Bilateral acute depigmentation of the iris

Increased risk of pigmentary degeneration of the iris and pigmentary glaucoma with fluoroquinolone antibiotics

PURPOSE

Fluoroquinolones are popular antibiotics used for a myriad of conditions including ocular procedures. Despite numerous case reports of acute pigmentary degeneration of the iris with fluoroquinolone use, a pharmacoepidemiological study has not been performed to examine and quantify this risk.

DESIGN

Retrospective cohort study with a case-control analysis.

PARTICIPANTS

A cohort of 1,231,881 new users of oral or topical moxifloxacin, levofloxacin, and azithromycin were followed to first diagnosis of pigmentary degeneration of the iris or pigmentary glaucoma. Four controls were selected for each case using density sampling, matching on age and calendar time.

METHODS

Users of oral or topical moxifloxacin were compared to levofloxacin and azithromycin, a negative control drug from a separate class.

MAIN OUTCOMES AND MEASURES

First incidence of pigmentary degeneration of the iris or pigmentary glaucoma.

RESULTS

The cohort was comprised of 1,231,881 new users of topical or oral levofloxacin, moxifloxacin, or azithromycin. 542 cases of pigmentary degeneration of the iris and 460 cases of pigmentary glaucoma were identified. The incidence of iris pigmentary degeneration or pigmentary glaucoma for topical moxifloxacin was 10.2/1000 person years compared to 2.6/1000 person years for topical azithromycin. Current topical moxifloxacin users had the highest adjusted IRR for pigmentary degeneration of the iris (IRR = 6.81, [95%CI:2.00-23.18]) and pigmentary glaucoma (IRR = 4.07 [95%CI:1.42-11.62]) respectively.

CONCLUSIONS

The study findings suggest that patients using topical moxifloxacin may have increased risk of developing pigmentary degeneration of the iris and pigmentary glaucoma although the absolute increase was low. Future studies are needed to confirm this association.

Bilateral Acute Iris Transillumination (BAIT): A Rare Syndrome Possibly Associated with COVID-19 and Moxifloxacin Use. A Report of 2 Cases

Bilateral acute iris transillumination (BAIT) is a rare clinical entity, presumed to be associated with preceding upper respiratory tract infection and/or use of certain antibiotics, marked by bilateral acute loss of iris pigment epithelium with pigment dispersion in the anterior chamber and trabecular meshwork, which can cause elevated intraocular pressure and glaucoma, and with iris transillumination and sphincter paralysis which lead to photophobia and blurry vision. We report the first two cases of BAIT in our center which both had a history of preceding COVID-19 (coronavirus disease 2019) and moxifloxacin use. With more awareness, ophthalmologists might diagnose more cases, and thus gain more information regarding the link between COVID-19 and BAIT, which might be underdiagnosed since it is rare or easily misdiagnosed as some more common diseases with similar features.

Bilateral Acute Depigmentation of Iris (BADI) and Bilateral Acute Iris Transillumination (BAIT)Following Acute COVID-19 Infection

PURPOSE

To report the presenting features and outcomes in patients who developed bilateral acute iris transillumination (BAIT) or bilateral acute depigmentation of iris (BADI) following acute COVID-19 infection.

METHODS

Thirty two eyes of 16 patients were reviewed retrospectively. The severity of COVID-19 infection, use of antibiotics, time of onset of ocular symptoms; ocular signs, the course and surgical procedures were recorded.

RESULTS

24 eyes of 12 BAIT and eight eyes of four consecutive BADI patients were included. The mean time between infection and onset of ocular symptoms was 2.5±1.1 weeks. Nine patients were treated with oral moxifloxacin for COVID-19 prior to presentation. Trabeculectomy was performed in 7 eyes (21.8%) of 5 BAIT patients; in the postoperative follow-up, IOP was controlled without medication in 6 eyes, with medication in 1 eye.

CONCLUSION

BADI and BAIT can also develop after COVID-19 infection. A significant proportion of BAIT patients may require glaucoma surgery.

