of the left eye disclosed no cells, and high levels of proteins (32 g/l), cholesterol (3.4 mmol/l), and triglycerides (4.9 mmol/l).
Visual acuity recovered at 20/50 and the flare resolved after lipidaemia and diabetes had been controlled by oral fibrates and insulin, respectively. Fundus examination of the left eye showed mild diabetic retinopathy including microaneurisms, hard exudates, and many paravascular retinal haemorrhages. Six weeks later, fundus examination of the left eye showed evidence of central retinal venous occlusion (CRVO).
Although clinical presentation including pain, perilimbal conjunctival hyperaemia, and anterior chamber flare, was consistent with acute anterior uveitis, many features favoured a strong relation between the metabolic disorders and the occurrence of the flare. These clues included the milky appearance of the flare, the results of the anterior chamber paracentesis, the lack of response to topical steroids, and the resolution of the flare only after the control of hyperlipidaemia.
To our knowledge, only one case of pseudoendophthalmitis related to hyperlipidaemia has been published.1 Both eyes were involved in a patient with bilateral proliferative diabetic retinopathy. Blood-aqueous barrier breakdown has been demonstrated in diabetic patients, especially those presenting with diabetic retinopathy,2 and in patients with CRVO.3 In the present case, an underlying mild diabetic retinopathy was diagnosed in both eyes. The unilateral leakage of lipids in the anterior chamber may be related to ipsilateral blood-aqueous barrier breakdown following an undiagnosed partial vein occlusion or an episode of transient iridocyclitis rapidly cured by topical steroid therapy.