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Recurring Iris Pigment Epithelial Cyst Induced by Topical Prostaglandin

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Recurring Iris Pigment Epithelial Cyst Induced by Topical Prostaglandin Correspondence: Dr Morini, Pediatric Ophthalmology Ser- Owing to planned cataract surgery of the right eye, bima- vice, Ospedale Pediatrico Bambino Gesù, Piazza S. Ono- toprost treatment was discontinued; periodic slitlamp ex- frio 4, 00165 Rome, Italy ([email protected]). aminations showed that the cyst gradually diminished and Financial Disclosure: None reported. finally disappeared within the following 6 weeks. Despite normal configuration of the anterior chamber and iris sur- 1. Gomes JA, Romano A, Santos MS, Dua HS. Amniotic membrane use in oph- thalmology. Curr Opin Ophthalmol. 2005;16(4):233-240. face, repeated ultrasound biomicroscopy revealed a small 2. Pires RT, Tseng SC, Prabhasawat P, et al. Amniotic membrane transplanta- cystic structure persisting close to the junction between the tion for symptomatic bullous keratopathy. Arch Ophthalmol. 1999;117(10): 1291-1297. iris and ciliary body (Figure 2B). 3. Paridaens D, Beekhuis H, van Den Bosh W, Remeyer L, Melles G. Amniotic membrane transplantation in the management of conjunctival malignant mela- Comment. Both latanoprost and bimatoprost are topi- noma and primary acquired melanosis with atypia. Br J Ophthalmol. 2001; 85(6):658-661. cally applied prostaglandin F2␣ analogues that lower in- 4. Goyal R, Jones SM, Espinosa M, Green V, Nischal KK. Amniotic membrane traocular pressure by improving uveoscleral outflow. In transplantation in children with symblepharon and massive pannus. Arch Ophthalmol. 2006;124(10):1435-1440. the reported case, the capability of latanoprost to induce 5. Lee SH, Tseng SC. Amniotic membrane transplantation for persistent epithe- iris cysts is confirmed by the recurrence of the cyst after lial defects with ulceration. Am J Ophthalmol. 1997;123(3):303-312. 6. Vail A, Gore SM, Bradley BA, Easty DL, Rogers CA, Armitage WJ. Conclusions of the corneal transplant follow up study. Br J Ophthalmol. 1997;81(8):631-636. Recurring Iris Pigment Epithelial Cyst Induced by Topical Prostaglandin F2␣ Analogues ris cysts are usually classified as primary or second- ary. Secondary cysts may be caused by uveitis, sur- gery, trauma, or miotics. Four cases of latanoprost- I 1-4 induced iris cysts have been reported in the literature. In the original article,1 we described a patient who developed a large iris pigment epithelial cyst in association with topi- cal administration of latanoprost. Latanoprost treatment was discontinued and periodic examinations revealed that the cyst disappeared within 3 weeks. We proposed that this rare adverse effect was related to increased uveoscleral out- Figure 1. Slitlamp photograph of the patient’s right eye after topical flow caused by latanoprost. Herein, we describe the fol- administration of bimatoprost. A large iris pigment epithelial cyst led to low-up of our initial patient in whom rechallenge with la- anterior displacement of the iris surface in the inferotemporal quadrant. tanoprost as well as subsequent administration of topical bimatoprost led to recurrences of the iris cyst. A Report of a Case. In 1998, a 76-year-old woman with pri- mary open-angle glaucoma had a latanoprost-induced iris cyst in her right eye. The cyst gradually resolved after sub- stitution of latanoprost with topical timolol.1 During the following 2 years, the intraocular pressure increased to lev- els greater than 20 mm Hg. After obtaining informed con- sent, the right eye was rechallenged with latanoprost, 0.005%, at bedtime. At examination 7 months later, the iris cyst had recurred and led to anterior displacement of the iris in the inferotemporal quadrant. Due to lasting el- evated intraocular pressure and the lack of any complica- B tions from the cyst, the patient continued to receive la- tanoprost therapy for approximately 2.5 years (until 2003). Then, an attempt to reduce the intraocular pressure was made by replacing latanoprost with bimatoprost, 0.03%, once every evening, which shortly thereafter resulted in a further increase in cyst size. The cyst bulged the iris for- ward between the 6- and 10-o’clock positions (Figure 1) and was visible as a slightly transilluminating, elongated, dark brown mass just posterior to the pupillary margin. The color and pigmentation of the iris stroma were normal, and Figure 2. Ultrasound biomicroscopic images of the patient’s right eye. there were no signs of intraocular inflammation. Ultra- A, After initiation of bimatoprost treatment, an iris pigment epithelial cyst sound biomicroscopy demonstrated a solitary, thin- extended from the iridociliary junction to the pupillary border. Note the thin walled cyst with clear intracavitary fluid posterior to the cyst wall and the anterior displacement of the iris stroma. B, Three months ϫ after discontinuation of bimatoprost treatment, a small residual cyst, not iris. The cyst, measuring 1.5 4 mm, extended from the seen clinically, persisted in the region of the iridociliary sulcus (arrow). Note