Wessley Immune Ring

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Overview

Wessely rings are sterile, corneal intrastromal reactions resulting from immune response to foreign antigens. It can be found in various corneal infections as well as in non-infectious processes.

Background

Wessely rings are corneal intrastromal sterile infiltrates, coined after Wessely who first documented the “Wessely phenomenon”, a reproducible immune reaction in rabbit corneas exposed to cattle or horse serum protein and later challenged with the same antigen in 1911.[1] In 1956, Morawiecki provided insight into the pathophysiology of the disease and the role of immune complex-mediated complement activation. [2] Later, it was found that other antigens may trigger antibody-independent, properdin-mediated alternative pathway complement activation, including bacterial endotoxins.[3][4][5][6]

Pathogenesis

The pathogenesis of Wessely rings involves the interaction of foreign antigens with antibodies diffusing from the limbal vasculature into the stroma, resulting in immune complex formation which activate the complement system, leading to polymorphonuclear leukocyte recruitment into the stroma. Both the classical and the alternate pathways of the complement system have been observed to lead to Wessely ring formation, which may explain the variable time courses between symptom onset and Wessely ring observation.[4] [7]Neutrophils are the predominant infiltrative cells in Wessely immune rings.[8]

Etiology

Corneal immune ring formation can be associated with infectious agents, or they can be sterile corneal infiltrates.

• Infectious agents

o Gram-negative rods (e.g. Pseudomonas)

o Gram-negative diplobacillus (e.g. Moraxella atlantae) [9]

o Herpes simplex [10] [11]

o Herpes zoster

o Acanthamoeba keratitis [12] [13]

o Microsporidium keratitis [14]

o Non-tuberculous Mycobacteria

o Fungal keratitis, including Pythium insidiosum keratitis [15]


• Sterile:

o Endotoxins

o Chronic contact lens use [5] [7]

o Antigenic corneal foreign bodies

o Excimer LASER photoablation [16]

o Topical drugs (e.g. diclofenac) [17]

o Corneal burns

o Intracorneal insect stings

o Palytoxin (PTX)-producing zoanthids (corals) [18]

o Behçet’s syndrome [19]

o Recurrent corneal erosions (RCE) [20] [21]

Diagnosis

History

Since the Wessely immune stromal ring arises in patients with underlying causes for stromal immune reactions, the patient’s symptoms are usually related to the underlying etiology; the Wessely ring is usually not visually significant.

Presenting symptoms may include ocular pain, foreign body sensation, or burning; tearing or purulent discharge; blurred vision, halos around lights; photophobia; and redness.

It is important to identify potential causative agents and/or inciting events, including contact lens wear, ocular trauma by physical (e.g. excimer LASER), thermal or chemical agents (e.g. topical diclofenac, palytoxin), and systemic auto-immune disease.

Physical examination

The typical Wessely phenomenon consists of a corneal stromal ring forming peripherally near the limbus, with centripetal migration ahead of peripheral clouding. The “true” Wessely ring (resulting of immune complex-mediated complement activation) usually appears at 10-14 days from symptom or disease onset, creating a visible ring separated from the central nidus of infection by a clear space. [9] However, immune rings may appear earlier (within 1 to 5 days of symptom onset) due to activation of the alternate pathway of the complement cascade, as in cases of Pseudomonas keratitis, or in cases of previous exposure to the inciting antigens.[9] In cases of microbial agents with more protacted clinical courses such as Acanthamoeba or Microsporidium keratitis, immune rings may appear after a longer delay. [9] [12] In cases of herpetic immune stromal keratitis, the Wessely immune ring appears as a mid-stromal of deep ring of stromal haze, usually central or paracentral in location, and may surround a disciform area of endotheliitis, [10] [11]

Differential diagnosis

The presence of a Wessely immune ring can aid in the differential diagnosis but can also be misleading.[22] When evaluating a corneal ring infiltrate, the most important alternative diagnostic consideration is an infectious ring infiltrate. It is especially important to differentiate infectious ring infiltrates from non-infectious immune rings since both may form in the course of microbial keratitis.

In patients with microbial keratitis, the following signs suggest infectious infiltrate with viable microorganisms invading host tissue rather than a pure immune ring:

• pain,

• conjunctival injection,

• epithelial defects,

• purulence,

• necrosis,

• anterior chamber reaction.

Milder findings of an infiltrate outside the ulcer borders and responsive to topical corticosteroids suggest areas of “pure” immune ring formation in patients with microbial keratitis.

Wessely rings have been reported in patients with herpetic keratitis, Pseudomonas keratitis and other Gram-negative rod keratitis, Moraxella atlantae keratitis, Acanthamoeba keratitis, fungal keratitis, and Microsporidia stromal keratitis. Although the Wessely immune ring of deep stromal haze has been classically described in herpes simplex immune stromal keratitis, immune stromal rings have also been reported in patients with herpes zoster keratitis.

