Primary Iris Stromal Cyst in a Female Patient Aged 26 Years.

This case report describes a diagnosis of primary iris stromal cyst in female patient aged 26 years during a routine ophthalmologic examination.

Management of an iris stromal cyst by fine needle aspiration with absolute alcohol irrigation and argon laser photocoagulation to induce sclerosis.

PURPOSE: To describe the management of an iris stromal cyst by fine needle aspiration and irrigation with absolute alcohol to induce cyst sclerosis. METHODS: We present the case of a 45-year-old patient with no previous history referred for a 3-month history of an iris lesion in his right eye. Examination revealed a 2.1×3mm cyst with transparent walls at the right inferonasal iris root, and a primary acquired iris stromal cyst was diagnosed. Initially, observation was recommended, but at the 2-month follow-up, growth of the lesion was observed, so fine needle aspiration and cryotherapy were performed, with recurrence after 2 months. Subsequently, fine needle aspiration and irrigation with absolute alcohol for 2minutes to induce sclerosis of the cyst was carried out. Two weeks after surgery, argon laser was performed on the iris root and remaining walls of the cyst to induce adherence. RESULTS: After 1 year of the procedure, the patient remains asymptomatic, without associated complications. A depression and hyperpigmentation of the iris in the inferonasal sector persists, without recurrence of internal fluid or increase in cyst volume. Endothelial cell count and intraocular pressure monitoring have remained stable. CONCLUSION: Iris stromal cyst sclerosis by aspiration and irrigation with absolute alcohol was effective and avoided complications associated with resection of the lesion.

Case Report: Modified Piggyback System to Treat Peripheral Iridotomies and Degenerative Myopia.

SIGNIFICANCE: This report details how a case with degenerative myopia and symptoms secondary to laser peripheral iridotomies is managed with a modified piggyback contact lens system. The benefits of using a system with tinted and gas-permeable (GP) lenses are discussed. PURPOSE: This study aimed to report the positive outcome of a modified piggyback system in the treatment of degenerative myopia and iris abnormalities. CASE REPORT: A patient with degenerative myopia presented with visual disturbances secondary to laser peripheral iridotomies in both eyes. A modified piggyback system was trialed using a corneal GP lens overlaying a tinted soft contact lens to provide optimal vision and visual comfort in both eyes. After optimizing the fit, there was a reduction in glare and improved vision. CONCLUSIONS: Hard contact lenses often provide superior optics and vision compared with soft lenses, especially to patients with high refractive errors. Patients who require hard lenses and also have visual disturbances secondary to iris abnormalities could be managed with a modified piggyback contact lens systems using a corneal GP lens and tinted soft lens.

[Laser treatment of giant iris cyst in the anterior chamber in a child (a clinical observation)]. / Lazernoe lechenie gigantskoi kisty raduzhki i perednei kamery u rebenka (klinicheskoe nabliudenie).

The article describes a clinical case of a giant post-traumatic iris cyst occupying the anterior chamber in a 3-year-old child successfully treated with laser methods (YAG-laser and diode-pumped laser with doubled frequency). Cyst scarring was achieved with preservation of visual acuity of 1.0. The follow-up period lasted 10 years. The question of indications for laser methods of eliminating cysts of the anterior segment of the eye in children remains debatable. The huge size is traditionally considered a contraindication for laser treatment of the cyst; it leads to death of the organ more often, especially after radical surgical removal of the cyst. The described case confirms the feasibility of non-invasive laser treatment efforts even if the cyst is huge in size.

Severe color change in corneal tattoos: Report of 3 cases.

INTRODUCTION: Corneal tattooing is a noninvasive technique which appears relatively well-tolerated in the medium term. We report the cases of 3 patients with a significant change in the color of their tattoos performed over 5 years previously. PATIENTS AND METHODS: Three patients with a history of intracorneal tattooing several years previously were studied because of a significant change from their initial color. Each patient's file was reviewed with analysis of slit lamp photographs, OCT and specular microscopy. RESULTS: All three patients experienced a significant color change in their tattoos between 5 and 6 years after surgery. The color had changed to golden-brown. DISCUSSION: Retrospective analysis of the components of the tattoo ink found the presence of iron in the black pigment. We believe that pigments composed of iron oxide are transformed into golden-brown ferric iron oxide in the presence of oxygen in the aqueous environment. The presence of moderate corneal edema in these three cases of multioperated patients could explain, in these specific cases, the occurrence of oxidation typically not described. CONCLUSION: Corneal tattooing remains a simple and very interesting technique when partial or total absence of iris causes significant photophobia. However, the significant changes in color that we report more than 5 years later suggest removing iron from the dyes used for the cornea and limiting its use in cases of limited endothelial prognosis. A long-term evaluation of corneal tattoos appears necessary.