Bilateral Acute Depigmentation of the Iris (BADI) following Covid-19 Infection

PURPOSE

To present a case of bilateral acute iris depigmentation after covid 19 infection.

CASE REPORT

A 55-year-old female presented with binocular pain and blurred vision a month after being diagnosed with severe acute respiratory syndrome - coronavirus-2 (SARS-CoV-2). She presented pigment dispersion in the anterior chamber and pigment depositions on the corneal endothelium. The patient was treated with dexamethasone and during follow-up visits, the pigment dispersion decreased and the symptoms ceased.

CONCLUSIONS

Covid-19 infection may be associated with rare ocular disorders such as BADI.

Bilateral Acute Depigmentation of Iris (BADI) Post COVID Infection following Systemic Moxifloxacin Therapy

PURPOSE

To report a case of BADI post Covid infection following systemic moxifloxacin therapy.

METHODS

Observational case study.

CASE REPORT

A 28-year-old female presented to us with complaints of redness and pain in the right eye since 5 days. History revealed use of systemic moxifloxacin for covid infection. She was managed with topical corticosteroids and cycloplegics following a diagnosis of BADI.

CONCLUSION

Bilateral acute depigmentation of iris (BADI) is a rare disease entity associated with the release of iris pigments. Various underlying aetiologies have been associated with the same. Although BADI is a benign, self-limiting disorder, it needs to be differentiated with other potential severe clinical entities. SARS-CoV2 has been associated with various ocular manifestations. However, to the best of our knowledge, BADI has never been associated with COVID infection yet. We report a case of BADI in a young healthy Asian middle - aged female 3 months after an acute COVID infection.

[Unusual anisocoria]

Eine 53-jährige Patientin beklagte erhöhte Blendempfindlichkeit 3 Wochen nach Einnahme von Moxifloxacin-Tabletten bei Infekt der oberen Atemwege. Es bestand eine Anisokorie, die Pupillenreaktion, sowohl auf Licht als auch auf Naheinstellung, war aufgehoben. In der Untersuchung des vorderen Augenabschnittes fielen beidseits ausgeprägte Iristransilluminationsdefekte (ITD) auf. Wir diagnostizierten ein BAIT-Syndrom (bilaterales akutes Iristransilluminationssyndrom). Dies ist ein seltenes Syndrom, welches mit einer massiven Depigmentierung der Iris sowie einer Atrophie der Irismuskulatur einhergeht. Risikofaktor für die Entstehung eines BAIT-Syndroms scheint die orale Einnahme von Antibiotika, insbesondere Moxifloxacin, im Rahmen eines Infektes der oberen Atemwege zu sein, aber auch spontan auftretende Fälle sind beschrieben. Betroffen sind v. a. Frauen mittleren Alters. Die genaue Ursache des BAIT-Syndroms ist bisher unklar. Diskutiert wird ein möglicher Einfluss der Konzentration des Antibiotikums im Glaskörper. Differenzialdiagnostisch muss bei Iristransilluminationsdefekten insbesondere auch an Albinismus, intraokuläre Entzündungen, Pseudoexfoliationssyndrom und Pigmentdispersionssyndrom gedacht werden. Eine spezifische Therapie des BAIT-Syndroms besteht bisher nicht. Erhöhte Lichtempfindlichkeit und ein Post-BAIT-Glaukom können mögliche Komplikationen sein. Die Kenntnis des seltenen BAIT-Syndroms kann im klinischen Alltag hilfreich bei der differenzialdiagnostischen Einordnung einer Anisokorie sein und ggf. zur Vermeidung unnötiger diagnostischer Schritte beitragen.