Regarding non-infectious stromal rings, the anamnesis and clinical findings guide the ophthalmologist to the most likely etiology. Notably, these have also been observed in patients with contact lens (CL), hypothesized to be immune responses to bacterial antigens, particularly Gram-negative rods such as Pseudomonas. [5] [7] In these cases, foreign antigens such as bacterial endotoxin may migrate into the corneal stroma and cause activation of the alternative pathway of the complement cascade. However, in patients with CL-related Wessely ring, a high index of suspicion for infectious keratitis is advised. Finally, storage fluid contamination may also be a cause of Wessely ring in CL wearers.[5]

Excimer LASER photoablation has been reported to cause ring-shaped immune stromal reactions, including both photorefractive keratectomy (PRK) and phototherapeutic keratectomy (PTK). [16] [17] The mechanisms behind excimer LASER-induced Wessely immune ring formation remains unclear. Although previously thought to result from liberation of trapped antigens (denaturated proteins of DNA at the edge of the ablation zone) could induce a reaction, more recently it has been hypothesized that mammalian heat-shock proteins (HSPs) produced following physical stress (LASER photoablation) may cross-react with circulating antibodies against bacterial HSPs originated from previous contact or infection.[16] Although topical diclofenac has been reported as a cause of sterile corneal infiltrates,[17] pure drug toxicity is unlikely to lead to a ring-shaped infiltrate.[16]

Systemic autoimmune diseases may also be associated with appearance of Wessely immune rings. Inflammation of the limbal vasculature in Behçet’s disease may facilitate the diffusion of immune complexes into the corneal peripheral stroma and stromal ring formation.[19]

Corneal immune infiltration is an uncommon complication of RCE.[20] [21] Epithelial injury produces a leukocyte chemotactic factor that can lead to sterile infiltrates.[21] These cases should probably always be treated as potentially infected, since clinical distinction between sterile or infected cases is seldom clear in this setting.[20] However, in cases of “truly sterile” infiltrates, resolution is usually rapid and complete, and addition of topical steroids may hasten resolution, especially in severe cases.[21]

PTX-induced toxic keratoconjunctivitis is a rarely reported ocular surface inflammatory disease reported in individuals handling zoanthid (coral) colonies or during cleaning of an aquarium containing these corals.[18] [23] [24]The receptor for PTX is the plasma membrane that contains the sodium-potassium adenosine triphosphatase (Na-K ATP-ase) pump, and consequently the toxicity of PTX can affect multiple organ systems and can be severe.[18] In the ocular surface, PTX can result in corneal epithelial sloughing and corneal nerve altered sensation, and may trigger Wessely ring formation as well as peripheral corneal thinning due to degradation of keratocytes, collagen, and proteoglycans.[18] The clinical presentation of PTX keratitis may range from mild ocular surface disease to vision-threatening corneal melting and perforation.[23]

Management

Management of Wessely rings depends on etiology. Infectious keratitis should be treated according to the causative agent. Sterile immune rings usually require no therapy, but frequently these patients are frequently managed with topical corticosteroids.

Prognosis

Immune rings heal by gradual fading while spreading centrifugally or centripetally. [16]Usually there are few sequelae, although some necrosis and scar formation are occasionally observed.[16]

The visual prognosis is largely related to etiology, as “purely” immune stromal infiltrates fade slowly and are usually not visually significant.

