Xanthogranuloma of the iris simulating melanoma in an adult

PURPOSE

To report a case in an adult of xanthogranuloma of the iris that clinically simulated iris melanoma.

DESIGN

Observational case report.

METHODS

Clinical and histopathologic examination of iris mass obtained from a 77-year-old white woman.

RESULTS

High-frequency ultrasonography of the right eye revealed a small, echodense lesion involving the iris root. The mass revealed histopathologic features identical to juvenile xanthogranuloma (JXG), including histiocytes and lymphocytes mixed with multinucleated giant cells, and eosinophilic leukocytes. The histiocytes stained positive for CD68, CD45, and factor XIIIa and negative for S-100 and CD1a.

CONCLUSIONS

Xanthogranuloma of the iris can occur in elderly patients. Such lesions should be considered in the differential diagnosis of iris melanoma.

Ultrabiomicroscopie et physiopathologie des kystes iriens congénitaux

AIMS

Iris epithelial cysts, congenital or acquired, are rare tumors of the anterior chamber. The use of ultrasound biomicroscopy (UBM) and high-resolution echography (50 MHz) specified the diagnosis and confirmed the developmental hypothesis.

METHODS

UBM examination with general anesthesia can provide very good vision of cysts and iris structure similar to histological examination. Successive slices are systematically produced. We report two cases: one in a 3-month-old boy with a pupillary type of pigment epithelial cyst and one in a 23-month-old boy with stromal iris cyst provides new information on iris cysts.

RESULTS

UBM can clearly differentiate two types of cyst, with results similar to histological slice examination. UBM slices of iris edge cysts show small cellular parietal groups with stromal echogenicity, with no visible tissular continuity. The stromal cyst has no particularity and no echogenicity.

DISCUSSION

The pupillary type of pigment epithelial cyst was generally recognized very early. The great majority of primary iris cysts, particularly those that arise from the iris pigment epithelial layers, are stable lesions that rarely progress or cause visual complications. Their slow progression could be explained by embryological history. Based on a comparison between the aspects of the two observations, the absence of enlargement of the cyst could be explained by the developmental mechanism.

CONCLUSION

The advantage of the UBM in diagnosis is confirmed for very young patients, but also in developmental investigations. These case reports also corroborate the migration cellular theory during eye development to explain the appearance of the pupillary type of pigment epithelial cyst.

Measurement of anterior lens growth after acute primary angle-closure glaucoma

BACKGROUND

To describe the utility of ultrasound biomicroscopy in diagnosing multiple bilateral iridociliary cysts and to determine the clinical significance of this condition.

METHODS

A retrospective review of 73 patients referred for ultrasound biomicroscopy who were found to have bilateral iridociliary cysts.

RESULTS

Seventy-three patients were identified who demonstrated 2 or more cysts in 1 eye and at least 1 in the other with ultrasound biomicroscopy. A solitary iris elevation was the most common reason for referral (84.9%). There were 44 patients for whom sufficient follow-up data were available, with a mean follow-up of 40.4 months. Clinical sequelae included 1 case of sectoral cataract (2.3%) and 4 cases of cyst-related glaucoma (9.1%).

INTERPRETATION

Multiple bilateral iridociliary cysts is a common condition with occasional clinical significance. Ultrasound biomicroscopy is a valuable technique in diagnosing this condition. Patients who have significant angle compromise should be followed and treated as required for glaucoma.

Multiple bilateral primary cysts of the iris pigment epithelium

CASE REPORT

Diagnostic and therapeutic considerations in the case of a 57-year-old man with multiple iris cysts in both eyes.

COMMENTS

Small and hidden from view, most primary iris cysts of the iris pigment epithelium remain clinically silent. Larger cysts may be noted on examination, but often remain difficult to visualize due to their location. By providing a high-resolution view of the iris and ciliary body, ultrasound biomicroscopy is a useful adjunct to the clinical examination in distinguishing primary cysts of the iris pigment epithelium from solid uveal neoplasms.

Transpupillary argon laser photocoagulation and Nd:YAG laser cystotomy for peripheral iris pigment epithelium cyst

PURPOSE

To report the use of a combination of transpupillary argon laser photocoagulation and Nd:YAG laser cystotomy in the treatment of peripheral iris pigment epithelium (IPE) cyst.

DESIGN

Case report.

