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 Table of Contents  
CASE REPORT
Year : 2023  |  Volume : 3  |  Issue : 1  |  Page : 26-29

Bilateral acute iris transillumination after photorefractive keratectomy: A case report


1 Cornea and Refractive Services, Dhami Eye Care Hospital, Ludhiana, Punjab, India
2 Cataract and Vitreo-Retina Sevices, Dhami Eye Care Hospital, Ludhiana, Punjab, India
3 Medical Director, Dhami Eye Care Hospital, Ludhiana, Punjab, India
4 Vitreo-Retina and Uvea Services, Dhami Eye Care Hospital, Ludhiana, Punjab, India
5 Retina, Vitreous and Uvea Services, Advanced Eye Centre, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India

Date of Submission31-Jul-2022
Date of Acceptance07-Nov-2022
Date of Web Publication20-Jan-2023

Correspondence Address:
Gobinder Singh Dhami
Cornea and Refractive Services, Dhami Eye Care Hospital, 82-B Kitchlu Nagar, Ludhiana - 141 001, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_1882_22

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  Abstract 


A 25-year-old male presented with ciliary congestion, pigmented cells in the anterior chamber, and raised intraocular pressure (IOP) in both eyes (left > right) two weeks after photorefractive keratectomy (PRK). The patient was treated for acute anterior uveitis with topical steroids, moxifloxacin, cycloplegic, and antiglaucoma eye drops. Systemic workup was unremarkable except elevated IgG CMV levels. Despite treatment, inflammation increased and IOP became treatment-refractory (peaked to 50 mmHg), with florid pigment deposition on lens capsule, diffuse iris transillumination defects, and dilated distorted pupils. Suspecting bilateral acute iris transillumination (BAIT), topical moxifloxacin was withdrawn with gradual resolution of disease over four months.

Keywords: BAIT, intraocular pressure, photorefractive keratectomy, transillumination defects, Uveitis


How to cite this article:
Dhami NB, Dhami A, Dhami GS, Malhi R, Gupta V. Bilateral acute iris transillumination after photorefractive keratectomy: A case report. Indian J Ophthalmol Case Rep 2023;3:26-9

How to cite this URL:
Dhami NB, Dhami A, Dhami GS, Malhi R, Gupta V. Bilateral acute iris transillumination after photorefractive keratectomy: A case report. Indian J Ophthalmol Case Rep [serial online] 2023 [cited 2023 Feb 1];3:26-9. Available from: https://www.ijoreports.in/text.asp?2023/3/1/26/368188



Bilateral acute iris transillumination (BAIT) is an enigmatic clinical entity, often masquerading as acute anterior uveitis, which confound and delay its diagnosis.[1] However, it has distinguishing features like iris transillumination defects, refractory glaucoma, and mydriatic, distorted pupils. Etiopathogenesis is still vague but associated with female preponderance, preceding respiratory illness and oral systemic moxifloxacin usage.[2] This is a novel case of BAIT-like presentation after refractive surgery with topical moxifloxacin usage.


  Case Report Top


25-year-old male, underwent photorefractive keratectomy (PRK) for ametropia of − 2.50 diopter sphere (DS) with − 1.00 diopter cylinder (DC) at 175 with 20/20 vision in the right eye (OD) and − 2.75 D sphere with − 0.50 diopter cylinder @ 180 with 20/20 vision in the left eye (OS), one year back. Preoperative anterior segment corneal topography and posterior segment was unremarkable, with an IOP of 20 mmHg in both eyes (OU). Alcohol-assisted PRK was performed with ablation on Alcon EX 500, 0.02% mitomycin C application for 15 seconds; then bandage contact lens (BCL) pre-soaked in preservative-free 0.5% moxifloxacin was applied. Postoperatively, carboxymethylcellulose and moxifloxacin 0.5% eye drops were prescribed. BCL was removed on the third postoperative day (POD). Then topical fluorometholone 0.1% drops added with uneventful postoperative period.

