Arlt’s Triangle, causes, examination and management

History

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Arlt’s triangle is named after Carl Ferdinand Ritter von Arlt’s (1812-1887), an Austrian ophthalmologist who was also the first physician to prove that myopia is a consequence of excessive axial length of the eye.

Etiology of Arlt’s Triangle

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Arlt’s distribution pattern of mutton fat keratic precipitates is suggestive of a chronic granulomatous inflammatory process. The differential diagnosis includes anterior uveitis associated with sarcoidosis, syphilis, and tuberculosis.

Clusters of large, fluffy, lardaceous KPs with greasy appearance forming Arlt’s triangle may also occur in other unusual chronic infections e.g. leprosy, brucellosis, coccidiomycosis.

Pathophysiology of Arlt’s Triangle

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Arlt’s distribution is caused by convection currents within the anterior chamber and the cooler temperature in the inferior cornea.

The larger granulomatous KPs will pigment and then shrink as inflammation abates or is controlled by steroid therapy.

They often fail to disappear completely, and they may alter the endothelium where they rest, leaving a halo on the endothelium.

Diagnosis of Arlt’s Triangle

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 Clinical Diagnosis

Arlt’s triangle is typically diagnosed during slit-lamp biomicroscopy. The keratic precipitates forming an inverted triangle on the inferior corneal epithelium can be visualized during slit-lamp examination in diffuse illumination, as well as direct focal illumination or an optic section.

in some cases, this collection of sticky inflammatory cells on the central and inferior cornea is so large in size, that it’s visible with the naked eye.

Differential Diagnosis

Arlt’s triangle is suggestive, but not pathognomonic, of granulomatous inflammation. Differential diagnosis should also include unusual chronic inflammatory conditions including :

• Sarcoidosis
• Syphilis
• Tuberculosis
• Vogt-Koyanagi-Harada disease
• Sympathetic ophthalmia
• Lens-induced uveitis
• Brucellosis
• Lyme disease
• Leprosy
• Presumed ocular histoplasmosis syndrome (POHS)
• toxocariasis
• Toccidiomycosis

Diagnostic Work-Up

• Venereal Disease Research Laboratory (VDRL) test, FTA-ABS (or similar treponemal specific serology) test for syphilis A specific antitreponemal test must be obtained, as RPR or VDRL can provide false-negative results on RPR or VDRL.

• CBC with differential

• Angiotensin-converting enzyme (ACE) test for sarcoidosis may be obtained but is not very sensitive or specific, especially in children.

• Anergy evaluation for sarcoidosis (rarely done)

• Lyme serology if Lyme disease is suspected (eg, endemic area, tick bite, systemic manifestations)

• Toxoplasmosis enzyme-linked immunosorbent assay (ELISA) if posterior uveitis associated

• Antineutrophil cytoplasmic autoantibodies: c-ANCA with PR3 specificity is most specific for Wegener granulomatosis. c-ANCA is found in 80-95% of active cases. Isolated anterior uveitis (without orbital, scleral, or corneal involvement) is a very rare presentation of Wegener granulomatosis.

• Cytology, polymerase chain reaction, and cultures of intra-ocular fluid when infection or masquerade suspected

• In cases of suspected Acute Retinal Necrosis, anterior chamber fluid and/or vitreous should be examined via polymerase chain reaction (PCR) for HSV and herpes zoster virus nucleic acid.

Take a break … read about slit-lamp smartphone photography

Management of Arlt’s Triangle

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General treatment

Cycloplegia: Use a long-acting cycloplegic agent, such as cyclopentolate or homatropine, to relieve both pain and photophobia (if present) and to prevent the formation of posterior synechiae.

this may not always be necessary for chronic disease, especially if the inflammation is well controlled. In any case, allowing for some pupil movement is helpful to prevent posterior synechiae formation in the dilated position.