METHODS

A 23-year-old man presented with a one-month history of blurred vision and pain in the right eye. Slit-lamp biomicroscopy and gonioscopy revealed, in the iridociliary sulcus, a large clear IPE cyst, which was demonstrated by ultrasound biomicroscopy (UBM). A combination of transpupillary photocoagulation to devitalize the epithelial lining and neodymium-doped yttrium aluminum garnet (Nd:YAG) laser cystotomy to drain the cyst was engaged.

RESULTS

Laser treatment resulted in vanishing of the cyst and disappearance of the subject symptoms. Two months postoperatively, no evidence existed of the iris pigment cyst regrowth.

CONCLUSIONS

The minimal invasiveness of the combination of transpupillary laser photocoagulation and cystotomy yielded a favorable result. This procedure may be an alternative to conservative regimen if IPE cyst is clearly defined and readily seen.

Bullous keratopathy and corneal decompensation secondary to iridoschisis: a clinicopathological report

PURPOSE

To report a case of localized bullous keratopathy and total corneal decompensation secondary to iridocorneal touch in iridoschisis.

DESIGN

Single interventional case report with pathologic correlation.

METHODS

An 80-year-old man with bilateral iridoschisis presented with loss of vision in the left eye (OS). Examination of the OS showed shallow anterior chamber (AC), cortical cataract, and free-floating iris fibers causing iridocorneal touch, leading to localized bullous keratopathy and total corneal decompensation. Ultrasound biomicroscopy (UBM) confirmed the area of iridocorneal contact.

RESULTS

Penetrating keratoplasty combined with cataract extraction and posterior chamber lens implantation was performed in the OS. Histopathology of the corneal button showed features of corneal edema and endothelial cell loss with evidence of iridocorneal contact.

CONCLUSIONS

Iridoschisis is an uncommon cause of bullous keratopathy and corneal decompensation. Patients with iridoschisis may need specular microscopy to determine the status of the corneal endothelium.

The Effect of Laser Iridotomy on the Anterior Segment Anatomy of Patients With Plateau Iris Configuration

PURPOSE

To determine if laser iridotomy altered the anterior segment anatomy of patients with plateau iris configuration.

METHODS

Twenty eyes of 9 female and 1 male patients were imaged using an ultrasound biomicroscope within 19 weeks before and 52 weeks after laser iridotomy. Measurements obtained included the anterior chamber depth (ACD), trabecular-ciliary process distance (TCPD), iris thickness (IT), angle opening distance at 500 micrometers (AOD), iridozonular distance (IZD), and trabecular-iris angle (TIA). Comparisons of the pre- and post- iridotomy measurements were made using a two-tailed paired t test.

RESULTS

Laser iridotomy elicited no statistically significant change in ACD, TCPD, IT, AOD, or TIA. However, IZD was decreased (P < 0.05) in both eyes after laser iridotomy. Configuration of the irides was flat before and after laser iridotomies.

CONCLUSION

This study suggests that laser iridotomy did not alter anterior segment anatomy, probably because of the fixed anterior insertion of the iris and ciliary body in plateau iris configuration. The decrease in IZD distance may be the result of a small posterior movement of the iris due to a reduction in relative pupillary block, secondary to laser iridotomy. The small reduction in relative papillary block in plateau iris configuration does not alter the width of the anterior chamber angle as measured by AOD and TIA.

Argon laser iridoplasty in the treatment of plateau-like iris configuration as result of numerous ciliary body cysts

PURPOSE

To report the use of argon laser peripheral iridoplasty in the treatment of plateau-like iris configuration as a result of iris and ciliary body cysts.

DESIGN

Case report.

METHODS

A 43-year-old male with plateau iris syndrome was demonstrated by high frequency ultrasound biomicroscopy (UBM), to have numerous iris and ciliary body cysts. Bilateral argon laser peripheral iridoplasty was performed.

RESULTS

Argon laser iridoplasty opened the drainage angle in both eyes.

CONCLUSION

Argon laser iridoplasty is an effective and safe treatment for plateau iris syndrome and may also prove valuable in the treatment of plateau-like iris configuration resulting from iridociliary cysts.

Evaluation and Comparison of Indentation Ultrasound Biomicroscopy Gonioscopy in Relative Pupillary Block, Peripheral Anterior Synechia, and Plateau Iris Configuration

PURPOSE

To evaluate and compare the findings and changes of the anterior chamber angle configuration with indentation ultrasound biomicroscopy (UBM) gonioscopy in relative pupillary block (RPB), peripheral anterior synechia (PAS), and plateau iris configuration (PIC).