On POD 14, patient came with complaints of redness and watering in the left eye. Examination revealed ciliary congestion, pigmented cells (grade 1+) in the anterior chamber (AC) (SUN uveitis classification), minimal flare, no keratic precipitates on the endothelium, normal posterior segment, with IOP of 24 mmHg. The right eye was quiet. On POD 19, the right eye also showed similar but milder grade inflammation, grade 0.5+ AC reaction (pigmented cells) and IOP of 23 mmHg.

A working diagnosis of acute hypertensive anterior uveitis was made (OS > OD) and the patient was prescribed 1% prednisolone acetate drops four times a day, moxifloxacin 0.5% drops four times, and atropine sulphate 1% two times a day, along with timolol 0.5% drops two times a day, with subsequent addition of brinzolamide 1% and brimonidine 0.2% combination and oral acetazolamide 250 mg twice a day as IOP kept soaring.

Meanwhile, complete systemic examination, blood investigations for blood cell count, urinalysis, erythrocyte sedimentation rate, venereal disease research laboratory test, angiotensin converting enzyme test, intradermal purified protein derivative test, human leucocyte antigen B27, hepatitis B and C, human immunodeficiency virus, serum immunoglobulin IgM and IgG test for herpes simplex virus (HSV 1 and 2), cytomegalovirus (CMV), varicella zoster virus (HZV), SARS-CoV-2 antigen, antibody (in view of the ongoing pandemic) were done. All workup was unremarkable except elevated IgG levels of 302.40 mIU/ml (normal <150) for CMV virus.

Due to the non-responsive nature of the disease and the unique clinical characteristics such as dense pigment dusting on anterior lens capsule [Figure 1], predominantly pigment cell dispersion in AC [Figure 2]a and [Figure 2]b, absence of posterior synechiae or keratic precipitates, normal corneal sensations, diffuse iris atrophic patches on oblique [Figure 3]a, and diffuse transillumination defects on retro-illumination [Figure 3]b, second opinion was taken. Gonioscopy showed hyperpigmented trabecular meshwork. Anterior segment optical coherence tomography (OCT) and posterior segment were unremarkable.
Figure 1: Arrow shows the presence of pigment dusting on the anterior lens capsule at one-month postoperatively. (The photograph has been taken under pharmacological dilatation with 1% atropine sulphate eye drops.)

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Figure 2: (a) right eye and (b) left eye show pigment dispersion in the anterior chamber (white arrows), taken 1 × 1 mm oblique slit-beam illumination at high magnification on slit lamp (left eye > right eye), showing asymmetric involvement in both eyes

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Figure 3: (a) shows the persistent mydriatic and distorted state of pupils, white arrow depicts depigmented patches on iris, and black arrow shows resolution of pigment dusting and a clear anterior lens capsule. (b) Blue arrows indicate diffuse transillumination defects in the iris on retroillumination on slit lamp. These photographs have been taken without pharmacological dilatation at 6 months postoperatively.

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The reviewed diagnosis was BAIT. Due to known association of moxifloxacin, topical moxifloxacin was withdrawn and substituted with chloramphenicol drops. With the limited role of steroids and ruling out the component of steroid responsiveness, topical steroids were slowly withdrawn. Over the next four months, the disease had a waxing and waning course with intermittent IOP and inflammation spikes despite addition of oral antivirals (tablet valcyclovir 1 gm thrice a day), and maximum oral and topical antiglaucoma polytherapy, including bolus doses of 20% intravenous mannitol for IOP spikes over 40 mmHg given under physician supervision. Pigment dispersion in AC lasted a median duration of 4.5 months OD and 5 months OS. Mean IOP was19.58 ± 1.63 (range 12–50 mmHg) in the right eye, 27.51 ± 1.81 in the left eye (range 12–52 mmHg). Gradually, pupils recovered from pharmacological dilation, but persisted in a dilated and distorted shape [Figure 3]a, a mean size of 3.80 ± 0.28 mm (photopic state), 4.10 ± 0.89 mm (scotopic state) in the right eye and 5.20 ± 0.78 (photopic state), 5.49 ± 0.71 mm (scotopic state) in the left eye, with poor light response. Final visual acuity was 20/20 in the right eye (unaided) and 20/40 in the left eye (unaided) with best-corrected visual acuity (BCVA) 20/20 with − 0.25 DS and − 0.50 DC at 120°. Since the last six months, the patient has been asymptomatic.