COVID-19 Associated Bilateral Acute Iris Transillumination

Purpose: To report a case of bilateral acute iris transillumination (BAIT) in association with coronavirus disease 2019 (COVID-19).Case report: A 44-year-old woman patient presented with decreased visual acuity, pain, photophobia, and redness in both eyes. The patient reported that she had recent close contact with severe acute respiratory syndrome - coronavirus-2 (SARS-CoV-2) case; also, she mentioned that she was hospitalized for bilateral pneumonia for 14 days. On examination, visual acuity of both eyes was 20/40. Slit-lamp biomicroscopy showed bilateral pigment deposition on the corneal endothelium, 4+ pigment dispersion in the anterior chamber, iris depigmentation with iris transillumination defects. Intraocular pressure was measured as 32 mmHg in right eye and 38 mmHg in left eye. The patient was started on bilaterally topical anti-inflammatory and anti-glaucomatous therapy.Conclusion: It is important to keep in mind that ocular manifestations associated with COVID-19 may include rare entities such as BAIT.

Toxic Anterior Segment Syndrome with Intracameral Moxifloxacin: Case Report and Review of the Literature

A case of severe anterior segment toxicity secondary to high-volume, undiluted intracameral moxifloxacin for endophthalmitis prophylaxis is reported. We examine the other reported cases of toxicity after intracameral moxifloxacin, as well as iris depigmentation and transillumination syndromes after oral and topical fluoroquinolone exposure. Additionally, we review the literature on safety, efficacy, and appropriate dosing of intracameral antibiotics with a focus on moxifloxacin.

Surgical Management of Glaucoma Secondary to Bilateral Acute Iris Transillumination: A Role for Gonioscopy-assisted Transluminal Trabeculotomy

Purpose

We report a case of bilateral acute iris transillumination (BAIT) in a young woman associated with ocular hypertension which eventually progressed to glaucoma that was treated with gonioscopy-assisted transluminal trabeculectomy (GATT).

Case Report

A 37-year-old otherwise healthy female presented with intermittently red and inflamed eyes and blurred vision. She was treated with oral moxifloxacin months prior to presentation. Iris transillumination defects, a pigmented anterior chamber reaction, the absence of keratic precipitates, and a history of upper respiratory infection treated with an oral fluoroquinolone prompted the diagnosis of BAIT. Intraocular pressure (IOP) remained uncontrolled on multiple glaucoma medications. Following the development of new visual field defects, indicating progression to glaucoma, GATT with cataract extraction was performed.

Conclusion

Although surgical intervention is rare with BAIT, our case demonstrates that GATT may be used effectively in those patients needing better IOP control before considering incisional glaucoma surgery.

Bilateral acute depigmentation of the iris in a child following exposure to insecticide spray

Bilateral acute depigmentation of the iris (BADI) is a rare disease of unkown etiology. We report a case of BADI in a 10-year-old child after accidental exposure to a herbal insecticide. Spontaneous iris repigmentation was observed during the follow-up period.

Unilateral acute iris depigmentation and transillumination after glaucoma surgery with mitomycin application and intracameral moxifloxacin

Purpose

Bilateral acute iris depigmentation (BADI) and transillumination (BATI) syndromes have been linked with the use of antibiotics, especially fluoroquinolones. They are characterized by acute onset of pigment dispersion in the anterior chamber, depigmentation of the iris and pigment deposition in the angle and in the posterior surface of the cornea (BADI), with iris transillumination defects and atonic pupil with sphincter paralysis (BATI). The purpose of this paper is to report the development of clinical depigmentation and iris damage similar to BADI and BATI in patients who had undergone uneventful glaucoma surgery with intracameral moxifloxacin as prophylaxis for endophthalmitis.

Observations

Four patients who had undergone Ex-Press implantation (cases 1 and 2) or non-penetrating deep sclerotomy (cases 3 and 4) developed asymptomatic pigment dispersion in the anterior chamber, which cleared after treatment with topical corticosteroids and NSAIDS. However, pupillary damage ensued, with mid-midriasis and pigment deposition under the filtration bleb.

Conclusions and importance

This is, to the best of our knowledge, the first report of acute unilateral iris depigmentation and transillumination after intracameral use of moxifloxacin. Moxifloxacin's toxic effect may have been promoted by the subconjuntival mitomycin employed to prevent scarring at the filtration bleb. Surgeons should be aware of these potential side-effects of drugs used as widely as moxifloxacin and mitomycin.