METHODS

This study included 73 eyes of 52 patients with RPB (n = 26), PAS (n = 21), or PIC (n = 26). First, a conventional UBM scan was performed using a normal size standard eye cup before indentation. Then, for indentation UBM gonioscopy, scans were performed using a new eye cup that we designed. For evaluation of the angle, angle opening distance 500 and angle recess area were recorded and evaluated with regard to the effect of expansion on the anterior chamber angle.

RESULTS

Indentation UBM gonioscopy showed the characteristic images in each of the eyes. The angle of all examined eyes was significantly widened with indentation (P < 0.01). The angle changes in eyes with RPB were significantly greater than in eyes with PAS or PIC (P < 0.01).

CONCLUSION

Indentation UBM gonioscopy is a very useful method for observing the angle and diagnosis of RPB, PAS, and PIC.

Cataract formation with a primary iris stromal cyst

An 11-year-old boy was diagnosed with a primary acquired iris stromal cyst. A 5-year follow-up showed growth of the cyst with visual impairment. An inferior iridectomy was performed including the whole cystic lesion. The presence of a cataract is rare, especially in adolescents, but requires treatment to preserve the globe and vision.

Buphtalmie secondaire à un kyste congénital de l’épithélium pigmentaire de l’iris

We report the case of a 2-day-old child with buphthalmia caused by a congenital pigmented epithelial iris cyst. The use of ultrasound biomicroscopy (UBM) and high-resolution echography (20MHz) specified the diagnosis before general anesthesia for complete examination and treatment. Surgery can control intraocular pressure and the opening of the visual axis; there is, however, relative amblyopia. This case confirms the advantage of UBM in examining tumors of the anterior segment. The early diagnosis, facilitated by use of the UBM, provided quick and well-adapted treatment.

Clinical Case Note. Incomplete and complete plateau iris syndrome

Plateau iris syndrome is considered to be a rare entity and has been classified into two subtypes, the complete and the incomplete forms. Herein a case is reported of plateau iris syndrome that had a postmydriatic rise in intraocular pressure (IOP) in one eye (complete syndrome) and no increase in IOP in the other (incomplete syndrome). The pre- and post-mydriasis ultrasound biomicroscopic findings were documented. These findings suggest that incomplete plateau iris syndrome may be caused by a difference in the extent of closure of the angle circumferentially over the 360 degrees of the angle.

Listeria monocytogenes-induced endogenous endophthalmitis: bioultrasonic findings

PURPOSE

To report bioultrasonic findings in Listeria monocytogenes-induced endophthalmitis (LMIE) that have not been described previously.

DESIGN

Interventional case report.

METHODS

To rule out intraocular tumor, ultrasound biomicroscopy was performed in a patient referred for a 2-day history of uveitis with elevated intraocular pressure, dark hypopyon, and pigment dispersion in the anterior chamber.

RESULTS

Ultrasound biomicroscopy examination showed increased iris thickness with rarefaction of tissue and irregular echogenicity as well as iris pigment epithelial detachment. A small choroidal detachment was also detected. The anterior chamber and vitreous sample confirmed the LMIE diagnosis.

CONCLUSIONS

The detection of both pigment epithelial detachment and changes in the iris tissue could explain why black hypopyon frequently develops in LMIE with significant pigment dispersion in some cases.

Evaluation of eyes with relative pupillary block by indentation ultrasound biomicroscopy gonioscopy

PURPOSE

To investigate changes in anterior chamber angle configuration with indentation ultrasound biomicroscopy gonioscopy of relative pupillary block (RPB).

DESIGN

Cross-sectional study.

METHODS

This study included 26 eyes of 26 patients with RPB. We determined angle opening distance 500 and angle recess area using indentation ultrasound biomicroscopy gonioscopy and compared a small-sized standard eye cup with a new eye cup with an area for inducing pressure.

RESULTS

Indentation ultrasound biomicroscopy images documented concavity of the iris in eyes with RPB. Both the new and the small standard eye cups widened the anterior chamber angle significantly (P <.0001) without causing corneal damage. Angle changes were significantly greater for the new eye cup design.

CONCLUSIONS

Indentation ultrasound biomicroscopy gonioscopy is a useful technique for observation and diagnosis of RPB. Using a small standard or the newly designed eye cup, the procedure can be performed easily and without causing corneal damage.

