Amsler (Amsler-Verrey) Sign

Article Author:
Koushik Tripathy
Article Editor:
Baby Salini UB
Updated:
2/11/2019 11:40:14 AM
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Amsler (Amsler-Verrey) Sign

Definition/Introduction

Amsler sign (aka Amsler-Verrey sign) presents in Fuchs heterochromic uveitis (FHU). It is characterized by hemorrhage in the anterior chamber (hyphema) after anterior chamber paracentesis or entry with the microvitreoretinal blade during anterior segment surgeries including cataract surgery or minor trauma. This hemorrhage is due to the presence of fine, fragile vessels in the angle of the anterior chamber. The sign got its name from Dr. Marc Amsler and Dr. Florian Verrey who described it in 1946.[1]

Dr. Marc Amsler (1891-1968) was a Swiss ophthalmologist and a great teacher.  He was a student of Jules Gonin (1870-1935) at the University of Lausanne. He was a strong supporter of Gonin's ideas on the repair of rhegmatogenous retinal detachments. Dr. Amsler was known as "Le marcheur de l'operation de Gonin" (The seller of Gonin's surgical procedure).[2] Dr. Amsler became the chief of Zurich Eye Clinic. His contribution to ophthalmology includes the Amsler grid and the Amsler- Dubois chart. Amsler grid is a 10 cm X 10 cm square-shaped chart which has seven different variants. The chart is a useful and inexpensive tool to monitor metamorphopsia and scotoma in various macular diseases, most commonly wet age-related macular degeneration. The Amsler-Dubois chart is an important chart to document posterior segment lesions including retinal detachment. Dr. Amsler's research interests included the study of the macular function, the study of aqueous humor in uveitis, and keratoconus. He invented a mirror for retinal examination using monocular indirect ophthalmoscope.

Dr. Florian Verrey (1911-1976) was a Swiss ophthalmologist who worked with Dr. Amsler at the University of Lausanne and later at Zurich Eye Clinic. His research focused on uveitis and aqueous humor.

FHU gets its name from Ernst Fuchs (1851-1930), an Austrian Ophthalmologist. He was the clinical director of the Second Vienna Eye Hospital.[3] The Textbook of Ophthalmology written by Dr. Fuchs was considered one of the best textbooks on the subject at that time. Fuchs endothelial corneal dystrophy and Fuchs spot in myopia have their name dedicated to him. 

Issues of Concern

Pathophysiology

Gonioscopy in FHU reveals[4][5]

  • Small twig-like vessels in the angle which likely give rise to Amsler-Verrey sign. 
  • The visibility of large vessels at the peripheral iris likely due to the atrophy of iris
  • Loss of the details of the angle of the anterior chamber with a 'dullness or felt-like covering'
  • Small irregular areas of non-confluent goniosynechiae

The fine vessels at the angle of the anterior chamber are fragile and prone to rupture after trivial trauma. The actual nature of these vessels is unknown and may be abnormal vasculature or new vessels. There is no clear correlation between the hyphema and abnormal angle vessels.[6] The hemorrhage in the anterior chamber originates from the angle in a filiform appearance and then may settle inferiorly when the patient is upright. Amsler-Verrey sign has been claimed to be a diagnostic sign in FHI, especially in Europe.[6]

However, similar anterior chamber hemorrhage after paracentesis may also present in other conditions including

  • Neovascular glaucoma
  • Neovascularization of the angle of the anterior chamber
  • Sudden hypotony or shallowing of the anterior chamber during anterior segment surgery. However, the sign may lead the clinician to a strong suspicion of FHI.  

Causes of Anterior chamber hemorrhage

Amsler and Verrey noted hyphema after paracentesis in FHI.[1][6] Other causes of Amsler-Verrey sign include[7][8]:

  • Spontaneous or possibly from trivial trauma like rubbing the eyes
  • Gonioscopy
  • Applanation tonometry
  • Pharmacological dilatation of the pupil
  • Posterior capsulotomy
  • Honan ballon before cataract surgery
  • During cataract surgery
  • Peribulbar anesthesia

Clinical Significance

The hyphema due to the Amsler sign is usually mild. Active bleeding from the angle into the anterior chamber may stop spontaneously. In cases with continuing intraoperative hemorrhage, forming the anterior chamber with a viscosurgical device or raising the intraocular pressure usually stops the bleeding. The hyphema typically does not worsen the visual outcomes, and most cases of FHU will have mild perioperative hemorrhage after cataract surgery. Hyphema may not be present on the first postoperative day. For postoperative mild hyphema, a medication regimen of antibiotic and steroid drops are usually enough to control inflammation. In severe hyphema or severe postoperative inflammation, topical cycloplegics are needed to prevent posterior synechia. Though posterior synechia is otherwise uncommon in FHU, postoperative inflammation can cause posterior synechia and thus requires control with both steroid and cycloplegics. Typically, the outcome of cataract surgery is good in FHU with cataract though some cases may have anterior chamber reaction, deposit over the intraocular lens (IOL), decentration of IOL, glaucoma, vitreous inflammation/haze, posterior capsular opacification, cystoid macular edema, corneal edema, and macular hole.[9][10] 


References

[1] AMSLER M,VERREY F, [Not Available]. Ophthalmologica. Journal international d'ophtalmologie. International journal of ophthalmology. Zeitschrift fur Augenheilkunde. 1946 Feb-Mar;     [PubMed PMID: 20275799]
[2] Sampaolesi R, Prof. Marc Amsler and the Cantonal Hospital Eye Clinic, Zurich. Survey of ophthalmology. 1996 Mar-Apr;     [PubMed PMID: 8779087]
[3] Muller A,McGhee CN, Professor Ernst Fuchs (1851-1930): a defining career in ophthalmology. Archives of ophthalmology (Chicago, Ill. : 1960). 2003 Jun;     [PubMed PMID: 12796263]
[4] Liesegang TJ, Clinical features and prognosis in Fuchs' uveitis syndrome. Archives of ophthalmology (Chicago, Ill. : 1960). 1982 Oct;     [PubMed PMID: 6890339]
[5] FRANCESCHETTI A, Heterochromic cyclitis: Fuchs' syndrome. American journal of ophthalmology. 1955 Apr;     [PubMed PMID: 14361605]
[6] Jones NP, Fuchs' heterochromic uveitis: an update. Survey of ophthalmology. 1993 Jan-Feb;     [PubMed PMID: 8441952]
[7] Srinivasan S,Lyall D,Kiire C, Amsler-Verrey sign during cataract surgery in Fuchs heterochromic uveitis. BMJ case reports. 2010 Oct 10;     [PubMed PMID: 22767537]
[8] Belfort R Jr,Muccioli C, Hyphema after peribulbar anesthesia for cataract surgery in Fuchs' heterochromic iridocyclitis. Ocular immunology and inflammation. 1998 Mar;     [PubMed PMID: 9798195]
[9] Tejwani S,Murthy S,Sangwan VS, Cataract extraction outcomes in patients with Fuchs' heterochromic cyclitis. Journal of cataract and refractive surgery. 2006 Oct;     [PubMed PMID: 17010867]
[10] Javadi MA,Jafarinasab MR,Araghi AA,Mohammadpour M,Yazdani S, Outcomes of phacoemulsification and in-the-bag intraocular lens implantation in Fuchs' heterochromic iridocyclitis. Journal of cataract and refractive surgery. 2005 May;     [PubMed PMID: 15975468]