Iridogoniodysgenesis: A Challenging Case.

Iridogoniodysgenesis is a rare autosomal dominant disorder affecting anterior segment of the eye. Fifty percent cases of iridogoniodysgenesis have glaucoma, which is particularly difficult to manage. We report here a case of 40 years old man with this rare disorder, presenting to our glaucoma department. It was characterised by iris hypoplasia and juvenile glaucoma. To stop fluctuation in his intraocular pressure (IOP) and to save his vision from glaucomatous damage, our team had to do three different surgical procedures, i.e. trabeculectomy with F5U, diode laser cycloablation and aqueous shunt procedure, over a period of 10 months. This case report discusses management of glaucoma in this particular patient and challenges faced during the treatment. Regular follow-up and timely intervention can save such patients from complete blindness. To authors' knowledge, this is the first reported case of iridogoniodysgenesis in Pakistan.

Iris cysts: A comprehensive review on diagnosis and treatment.

Iris cysts, both primary and secondary, are a diagnostic and treatment challenge. Primary cysts arise either from the iris pigment epithelium or the iris stroma. Posterior pigment epithelial cysts are subdivided according to their location as central, midzonal, and peripheral. Iris stromal cysts are classified either as congenital or acquired. Free-floating cysts are usually dislodged pigment epithelial cysts. Secondary cysts are classified according to the underlying cause as implantation cysts, drug-induced, uveitic, tumor-induced, parasitic, or as cysts associated with systemic disorders. Differential diagnosis is based on the clinical presentation and imaging. Ultrasound biomicroscopy is the gold standard for the imaging of iris cysts, combining excellent resolution with sufficient tissue penetration. Treatment of iris cysts depends largely on whether they become symptomatic or not. Symptoms include obstruction of the visual axis, corneal decompensation, secondary uveitis, and secondary glaucoma. Treatment options cover a range from simple observation to fine-needle aspiration (with or without intracystic injection of absolute alcohol or antimitotic agents), laser (argon, Nd:YAG), or surgical excision. In the past, the prevailing notion was that of a radical surgical intervention in the form of iridectomy or iridocyclectomy. Given the high rate of recurrence, a stepwise conservative approach is currently favored by most clinicians.

[Diagnosis and Therapy of Iris Lesions]. / Diagnostik und Therapie von Irisläsionen.

The most common iris lesions are iris nevi, iris melanomas and iris pigment epithelium cysts. However, there is an abundance of rare differential diagnoses that have to be considered, including other melanocytic and non-melanocytic lesions. Diagnostic tools include the slit lamp examination, gonioscopy, tonometry, transillumination, ultrasound biomicroscopy (UBM), optical coherence tomography, fluorescein angiography and standardized photography-assisted documentation. The timely identification of malignant lesions (i.e. iris melanoma) is paramount. To assess malignancy criteria of iris nevi, the ABCDEF rule (age young, blood, clock hour inferior, diffuse growth, ektropion uveae, feathery margins) can be applied. Statistically, up to 11% of iris nevi may develop into iris melanomas within 20 years. TNM Staging follows the 2010 AJCC cancer staging manual and helps determine the optimal treatment strategy. Treatment options include radiotherapy, such as plaque brachytherapy and proton beam radiation therapy, as well as surgical excision. Both the surgical and the radiotherapeutic approaches show comparable local tumor control rates. However, the spectrum of therapy-related side effects and complications may differ amongst treatment modalities. After initial treatment, patients should be followed up every 3 - 6 months. Tumor-related mortality ranges between 0 - 11% and is significantly lower than in other uveal melanomas. A prognostic value of common genetic alterations, which have been identified as significant prognostic factors in posterior uveal melanoma, could not be shown for iris melanoma.