Anterior chamber depth in plateau iris syndrome and pupillary block as measured by ultrasound biomicroscopy

PURPOSE

To quantitatively analyze the anterior chamber depth (ACD) in patients with pupillary block and plateau iris syndrome.

DESIGN

Retrospective, consecutive, observational case series.

METHODS

We measured the ACD in 318 eyes of 318 patients who had been diagnosed by ultrasound biomicroscopy as having either pupillary block or plateau iris syndrome. Pupillary block patients were all preiridotomy and plateau iris patients were all postiridotomy. Anterior chamber depth was measured axially from the internal corneal surface to the lens surface using the ultrasound instrument's internal measuring capability.

RESULTS

The mean ACD in patients with plateau iris syndrome (n = 181) was significantly smaller than the hypothesized normal ACD (2.04 +/- 0.30 mm vs 3.0 mm, P =.0001). The mean ACD in patients with pupillary block (n = 137) was also significantly smaller than the hypothesized normal ACD (2.17 +/- 0.30 mm vs 3.0 mm, P =.0001). The mean ACD in patients with plateau iris syndrome was significantly smaller than the ACD in patients with pupillary block (2.04 +/- 0.30 mm vs 2.17 +/- 0.30 mm, P =.001).

CONCLUSIONS

Review of the literature suggests that patients with plateau iris have a normal or deeper axial ACD compared with pupillary block. This study found that the ACD associated with plateau iris syndrome is shallower than normal and also shallower than in pupillary block.

Iris retraction and retroflexion after transscleral contact diode laser photocoagulation

A 9-year-old girl with refractory glaucoma with an anterior chamber intraocular lens underwent transscleral contact diode laser cyclophotocoagulation. Slit-lamp examination and ultrasound biomicroscopy revealed iris retraction and retroflexion at 2 weeks of follow-up. The probable cause of this complication is discussed.

Free-floating cyst in the anterior chamber: ultrasound biomicroscopic reports

PURPOSE

To report a free-floating dislodged pigmented cyst in the anterior chamber and to describe the ultrasound biomicroscopic (UBM) features of the lesion.

METHODS

Case report.

RESULTS

A 26-year-old man presented with noise in his left eye in the prone position. Slit-lamp examination revealed a small pigmented mass lesion at the 6 o'clock position in the anterior chamber, slowly moving with changing head postures. UBM revealed an unfixed dislodged pigmented cyst with a thin wall and no internal reflectivity, changing its shape from ovoid to circular. Five years later, the anterior segment does not show any modification and the cyst has not changed in size or appearance.

CONCLUSIONS

Cysts of the iris pigment epithelium arise in the posterior iris layer. They may be central, midzonal, peripheral, or dislodged. Dislodged cysts may be repositioned and fixed or free-floating in the vitreous or in the anterior chamber. Surgical removal must be considered only for a rapid enlargement or significant reduction in endothelial cell count. UBM can distinguish solid from cystic lesions, giving detailed information on internal structure, reflectivity, shape, and thickness.

A case of angle closure glaucoma caused by plateau iris and adie's pupil

PURPOSE

To describe a case of plateau iris associated with bilateral Adie's pupil.

DESIGN

Interventional case report.

METHODS

A 54-year-old woman presented with pain in her right eye and headache. Intraocular pressure was 34 mm Hg in the right eye. Light reflex was defective bilaterally.

RESULTS

Ultrasound biomicroscopic imaging revealed normal anterior chamber depth and narrow angle. The ciliary processes were situated anteriorly. The eyes showed supersensitivity to 0.125% pilocarpine. The patient was diagnosed as having bilateral angle-closure glaucoma induced by Adie's pupil and plateau iris.

CONCLUSION

Mild pupillary dilation caused by Adie's pupil may have played a role in the development of angle closure in the plateau iris configuration of our patient.

Ultrasound biomicroscopy in the diagnosis of a primary peripheral iris cyst

A primary peripheral cyst behind the iris is difficult to detect during a routine slit lamp examination. It is usually asymptomatic unless the cyst is sufficiently large. We report on a 73-year-old woman who underwent phacoemulsification of a cataract and incidentally presented a small dark mass behind the peripheral iris. The lesion was initially suspected of being a melanoma, but it could not be localized by conventional techniques postoperatively. A diagnosis of primary iris cyst was not made until 1 year later when high-frequency ultrasound biomicroscopy (UBM) was employed. UBM displayed a distinct thin-wall cystic lesion (0.5 x 0.8 x 0.6 mm) with low internal reflectivity at the iridociliary sulcus of the inferotemporal quadrant. UBM allows good imaging access to a lesion behind the iris that is otherwise difficult to detect with traditional techniques.