•

Moxifloxacin is widely used as prophylaxis for endophthalmitis after cataract surgery.

•

Bilateral acute iris depigmentation and transillumination syndromes have been reported after the use of antibiotics.

•

We report four cases of similar syndromes in patients undergoing glaucoma surgery after intracameral moxifloxacin.

A case of bilateral acute depigmentation of the Iris in one of two identical twins

Background

Bilateral Acute Depigmentation of the Iris (BADI) is a condition which was first described in a case series from Turkey by Tugal-Tutkin and Urgancioglu in (Graefes Arch Clin Exp Ophthalmol 244:742-6, 2006). The condition is characterized by bilateral acute depigmentation and discoloration of the iris stroma, pigment dispersion, and deposition of pigment in the angle. In our case we report a patient who developed BADI after receiving pitcher plant extract injections for chronic migraine, while her identical twin sister has normal iris architecture and pigmentation and never received any pitcher plant injections.

Case presentation

Patient is a 41-year-old female with history of pitcher plant extract injections to her face for chronic migraine, who later developed bilateral depigmentation of the iris. She did not have any signs of anterior segment uveitis or iridocyclitis. She has an identical twin sister who maintained normal iris pigmentation during the entire course.

Conclusions

Bilateral Acute depigmentation of the is a recently discovered condition described in the literature in Turkish patients (Tugal-Tutkun and Urgancioglu, Graefes Arch Clin Exp Ophthalmol 244:742-6, 2006; Tugal-Tutkun et al., Ophthalmology 116(8):1552-7, 2009). This condition affects mainly young females and is characterized by acute bilateral stromal depigmentation, without other pathologic ocular findings. These patients usually maintain normal vision and do not develop significant glaucoma from pigment collecting in the anterior chamber angle. This condition can be mistaken for Fuchs’ heterochromic iridocyclitis, pigment dispersion syndrome, pseudoexfoliation syndrome, and viral iridocyclitis. This is the first reported case in North America and is important for differentiation from the above pathologies. Our patient had a history of pitcher plant extract injections to the face but it is unclear if this is associated with our patient’s development of BADI. As awareness of this condition progresses, a possible etiology may be elucidated.

Bilateral acute iris transillumination (BAIT) syndrome: literature review

The authors conducted a literature review about bilateral acute iris transillumination (BAIT) syndrome, a new and relatively unknown syndrome that should be described and made known to the greatest number to avoid potential diagnostic and therapeutic errors. The first cases date back only to 2004 and a total of 79 cases have been published to date, mainly in Europe and especially in Turkey and Belgium. It mainly affects young women between the ages of 30 and 50, and symptoms are often preceded by an upper airway infection. There is also a majority of cases where the onset of the syndrome follows oral intake of moxyfloxacin. The clinical signs are dominated by strong photophobia, secondary to a spectacular transillumination of the iris. Other classical symptoms are conjunctival infection, eye pain, blurred vision, temporary ocular hypertonia, fixed mid-dilated pupils, and pigment dispersion in the anterior chamber with pigmentary deposits in the trabecular meshwork in gonioscopy, symptoms that may be mistaken for uveitis. After a few weeks or months of evolution, persistent sequelae were pupillary atony and chronic and bilateral transillumination of the iris, leading to significant photophobia and sometimes persistent ocular hypertension. The BAIT syndrome is close to the bilateral acute depigmentation of the iris (BADI) syndrome, which is similar to BAIT but lacks associated transillumination. A few cases of patients with BAIT syndrome on one eye and BADI syndrome on the contralateral eye have been described, which confirms some form of link between the two clinical entities.

Bilateral acute iris depigmentation and bilateral acute iris transillumination syndrome

The case is presented of a 32 year-old male who arrived with acute bilateral symptoms with blurred vision, red eye, severe photophobia and severe ocular pain after suffering from a flu-like syndrome. The patient presented with a clinical picture of bilateral involvement characterised by pupils in mid-mydriasis, scarcely reactive to light, iris transillumination, diffuse depigmentation of the iridian stroma, pigment dispersion in the anterior chamber, and ocular hypertension. After the eye examination an inflammatory syndrome and pigmentary glaucoma were ruled out. The patient showed depigmentation characteristics as well as bilateral iris transillumination. Both conditions could form part of the spectrum of the same disease.