Cysts of the Iris Pigment Epithelium. What Is New and Interesting? The 2016 Jose Rizal International Medal Lecture.

PURPOSE: Cysts of the iris pigment epithelium (IPE) can involve the pupillary margin, midzone, or peripheral location or can be free-floating in the aqueous or vitreous or lodged in the anterior chamber angle. Avariant of IPE cyst, known as iris flocculi, can be a marker for systemic thoracic aneurysm. DESIGN: Review of IPE cysts and description of new observations of the lesions. METHODS: Review of IPE cysts. RESULTS: Lesions in 672 eyes were classified as of the pupillary margin (n = 49; 7%), midzone (n = 188; 28%), peripheral (n = 424; 63%), or dislodged/free-floating (n = 11; 2%). Cysts of the IPE occurred most often in young adults (21-40 years) (n = 229; 34%) manifesting with peripheral or midzonal cysts. The characteristic clinical features of pupillary margin cyst were teardrop configuration at the pupillary margin, midzonal cyst with fusiform brown appearance, peripheral cyst as iris stromal bulge, dislodged cyst as a brown lesion in the angle, and free-floating cyst with round mass moving by gravitational forces in the aqueous or vitreous. Ultrasound biomicroscopy and anterior segment optical coherence tomography demonstrated the lesions. Surgical intervention for drainage/resection was rarely necessary (<1%). Some (<1%) cysts were associated with iris nevus, iris melanoma, or ciliary body melanoma. Pupillary margin cysts (flocculi) can be found with dissecting thoracic aortic aneurysm, related to genetic mutation in smooth muscle of the iris and aorta. CONCLUSIONS: Cysts of the IPE most often affect the peripheral region (iridociliary) and rarely require intervention. These cysts can be associated with underlying iris or ciliary body nevus or melanoma. Patients with iris flocculi should be monitored for dissecting thoracic aneurysm.

Plateau Iris - Therapeutic options and functional results after treatment.

We present the therapeutic options and functional results in patients with plateau iris (syndrome or configuration) in consecutive case series. Material and method: Our study included newly diagnosed patients with acute angle closure by "plateau iris" (configuration or syndrome), between June 2016 and April 2017. Series of 8 consecutive patients met the inclusion criteria, all being females. All the patients underwent an individualized treatment according to the underlying mechanism and evolution. Functional results (visual acuity, IOP, topical medication) were reported in the current paper. Results: For 10 months, we diagnosed 14 eyes, from 9 patients with acute angle closure by Plateau Iris, distributed as it follows: 6 eyes with closed angle glaucoma (optic disk and visual field changes), 8 eyes with plateau iris syndrome and 2 eyes with plateau iris configuration. 7/ 8 patients were misdiagnosed with primary open angle glaucoma, whereas only one patient had the correct diagnosis of closed angle glaucoma and underwent peripheral laser iridotomy. As treatment options in our study, we recommended and performed argon laser peripheral iridoplasty + iridotomy in 10/ 14 eyes, cataract lens was extracted in 4 eyes and then replaced with PC-IOL, whereas 2 eyes required a filtering anti-glaucoma surgery (trabeculectomy + PI). 2 eyes from the same patient could not be treated as intended as the patient refused the treatment. In this unique case, Pilocarpine (4%) was temporarily indicated. Conclusion: Plateau iris represents a diagnostic trap, but based on a thorough gonioscopic examination and a good patient history, the right diagnosis can be made, all along with a correct therapeutic approach.

Vitiligo iridis and glaucoma: a rare sequelae of small pox.

PURPOSE: Vitiligo iridis refers to focal areas of iris atrophy as sequelae of small pox infection. We report a series of patients with unilateral vitiligo iridis, some of whom presented with secondary open-angle glaucoma. METHODS: Three patients with vitiligo iridis underwent a comprehensive ophthalmic examination including intraocular pressure (IOP) measurement, slit lamp biomicroscopy, gonioscopy, and fundus evaluation. Patients' facial features were also documented and photographed. RESULTS: All patients were in their sixth decade. Two out the three had elevated IOP (52 mm Hg and 36 mm Hg) in the same eye as vitiligo iridis, at initial presentation. Gonioscopy showed patchy iris hyperpigmentation and fundus evaluation showed glaucomatous optic disc changes in the involved eye. One patient responded favourably to topical antiglaucoma medications, whereas the other was taken up for combined phacoemulsification-trabeculectomy with good results. The third patient had normal IOP in the involved eye. All three patients gave a history of small pox in childhood and had pitted facial scars typical of previous small pox infection. CONCLUSIONS: Vitiligo iridis may be associated with the secondary glaucoma as a long-term sequelae of small pox. It may be prudent to periodically follow-up such patients for development of raised IOP in the future.

