Bilateral laser peripheral iridotomy in a co-occurrence of unilateral iridocorneal endothelial syndrome and chronic angle closure glaucoma

Purpose To report a case of unilateral Iridocorneal endothelial (ICE) syndrome- Progressive iris atrophy (PIA) with an overlapping chronic angle closure glaucoma (CACG) and to highlight the effect of bilateral Laser peripheral iridotomy (LPI) in such a co-occurrence. Case description A patient presented to us with bilateral gradual painless progressive diminution of vision. Both eyes (BE) had a clear cornea, shallow peripheral anterior chamber depth, grade 2 nuclear sclerosis, raised intraocular pressure and glaucomatous optic neuropathy. In addition, the Left eye (LE) had an irregular anterior chamber, peripheral anterior synechiae (PAS) extending to cornea, patchy iris atrophy, subtle corectopia and a low endothelial cell count on specular microscopy. Indentation gonioscopy led to the diagnoses of CACG BE with ICE syndrome- PIA LE. LPI was performed bilaterally. On Anterior Segment Optical Coherence Tomography (ASOCT), there was evident widening of the angle away from PAS in the Right eye as well as in the LE with PIA post LPI. Conclusion This is a unique case of unilateral PIA with an associated CACG in BE. It is the first case demonstrating the effect of bilateral LPI in such a case scenario. Though not indicated in ICE syndrome, LPI did show short term evidence of significant widening of the angle away from areas of PAS even in the eye with PIA having a limited high PAS and a concurrent primary (chronic) angle closure disease.

Bilaterally displaced Schwalbe’s line: An unusual presentation of Axenfeld Rieger syndrome

To report a case on unusual presentation of Axenfeld Reiger (A-R) syndrome. Axenfeld Rieger syndrome commonly presents with prominent Schwalbe’s line near the limbus. Presentation with displaced Schwalbe’s line is rarely reported. We report 2 cases who presented with bilaterally displaced Schwalbe ring as strange cord like structure in anterior chamber with iris tissue adhesions. Axenfeld – Reiger syndrome is an autosomal dominant disease with ocular findings involving cornea (megalocornea), iris (iris atrophy,correctopia) and angle (anterior insertion of iris, prominent Schwalbe line). We report unsual case of detached Schwalbe’s line with iris tissue adhesions in anterior chamber A-R syndrome.

Novel mechanism of decreased iris vasculature density after cosmetic iris implants

A 25-year-old man presented with decreased vision in both eyes, approximately 4 years following bilateral bright ocular cosmetic iris implantation. On examination, he was found to have bilateral elevated intraocular pressures, anterior chamber cells and flare, chronic peripheral anterior synechiae and significantly reduced endothelial cell counts. Ultrasound biomicroscopy demonstrated compression of the peripheral iris, resulting in synechial angle closure in both eyes. Surgical removal of the implants was performed without additional complication. On removal, bilateral iris atrophy was evident with non-reacting pupils and permanent mydriasis. Optical coherence tomography angiography showed a reduction in iris vasculature density that is more pronounced in the area of the iris atrophic defects. This case suggests that cosmetic iris implants may compress iris vasculature, resulting in decreased iris perfusion resulting in atrophic mydriasis and iris defects. This is a potential novel mechanism for complications in eyes with cosmetic iris implants.

Fuchs Heterochromic Iridocyclitis: Clinic, Diagnosis, and Treatment

Fuchs heterochromic iridocyclitis (FHI) is a mild grade, chronic, non-granulomatous uveitis. Due to the asymptomatic course and variation of clinical findings, FHI is the uveitis with the highest number of late and wrong diagnosis. Decreased visual acuity due to floaters and cataracts are the most frequent complaints at presentation. It has characteristic features like unilateral involvement, diffuse, small stellate keratic precipitates, iris atrophy leading to heterochromia, abnormal angle vessels, and lack of posterior synechia or macular edema. Etiology is still uncertain however acquired rubella infection is the most approved. Visual prognosis is excellent in FHI. Cataract and glaucoma are among the major complications leading to visual loss. For the treatment, steroids might be used for the short term. Unnecessary long term use of steroids increases the risk for cataract and glaucoma

Ocular Injury Caused by the Sprayed Venom of the Asian Giant Hornet (Vespa mandarinia)

This report presents the details of a case of sight-threatening injury in the right eye of a 77-year-old man which was caused by the venom of the Asian giant hornet (Vespa mandarinia). The patient was not stung, rather the venom was sprayed into his eye. Although the injured eye was washed as a first aid treatment, persistent corneal defect, corneal endothelial decompensation, iris atrophy, pupil dilation, and mature cataract were observed and a hand movement visual acuity was recorded 8 weeks after the injury. Since a slight a-wave was detected in his electroretinogram (ERG) result after the corneal epithelial defect had healed, we performed cataract surgery and Descemet stripping automated endothelial keratoplasty (DSAEK). After the DSAEK, the cornea of the right eye became clearer; however, the visual acuity of his right eye did not improve. Fundus examination revealed branch retinal artery occlusion but no optic disc atrophy. ERG showed that the a-wave amplitude of the injured eye recorded after the surgery was almost half of that of the fellow eye. The iris atrophy and mature cataract show that the sprayed Vespa venom of the Asian giant hornet can permeate into the intraocular area even without stinging. Whether the venom directly affects retinal function is unclear, but the decreased a-wave of the injured eye shows that the venom caused damage of retinal function in some way. Irrigation of the anterior chamber as well as eye washing is needed as a first aid treatment in similar cases.

Literature Review of Cystoid Macular Edema in Iridocorneal Endothelial Syndrome and Its Response to Nepafenac 0.1%

Background Iridocorneal endothelial syndrome (ICE) is a rare disease which happens usually in women at 20-40 years of age. About 50% of patient with such disease develops glaucoma.Case presentation A 29-year-old woman presented in August 2015 with right eye blurring of vision for 6 months. On examination, the corneal endothelial with beaten metal appearance was noted. Right eye correctopia with iris atrophy and periphery anterior synechiae were seen. Mottled appearance of the macula which tallied with the optical coherence tomography (OCT) findings of cystoid macular edema (CME) was found. An non-steroidal anti-inflammatory drugs (NSAIDs) eye drops (NEVANACÒ Nepafenac ophthalmic suspension 0.1%) was commenced for long term. She was re-examined 2 years later in 2018. Her vision was 6/6. OCT and fundus fluorescence angiography (FFA) finding were normal.Conclusion The NSAIDs was the only treatment received by the patient and throughout the years, her CME has subsided. A long term use of Nepafenac 0.1% has shown to be effective in treating CME in ICE syndrome.

Bilateral acute anterior uveitis and iris atrophy caused by moxifloxacin

A 56-year-old paramedic was admitted to hospital and treated for severe pneumonia. Shortly after initiating antibiotic treatment (including moxifloxacin), he developed bilaterally painful eyes and was diagnosed with bilateral acute anterior uveitis (AAU). Three years later, he was referred to the ophthalmology clinic with bilateral iris transillumination suggesting iris atrophy and limited pupillary dilation, indicating iris sphincter muscle paralysis. AAU typically presents unilaterally. An onset of bilateral AAU is unusual and warrants investigation for underlying systemic cause. The fluoroquinolone moxifloxacin has been reported in a limited number of cases as a causative agent of bilateral AAU and iris atrophy. This case provides additional supporting evidence that moxifloxacin may cause degradation of collagen and iris muscle in the eye, as well as elsewhere in the body, such as in blood vessels. Additionally, we present novel anterior segment ocular imaging (using optical coherence tomography) demonstrating the ability to detect iris atrophy using non-invasive imaging.