References

  1. Wessely K. about anaphylactic phenomena of the cornea. Munchen Med Wehascher. 1911;58:1713.
  2. Morawiecki J. Antigen-antibody precipitation phenomena in the living cornea. Ophthalmologica. 1956;132:236–43.
  3. Mondino BJ, Rabin BS, Kessler E, et al. Corneal rings with Gram-negative bacteria. Arch Ophthalmol. 1977;95:2222–5. 4.
  4. 4.0 4.1 Mondino BJ, Ratajczak HV, Goldberg DB, et al. Alternate and classical pathway components of complement in the normal cornea. Arch Ophthalmol. 1980;98:346–9.
  5. 5.0 5.1 5.2 5.3 Non-infectious ring-shaped keratitis associated with Pseudomonas aeruginosa. Am J Ophthalmol. 1982;93(3):338-341. doi:10.1016/0002-9394(82)90536-0.
  6. Rabinowitz SM, Starr MB, Gorman BD, Kezirian GM. Properdin-mediated immune ring formation associated with Pseudomonas keratitis. Arch Ophthalmol. 1987;105(2):173-174. doi:10.1001/archopht.1987.01060020027013.
  7. 7.0 7.1 7.2 Qiao GL, O'Donnell H, Yeung SN, Iovieno A. Case of bilateral Wessely rings in a contact lens wearer. Can J Ophthalmol. 2019;54(4):e182-e183. doi:10.1016/j.jcjo.2018.10.023
  8. Felberg NT, Sery TW. The reverse Wessely phenomenon: immune corneal rings following systemic immunisation. Br J Ophthalmol. 1978;62(12):831-835. doi:10.1136/bjo.62.12.831
  9. 9.0 9.1 9.2 9.3 Barash A, Chou TY. Moraxella atlantae keratitis presenting with an infectious ring ulcer. Am J Ophthalmol Case Rep. 2017;7:62-65. Published 2017 Jun 12. doi:10.1016/j.ajoc.2017.06.003
  10. 10.0 10.1 Salmon JF. Cornea. Book Chapter Kanski’s Clinical Ophthalmology – A Systematic Approach, Chapter 7, 203-273. Ninth Edition (2020) Elsevier Limited. ISBN: 978-0-7020-7711-1.
  11. 11.0 11.1 Holland EJ, Vislisel JM, Schwartz GS. Herpes Simplex Keratitis. Book Chapter Cornea, 78, 832.e1-860. Fifth Edition (2022). Elsevier Limited. ISBN E-book: 978-0-323-67472-0
  12. 12.0 12.1 Szentmáry N, Daas L, Shi L, et al. Acanthamoeba keratitis - Clinical signs, differential diagnosis and treatment. J Curr Ophthalmol. 2018;31(1):16-23. Published 2018 Oct 19. doi:10.1016/j.joco.2018.09.008
  13. Varacalli G, Di Zazzo A, Mori T, et al. Challenges in Acanthamoeba Keratitis: A Review. J Clin Med. 2021;10(5):942. Published 2021 Mar 1. doi:10.3390/jcm10050942
  14. Thomas KE, Purcell TL, Tanzer DJ, Schanzlin DJ. Delayed diagnosis of microsporidial stromal keratitis: unusual Wessely ring presentation and partial treatment with medications against Acanthamoeba. BMJ Case Rep. 2011;2011:bcr0820103233. Published 2011 Feb 24. doi:10.1136/bcr.08.2010.3233
  15. Lelievre L, Borderie V, Garcia-Hermoso D, et al. Imported pythium insidiosum keratitis after a swim in Thailand by a contact lens-wearing traveler. Am J Trop Med Hyg. 2015;92(2):270-273. doi:10.4269/ajtmh.14-0380
  16. 16.0 16.1 16.2 16.3 16.4 16.5 Teichmann KD, Cameron J, Huaman A, Rahi AH, Badr I. Wessely-type immune ring following phototherapeutic keratectomy. J Cataract Refract Surg. 1996;22(1):142-146. doi:10.1016/s0886-3350(96)80284-7
  17. 17.0 17.1 17.2 Sher NA, Frantz JM, Talley A, et al. Topical diclofenac in the treatment of ocular pain after excimer photorefractive keratectomy. Refract Corneal Surg. 1993;9(6):425-436.
  18. 18.0 18.1 18.2 Moshirfar M, Khalifa YM, Espandar L, Mifflin MD. Aquarium coral keratoconjunctivitis. Arch Ophthalmol. 2010;128(10):1360-1362. doi:10.1001/archophthalmol.2010.206
  19. 19.0 19.1 Cohen S, Kremer I. Bilateral corneal immune ring opacity in Behçet's syndrome. Arch Ophthalmol. 1991;109(3):324-325. doi:10.1001/archopht.1991.01080030026023
  20. 20.0 20.1 20.2 Ionides AC, Tuft SJ, Ferguson VM, Matheson MM, Hykin PG. Corneal infiltration after recurrent corneal epithelial erosion. Br J Ophthalmol. 1997;81(7):537-540. doi:10.1136/bjo.81.7.537
  21. 21.0 21.1 21.2 21.3 Papathanassiou M, Gartry D. Sterile corneal ulcer with ring infiltrate and hypopyon after recurrent erosions. Eye (Lond). 2007;21(1):124-126. doi:10.1038/sj.eye.6702438
  22. Weinstein I, Fries FN, Szentmáry N, Seitz B, Daas L. Ausgeprägter Wessely-Immunring bei Keratitis – ein Chamäleon [Distinctive Wessely immune ring in keratitis-a chameleon]. Ophthalmologe. 2021;118(1):53-55. doi:10.1007/s00347-020-01084-8.
  23. 23.0 23.1 Farooq AV, Gibbons AG, Council MD, et al. Corneal Toxicity Associated With Aquarium Coral Palytoxin. Am J Ophthalmol. 2017;174:119-125. doi:10.1016/j.ajo.2016.10.007
  24. Barrett RT, Hastings JP, Ronquillo YC, Hoopes PC, Moshirfar M. Coral Keratitis: Case Report and Review of Mechanisms of Action, Clinical Management and Prognosis of Ocular Exposure to Palytoxin. Clin Ophthalmol. 2021;15:141-156. Published 2021 Jan 12. doi:10.2147/OPTH.S290455