Iridociliary apposition in plateau iris syndrome persists after cataract extraction

PURPOSE

To evaluate the ultrasound biomicroscopic appearance of the anterior segment before and after cataract extraction in eyes with plateau iris syndrome and to determine the effect of postoperative zonular relaxation on ciliary body position.

DESIGN

Interventional case series.

METHODS

Eyes with plateau iris syndrome scanned before and after cataract extraction between January 1994 and September 2001 were enrolled. The iridociliary relationship and the anterior chamber depth at a distance of 3 mm from the scleral spur were assessed.

RESULTS

We examined six eyes of six patients. Mean patient age was 74.2 +/- 6.4 years (standard deviation [SD]) (range, 65-81 years). Mean refractive error was + 1.0 +/- 3.9 diopters [D] (range, -5.75-+5.50), and mean axial length was 21.85 +/- 0.77 mm (range, 20.90-22.95 mm). All eyes had undergone laser iridotomy and argon laser peripheral iridoplasty before cataract extraction. Ultrasound biomicroscopy examination revealed a narrow angle and absence of a ciliary body sulcus in all eyes with focal areas of iridotrabecular apposition in three eyes. Following cataract extraction, the anterior chamber depth increased (P =.0006, paired t test), while the iridociliary contact remained unchanged.

CONCLUSIONS

Iridociliary apposition persists after cataract extraction in plateau iris syndrome. Whether the cause is congenital or acquired, or both, remains to be determined.

[Complications of a voluminous congenital ciliary body cyst]

BACKGROUND

Multiple cysts of iris and ciliary body may cause many complications such as acute or chronic angle closure glaucoma.

PATIENT

We present a boy with multiple congenital cysts of the iris pigment epithelium and a voluminous cyst of the unpigmented ciliary body epithelium of the right eye. This resulted in lenticular astigmatism, concomitant strabismus divergens and subsequently to anisometropia. The voluminous cyst (8 x 12 mm in diameter) was folded around the lens, reached the optic axis and resulted in displacement of the lens and contact between the iris and the corneal endothelium from 6.30 to 11. After puncture and partial resection of the cyst at the age of 8 months the boy developed a subcapsular multivesicular cataractic clouding of the temporal lens and a progredient myopia (up to - 14.0/- 2.0/0 degrees ); in contrast the left eye was hyperopic (+ 3.5/- 3.75/0 degrees ). The lens was subluxated superonasally due to congenital damage of the zonular fibres. Because development of visual acuity seemed limited by these determinants (20/200 at the right eye), cataract surgery with posterior capsulorhexis, anterior vitrectomy, and implantation of a capsular tension ring and posterior chamber intraocular lens was performed at the age of nearly five. Actually, there is an orthotropia, best corrected visual acuity in the distance of 20/32 in the right and 20/20 in the left eye; binocular vision is somewhat restricted.

CONCLUSION

Usually congenital cysts are clinically not very relevant; occasionally surgical intervention is required to ensure adequate development of visual acuity.

Three-dimensional ultrasound findings of the posterior iris region

PURPOSE

The aim of this study was to assess the benefit of the three-dimensional ultrasound biomicroscopy in examination of the posterior iris and ciliary body.

METHODS

Three-dimensional visualisation of the anterior eye section was achieved through extension of the existing ultrasound biomicroscope system (Humphrey Instruments). Visualisation of posterior iris and ciliary body pathologies in three patients was performed with a three-dimensional reconstruction technique of B-scans.

RESULTS

The extended ultrasound system provided three-dimensional visualisation of alterations of the posterior iris region, i.e. iris cysts, ciliary body cysts and solid tumours of the ciliary body and iris.

CONCLUSIONS

The three-dimensional ultrasound biomicroscopy yields extended diagnostic findings regarding iris and ciliary body pathology. This method offers an improved assessment of the posterior surface of the iris and the volume of the ciliary body. Furthermore, these data can be useful for procedures in computer simulation and calculation for a better understanding of the function of the ciliary body in the accommodation process.