Bilateral acute depigmentation of iris: 3-year follow-up of a case

Bilateral acute depigmentation of the iris (BADI) usually affecting young women, is a newly defined clinical diagnosis with bilateral symmetrical pigment loss of iris stroma without iris transillumination defect. Herein, we want to share the results of a 3-year-long follow-up of a 23-year old female patient with BADI. She was admitted to our clinic with a complaint of discoloration of both her brown irises. An ocular evaluation of the patient revealed symmetrical pigment deposition in trabecular meshwork. No iris transillumination defect, pupillary sphincter paralysis, keratic precipitates, and inflammatory reaction in anterior chamber were seen. The depigmented iris stroma became repigmented symmetrically after 3-year follow-up period. Although it is rare, BADI should be considered in the differential diagnosis of the diseases with bilateral iris depigmentation.

Bilateral acute depigmentation of the iris in two siblings simultaneously

Purpose

To report the first simultaneous onset of bilateral acute depigmentation of the iris (BADI) in two siblings.

Observations

Two sisters presented with bilateral ocular pain, redness and light sensitivity. Examination revealed bilateral circulating pigment in the anterior chamber with pigment dusting on backs of the corneas, patchy iris depigmentation and heavy pigment deposition in the angle. Both patients had recently suffered from upper respiratory tract infections. Bilateral visual acuities were preserved and no transillumination defects were observed. The patients were diagnosed with BADI. Both cases were successfully controlled with topical corticosteroids and anti-glaucoma drops as well as topical glanciclovir gel.

Conclusions and Importance

To date, there had been no published reports of BADI in the Middle East and Africa. This is the first observation of this entity in these regions. Moreover it is the first occurrence of BADI in two immediate siblings simultaneously. We also report the rare asymmetrical presentation with BADI in one of our patients. These observations point to the possibility of genetic factors underlying BADI as well as an infectious cause behind the etiology.

Bilateral acute iris transillumination following systemic administration of antibiotics

OBJECTIVES

To describe the demographic characteristics, clinical features, and potential prognostic factors of bilateral acute iris transillumination (BAIT) following oral antibiotic uptake.

METHODS

A retrospective study of 16 consecutive patients who developed BAIT following treatment with systemic antibiotics. Detailed past medical and ocular history was obtained, presenting signs and symptoms were documented and demographic characteristics were analyzed. All patients underwent a complete ocular examination and laboratory investigation. The course of best corrected visual acuity (BCVA), anterior chamber activity, and intraocular pressure (IOP) during the follow-up period were recorded and possible correlations with potential prognosticators were investigated.

RESULTS

Fourteen females and two males were included in the present study. The mean age (SD) of the patients was 43 (14) years. All individuals presented conjunctival injection and photophobia and developed bilateral transillumination defects, fixed mid-dilated pupils and pigment dispersion in the anterior chamber. Systemic antibiotics were previously prescribed in all cases (13 patients with moxifloxacin and three patients with clarithromycin) and the mean (SD) interval between onset of symptoms and antibiotic administration was 17 (4) days. Ocular hypertension complicated all eyes and required antiglaucoma medication in 25 eyes. Severe anterior chamber pigment dispersion and higher IOP during the first week after presentation was significantly associated with longer duration of ocular hypertension (OHT) (p = 0.019).

CONCLUSIONS

BAIT represents a rare clinical entity with characteristic features. Although etiopathogenesis of this condition remains unclear, a series of cases that indicate a strong correlation between systemic antibiotic administration and BAIT is herein presented.