iridociliary junction to the pupillary border (Figure 2A). the normal configuration of the anterior chamber and iris. (REPRINTED) ARCH OPHTHALMOL / VOL 126 (NO. 6), JUNE 2008 WWW.ARCHOPHTHALMOL.COM 867 ©2008 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/01/2021 rechallenge with the drug. The fluctuations in cyst size fol- Dilated examination of the right eye revealed a mass lowing initiation and discontinuation of bimatoprost involving the ciliary body and posterior iris at the 2-o’clock strongly indicate that this adverse effect can be caused by position. There was evidence of direct tumor extension into other topical prostaglandin F2␣ analogues as well. the angle in the area of narrowing. Transillumination re- Ultrasound biomicroscopy demonstrated that the pa- vealed no evidence of a ring melanoma. The vitreous was tient had a large iris pigment epithelial cyst. However, the clear and the posterior pole was otherwise normal. small residual cyst at the iridociliary junction raises the ques- High-frequency ultrasonography revealed a mass cen- tion of whether this was a secondary iris cyst arising de novo tered in the ciliary body with low internal reflectivity. The after administration of latanoprost or a preexisting pri- tumor measured 12.0ϫ7.9 mm in basal dimension with mary cyst where only its volume was influenced by the eye- a height of 3.3 mm. drops. In both circumstances, the increased uveoscleral out- The patient was diagnosed with a ciliary body mela- flow may have contributed to cyst formation by changing noma involving the iris and angle with secondary mela- the fluid dynamics through the interepithelial space of the nomalytic glaucoma. The systemic workup results were nor- posterior iris. In theory, the drugs could also have acted mal. The eye was enucleated based on patient preference. directly on the cyst-lining epithelial cells and thereby in- Histopathological analysis revealed a ciliary body mela- creased intracavitary fluid secretion. As anterior uveitis has noma of the mixed cell type. The tumor involved the iris root been associated with the use of prostaglandin F2␣ ana- and angle with tumor seeding of the anterior segment. There logues,5,6 an alternative mechanism of induction of the cyst was posterior extension of the tumor as well (Figure 2). could be inflammation due to subclinical uveitis. Comment. Although ciliary body melanomas are less com- Jørgen Krohn, MD, PhD mon than their more posterior counterparts, the prog- Vibeke K. Hove, MD nosis for metastases is worse. This is likely owing to the Correspondence: Dr Krohn, Department of Clinical Medi- larger average size of the tumor at detection as well as the association with more malignant cell types.1 Even with cine, Section of Ophthalmology, University of Bergen, and 2 Department of Ophthalmology, Haukeland University treatment, the rate of metastasis at 5 years is 28%. Hospital, N-5021 Bergen, Norway (jorgen.krohn Ciliary body melanomas can remain hidden from the @helse-bergen.no). eye care provider owing to their location posterior to the Financial Disclosure: None reported. iris. Patients often become symptomatic only after the tu- mor becomes large enough to cause cataract formation or 1. Krohn J, Hove VK. Iris cyst associated with topical administration of latanoprost. Am J Ophthalmol. 1999;127(1):91-93. lenticular astigmatism or to displace the crystalline lens. 2. Browning DJ, Perkins SL, Lark KK. Iris cyst secondary to latanoprost mim- icking iris melanoma. Am J Ophthalmol. 2003;135(3):419-421. 3. Lai IC, Kuo MT, Teng LM. Iris pigment epithelial cyst induced by topical ad- A ministration of latanoprost. Br J Ophthalmol. 2003;87(3):366. 4. Pruthi S, Kashani S, Ruben S. Bilateral iris cyst secondary to topical latano- prost. Acta Ophthalmol. 2008;86(2):233-234. doi:10.1111/j.1600-0420.2007 .01028.x. 5. Warwar RE, Bullock JD, Ballal D. Cystoid macular edema and anterior uve- itis associated with latanoprost use: experience and incidence in a retrospec- tive review of 94 patients. Ophthalmology. 1998;105(2):263-268. 6. Packer M, Fine IH, Hoffmann RS. Bilateral nongranulomatous anterior uveitis associated with bimatoprost. J Cataract Refract Surg. 2003;29(11):2242-2243. Uveal Melanoma Masquerading as Pigment Dispersion Glaucoma 64-year-old white woman from an outside oph- thalmologist had a history of pigment disper- sion glaucoma unresponsive to medical therapy A B in the right eye. She was subsequently found to have a ciliary body melanoma and was sent to our ocular on- cology clinic for further evaluation. The clinical course and outcome are described. Report of a Case. The visual acuity in the affected eye was 20/60 OD with an intraocular pressure of 38 mm Hg and an elevated lesion beneath the peripheral iris at the 2-o’clock position. The left eye was normal. In the right eye, the peripheral iris and anterior lens cap- sule were covered by a fine dusting of pigment (Figure 1). There was a small amount of corectopia superonasally. On gonioscopy, the angle was narrowed superonasally and there was intense, homogeneous pigmentation of the trabecu- Figure 1.
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