Iris stromal cyst management with absolute alcohol-induced sclerosis in 16 patients.

IMPORTANCE: The management of symptomatic iris stromal cyst is challenging using methods of aspiration with or without adjunctive cryotherapy, intracameral cautery, or photocoagulation. Failed cases often require surgical resection, with risks for epithelial downgrowth, glaucoma, blindness, and loss of the eye. OBJECTIVE: To study the safety and efficacy of the management of iris stromal cysts with aspiration and alcohol irrigation to induce cyst sclerosis. DESIGN, SETTING, AND PARTICIPANTS: Interventional case series at a tertiary referral center among 16 patients. EXPOSURES: Microscopically monitored transcorneal aspiration of cysts was performed with a 30-gauge needle on a 3-way T-extension into a 3-mL syringe, followed by immediate infusion of absolute alcohol from a separate 1-mL syringe through the other arm of the T-extension. Subsequent alcohol aspiration and repetition of the cycle was performed until the collapsed cyst wall appeared gray. MAIN OUTCOMES AND MEASURES: Cyst involution, visual acuity, and treatment complications. RESULTS: The iris stromal cysts were primary congenital (n = 6), primary acquired (n = 4), or secondary (n = 6). The cysts had a median basal diameter of 12 mm and a thickness of 4 mm, occupying 50% or more of the anterior or posterior chamber in each case. Treatment was administered following failure of simple aspiration (n = 16) and additional methods (n = 8). During a median follow-up period of 5 years, treatment was successful in 14 of 15 patients (1 patient was lost to follow-up). Cyst sclerosis with stabilization (n = 1) or involution (n = 13) was achieved following 1 (n = 10), 2 (n = 2), or 3 (n = 2) procedures. The single failure occurred in a 3-year-old child with cyst recurrence and severe photophobia requiring resection. Visual acuity remained stable or had improved in 14 patients and was reduced in 1 patient because of cataract. Complications included transient corneal edema (n = 4) and transient anterior chamber inflammation (n = 1), which resolved following topical corticosteroid therapy. No evidence was seen of treatment-related glaucoma, epithelial downgrowth, tissue necrosis, cataract, posterior segment toxic effects, or need for enucleation. CONCLUSIONS AND RELEVANCE: Microscopically monitored aspiration and absolute alcohol-induced sclerosis of iris stromal cysts is safe and effective, with cyst involution obtained in 93% (14 of 15) of patients.

Iris rubeosis, severe respiratory failure and retinopathy of prematurity--case report.

THE AIM: Case study reports for the first time about development of massive iris neovascular complication in course of retinopathy of prematurity related to systemic and ocular ischemic syndrome due to tracheostomy-requiring extremely severe premature respiratory failure. MATERIAL AND METHOD: Premature female, 950 grams birth weight, born from 17-year-old gravida 1, at 28 weeks' gestation by cesarean section due to premature placental abruption with threatening hemorrhages, with 1 to 5 Apgar score. The baby developed severe respiratory failure which required tracheostomy advanced bronchopulmonary dysplasia treated with steroids (BPD) and respiratory distress syndrome (RDS) with failure to extubate together with secondary ocular ischemia. All the mentioned with multifactorial organs complications (NEC, leucopenia, anemia, pneumonia, periventricular leucomalacia, electrolyte abnormalities and metabolic acidosis) resulted in massive peripupillary iris neovascularization (NVI) in both eyes coexisting with retinopathy of prematurity (ROP) in 38 weeks' PMA infant. Ultrasonography-B, slit-lamp and indirect fundus examinations with photography were used to document focusing ocular diagnosis. The previous retinopathy of prematurity screening examinations performed at standard intervals of time starting from four weeks of life, that is 32 weeks' PMA continuing every two weeks did not present typical lesions seen in retinopathy however in the second zone of retina slightly marked "plus sign" was visible. Ophthalmological examination at 38 weeks' PMA disclosed massive, round capillary dilatation of the minor arterial circle, spreading to the iris periphery form pupillary margin, and narrow pupils which did not fully react to mydriasis. The intraocular pressure was normal. Ultrasound examination revealed major thickening and echo increase of peripheral retina with its partial detachment. RESULT: Diode-laser pan-retinal photocoagulation and cryoapplication was performed leading to successful regression of neovascular anterior segment (rubeosis was no longer visible by slit-lamp examination) as well as inhibition of retinopathy of prematurity progression. CONCLUSION: In described preterm infant, vasoactive molecules released by the ischemic retina may have induced vasodilation of iridal vessels, therefore increasing the perfusion of segments of the minor arterial circle, rendering them clinically visible by examination. It has been observed that hypoxia besides other inflammatory risk factors may have significant influence not only on the development of severe anterior-neovascular complications but also on rapid progression of advanced ROP stages with omission of typical clinical stages of ROP. Simultaneously retinal laser-panphotocoagulation with cryotheraphy seems to be the beneficial method for treatment of these complications. The therapy is effective and destroys the cells that produce Vascular Endothelial Growth Factor (VEGF) which is known to be the most important key factor in the progression of ROP.