Aqueous humor tyrosinase activity is indicative of iris melanocyte toxicity

Antibiotics such as fluoroquinolones (FQLs) are commonly used to treat ocular infections but are also known to cause dermal melanocyte toxicity. The release of dispersed pigments from the iris into the aqueous humor has been considered a possible ocular side effect of the systemic administration of FQLs such as Moxifloxacin, and this condition is known as bilateral acute iris transillumination (BAIT). Bilateral acute depigmentation of iris (BADI) is a similar condition, with iris pigment released into the aqueous, but it has not been reported as a side effect of FQL. Iris pigments are synthesized by the melanogenic enzyme tyrosinase (TYR) and can be detected but not quantified by using slit-lamp biomicroscopy. The correlation between dispersed pigments in the aqueous and the extent of melanocyte toxicity due to topical antibiotics in vivo is not well studied. Here, we aimed to study the effect of topical FQLs on iris tissue, the pigment release in the aqueous humor and the development of clinically evident iris atrophic changes. We evaluated this process by measuring the activity of TYR in the aqueous humor of 82 healthy eyes undergoing cataract surgery following topical application of FQLs such as Moxifloxacin (27 eyes, preservative-free) or Ciprofloxacin (29 eyes, with preservative) or the application of non-FQL Tobramycin (26 eyes, with preservative) as a control. In addition, the patients were questioned and examined for ocular side effects in pre- and post-operative periods. Our data showed a significantly higher mean TYR activity in the aqueous humor of Ciprofloxacin-treated eyes compared to Moxifloxacin- (preservative free, p < 0.0001) or Tobramycin-treated eyes (p < 0.0001), which indicated that few quinolones under certain conditions are toxic to the iris melanocytes. However, the reduced TYR activity in the aqueous of Moxifloxacin-treated eyes was possibly due to the presence of a higher drug concentration, which inhibits TYR activity. Consistently, immunoblotting analysis of the aqueous humor from both Ciprofloxacin- and Moxifloxacin-treated eyes showed the presence of soluble TYR enzyme, thus reflecting its toxicity to iris melanocytes and corresponding to its activity in the aqueous humor. Intriguingly, none of these patients developed any clinically appreciable ocular side effects characteristic of BAIT or BADI. Overall, our results suggest that topical antibiotics cause different levels of iris melanocyte toxicity, releasing dispersed pigments into the aqueous humor, which can be measured through TYR enzyme activity. Hence, we conclude that topical FQLs may cause subclinical toxicity to the iris melanocytes but may not be the sole cause of the development of BAIT or BADI.

Moxifloxacin Concentration and Proteomic Analysis of Aqueous Humor in Human Uveitis Associated with Oral Moxifloxacin Therapy

PURPOSE

The aim was to report the aqueous humor moxifloxacin concentration and proteome profile of an individual with bilateral uveitis-like syndrome with pigment dispersion.

METHODS

Multiple reactions monitoring mass spectrometry quantified the aqueous concentration of moxifloxacin in the affected individual. Shotgun proteomic analysis performed via liquid chromatography tandem mass spectrometry (LC-MS/MS) defined the protein profile in the affected individual and unaffected control samples.

RESULTS

Moxifloxacin was present at higher than expected levels in aqueous humor 18 days following oral administration. One-third of the proteins were identified by significantly lower spectral counts in the aqueous of the individual with moxifloxacin associated uveitis compared to the unaffected control.

CONCLUSION

Moxifloxacin was detected in aqueous humor 18 days following the completion of oral administration. These results suggest that moxifloxacin toxicity may be responsible for the uveitis-like syndrome with pigment dispersion syndrome induced by moxifloxacin therapy.

Bilateral acute iris transillumination: Case report

Bilateral acute iris transillumination (BAIT) is a recently defined disease characterized with bilateral acute, severe pigment dispersion of iris and pupil sphincter paralysis. The etiopathogenesis of the disease is unknown, but antibiotics such as moxifloxacin, clarithromycin, viral infections, and fumigation therapies were considered as probable etiologic factors. A 33-year-old female was referred to our clinic for acute iridocyclitis refractory to azathioprine, colchicum and corticosteroid treatments. Ophthalmic examination revealed bilateral pigment dispersion, significant iris transillumination, heavy pigment deposition in iridocorneal angle, and elevated intraocular pressure. Upon systemic evaluation she was found to have bacterial urinary tract infection. BAIT is an important cause of pigment dispersion and clinicians must be vigilant for this condition to avoid unnecessary diagnostic tests and treatment.