  Discussion Top


BAIT in a healthy young male without prior oral moxifloxacin usage or respiratory illness is an uncommon scenario, in contrast to earlier case reports.[2–4] Although, in our case, topical moxifloxacin can be an implicating factor. Local application in the form moxifloxacin dipped BCL, and topical moxifloxacin eye drops used postoperatively, probably served as a drug depot on a de epithelialized cornea and compounded the bioavailable moxifloxacin intraocularly. Light et al. also reported a case of unilateral BAIT with intracameral moxifloxacin in cataract surgery.[5]

Another serological similarity to our case—the largest BAIT case series of 26 patients conducted by Tugal-Tutkun et al.[2]—was elevated serum IgG CMV levels, although its significance needs to be explored.

Other differentials of florid pigment dispersion in our case were pigment dispersion syndrome (PDS), pseudoexfoliation syndrome (PXF), and viral iridocyclitis.[6] Unlike PDS, our case had acute onset of inflammation and rise in IOP, diffuse iris transillumination, poorly responsive pupils and no posterior iris bowing pattern. Absence of microfibrillary deposits and peripupillary transillumination defects ruled out PXF.[1] Viral iridocyclitis is usually unilateral, with keratic precipitates and inflammatory cells in AC absent in this case. However, glaucoma and diffuse iris atrophy are similar to viral presentation.[7]


  Conclusion Top


In this evolving era of refractive surgery, perplexing complications like BAIT are a frustrating challenge. More conclusive tests like laser flare meter for prognosis and anterior chamber tap polymerase chain analysis will be required in the future.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Perone JM, Chaussard D, Hayek G. Bilateral acute iris transillumination (BAIT) syndrome: Literature review. Clin Ophthalmol 2019;13:935-43.  Back to cited text no. 1
    
2.
Tugal-Tutkun I, Onal S, Garip A, Taskapili M, Kazokoglu H, Kadayifcilar S, et al. Bilateral acute iris transillumination. Arch Ophthalmol 2011;129:1312-9.  Back to cited text no. 2
    
3.
Calvo RB, Cortiñas DI. Acute and bilateral uveitis secondary to moxifloxacin. Arch Soc Esp Oftalmol 2004;79:357-9.  Back to cited text no. 3
    
4.
Bettink-Remeijer MW, Brouwers K, Van Langenhove L, De Waard PW, Missotten TO, Ciriano JM, et al. Uveitis-like syndrome and iris transillumination after the use of oral moxifloxacin. Eye 2009;23:2260-2.  Back to cited text no. 4
    
5.
Light JG, Falkenberry SM. Unilateral bilateral acute iris transillumination-like syndrome after intracameral moxifloxacin injection for intraoperative endophthalmitis prophylaxis. JCRS Online Case Rep 2019;7:3-5.  Back to cited text no. 5
    
6.
Scuderi G, Contestabile MT, Scuderi L, Librando A, Fenicia V, Rahimi S. Pigment dispersion syndrome and pigmentary glaucoma: A review and update. Int Ophthalmol 2019;39:1651-62.  Back to cited text no. 6
    
7.
Gonul S, Bozkurt B. Bilateral acute iris transillumination (BAIT) initially misdiagnosed as acute iridocyclitis. Arq Bras Oftalmol 2015;78:115-7.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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