Intraoperative floppy-iris syndrome.

OBJECTIVE: Intraoperative-floppy iris syndrome (IFIS) has been recently described. It has been demonstrated that this new syndrome complicates cataract surgery. In this paper we have reviewed the syndrome, and offer practical information specially related to the origin and management of this syndrome and we offer practical information. MATERIAL AND METHODS: A review of the related medical literature using PubMed and Cochrane databases. Combining the search terms tamsulosin, cataract, IFIS and intraoperative floppy iris syndrome, more than 200 articles were found. Eighty-two of them were obtained and analysed. In the remaining only the abstract could be studied. RESULTS: The aetiological association between IFIS and tamsulosin (and to a lesser degree between IFIS and other alpha-antagonists) is well established. Other aetiological associations are doubtful. Most of the literature is centred on cataract surgery. However, a similar syndrome has been described during trabeculectomy. A possible association between these drugs and choroidal detachments has also been described. Undoubtedly tamsulosin treatment makes cataract surgery more difficult and increases the probability of intraoperative complications. Protocols to manage the syndrome have not yet been developed. Intracameral injection of alpha-adrenergic agonists seems to be useful. However there is no evidence of the usefulness of discontinuing the drug or using preoperative mydriatics. CONCLUSION: The aetiological and clinic features of the syndrome are well established. More studies are needed to provide scientific evidence on the most appropriate way to cope with this syndrome.

Varied clinical course in plateau iris syndrome: a case series.

PURPOSE: To present a selected case series of plateau iris syndrome (PIS) that attempts to highlight the varied outcomes. METHODS: Retrospective review of three selected cases of plateau iris. RESULTS: Case 1 with 23 years follow-up highlights the benign nature of the disease with no disc and field changes. Case 2 represents the progressive form of the disease. Case 3 demonstrates the better efficacy of pilocarpine in comparison to other anti-glaucoma medications in the treatment of plateau iris. CONCLUSION: The understanding of the varied clinical course of plateau iris syndrome, as demonstrated by the above cases, might aid in therapeutic decision making.

Rubeosis iridis as a sign of underlying carotid stenosis.

Severe carotid stenosis may be associated with uncommon clinical symptoms. We report a case of ocular ischemic syndrome and subsequent rubeosis iridis due to a high-grade carotid stenosis. The patient recovered visual acuity and his normal iris coloring after carotid endarterectomy. Rubeosis iridis may be the only clinical sign associated with severe carotid stenosis, making it mandatory to rule out the presence of carotid narrowing when it is detected. Establishing an early diagnosis is essential to improve quality of life, prognosis, and patients' outcome.

Traumatic expulsive iridodialysis with vitreous prolapse.

Traumatic expulsive iridodialysis is a rare complication after trauma by a blunt object in eyes with previous small-incision cataract surgery. The presence of an intact lens capsule with an intraocular lens was thought to protect against damage beyond the posterior capsule. We report a case of dehiscence of the cataract wound and traumatic expulsive iridodialysis that also exhibited vitreous prolapse.