[A new clinical entity: ascending solar iris degeneration. Report of 284 cases]

The observation in a certain number of subjects of an atypical iris depigmentation led us to study this phenomenon. Therefore, the authors engaged in a prospective study of 398 subjects (100 cases in the city of Marrakesh, and 298 in the city of Dakhla). The geography, clinical signs and environmental factors were studied. Depigmentation was observed in 55% of the population of Marrakesh and 77% of the population of Dakhla. It is bilateral, symmetric, very progressive, always begins in the inferior one-third of the iris, and always spares the superior iris covered by the eyelid. By the time the depigmentation reaches the middle one-third, the inferior one-third also begins to demonstrate stromal atrophy: (26 cases). Of the 45 subjects with normal iris pigmentation, 31 cases spend more than 8 hours per day in the shade, and 26 cases constantly use some means of solar protection (sunglasses, caps, "Taraza", "Feroual"). Thus, this acquired iris depigmentation of an ascending nature, accompanied by an advanced stage involving primarily inferior iris atrophy, appears to be closely associated with exposure to the sun. Ascending solar iris degeneration, if we may refer to it as such, is a clinical entity never before reported in the literature. Now that we are faced with this new condition, numerous questions arise, to which future research must respond. Are there other factors in addition to sun exposure, which may lead to the depigmentation? Does this condition lead to further ocular pathology (due to the depigmentation and stromal atrophy)? Must solar protection be prescribed systematically for anyone at risk?

Bilateral acute depigmentation of the iris: report of 26 new cases and four-year follow-up of two patients

PURPOSE

To report new cases of bilateral acute depigmentation of the iris (BADI), a recently described clinical entity, and to report the 4-year follow-up of 2 patients that was published previously.

DESIGN

A retrospective case series.

PARTICIPANTS

Twenty-six Turkish patients who were diagnosed with BADI between 2006 and 2008 and 2 patients who were reported previously.

METHODS

We reviewed the patients' charts and clinical photographs. Observation procedures included clinical examination, anterior segment color photography, laser flare photometry, and pupillometry. We performed an anterior chamber tap in 2 patients for polymerase chain reaction (PCR) to demonstrate the DNA of herpes simplex virus (HSV), varicella zoster virus (VZV), and cytomegalovirus (CMV) in the aqueous samples.

MAIN OUTCOME MEASURES

Demographic features, presenting symptoms, laboratory findings, changes in iris stromal pigment and architecture, and time to resolution of pigment dispersion in the anterior chamber.

RESULTS

Nineteen patients were female, and 7 patients were male. Mean age was 32.3+/-8.6 years. All had bilateral involvement. Twenty patients (76.9%) presented with photophobia and red eyes, and 4 patients (15.4%) presented with a recent change in eye color. Ten patients (38.5%) had flu-like symptoms preceding the onset of ocular symptoms. Diagnostic laboratory workup, viral serology, and PCR analysis of the aqueous humor were unrewarding. Diffuse depigmentation of the iris stroma from the collarette to the iris root was seen in 16 patients, and geographic areas of depigmentation were seen in 10 patients. There was heavy pigment deposition in the trabecular meshwork in all patients. Anterior chamber flare was elevated in eyes with circulating pigment. The pupil was not affected. Twenty patients received topical corticosteroids. Pigment dispersion resolved in 1 to 16 weeks (median, 9 weeks). The intraocular pressure was elevated in 8 steroid-treated eyes but was controlled with antiglaucomatous medications. In 2 patients reported previously, the depigmented iris stroma became repigmented after 4 years.

CONCLUSIONS

Patients with BADI present with bilateral, symmetrical, nontransilluminating depigmentation of the iris stroma and pigment discharge into the anterior chamber. Young female persons are more commonly affected. The cause remains unknown. After 4 years, the ocular findings in 2 patients normalized.