CASE REPORT A Rare Presentation of Cyclitis Induced Myopia Umar Ijaz, Asad Habib and Hassan Sajjad Rathore ABSTRACT Unilateral cyclitis leading to myopia is a rare and clinical relevant entity. In clinical settings, pseudomyopia is generally encountered in the form of accommodative spasm, which is always bilateral. Cyclitis due to inflammation, on the other hand, can cause pseudomyopia unilaterally and it is a very rare presentation. A young male with acute anterior uveitis, presented with acute episode of unilateral myopia. When patient was examined on first visit, there were no cells in anterior chamber; so he was started on cycloplegic eye drops, but his condition didn't improve. Examination on subsequent visit revealed cellular reaction in anterior chamber and narrowing of anterior chamber angles on anterior segment optical coherence tomography (OCT). Treatment for uveitis was started and patient's visual acuity and refractive error improved. Pseudomyopia is a known complication of several drugs and certain medical conditions. The possible mechanism is supraciliary exudation causing relaxation of zonular fibers and increased convexity of the crystalline lens. Myopia in the setting of a mild cellular reaction can easily be missed and has not been reported yet to the best of authors’ literature search. Key Words: Myopia. Uveitis. Iridocyclitis. INTRODUCTION started on cyclopentolate eye drops and then atropine Myopia or near-sightedness means that light rays coming eye drops, but no improvement in visual acuity was from a distance are unable to focus on retina, but they observed. Next visit revealed a visual acuity of 6/75 right eye improving to 6/9 with refraction of -4.00 DS along focus short of retina causing a blurred vision. Either it with cells in anterior chamber (AC) in right eye and can be due to enlarged eye ball (axial myopia) or due to pharmacologically dilated pupils bilaterally. Posterior increase dioptric power of lens itself (lenticular). Some segment examination was normal. Intraocular pressure medical conditions and drugs are also known to cause a (IOP) measured by Goldman applanation tonometer myopic shift. Commonly reported medical conditions are was 12 and 18 mmHg in right and left eye, respectively. hyperglycemia, scleritis, choroidal inflammation, Vogt- Both these new findings, i.e. difference in IOP and cells Koyonagi-Harada disease, and juvenile idiopathic in AC, pointed towards cyclitis. To confirm, anterior arthritis.1 Certain drugs which are reported to cause a chamber optical coherence tomography (OCT) was myopic shift include corticosteroids, sulfa drugs, done to measure the anterior chamber angle, which acetazolamides and topiramate.2-6 came out to be 17.5 degrees in right eye as compared to The relationship between uveitis and pseudomyopia is 58.9 degrees in the left eye (Figure 2). Patient was of clinical significance; and can easily be missed. It is started on steroid eye drops 3 hourly and systemic rarely reported in the literature,7 and is, therefore, worth steroids 1 mg/ kg body weight in divided doses. publishing. Patient was asked for follow-up after three days. Cells in CASE REPORT AC disappeared, redness and conjunctival congestion A 35-year man reported with complaints of decreased disappeared, and visual acuity improved to 6/9 with a vision from his right eye for the last few days associated refractive error of +0.50 DS on AR. Patient was advised with mild redness and pain. On examination, he had visual acuity of 6/36 improving to 6/6 with refraction of - 3.00 diopter sphere (DS), while that in left eye was 6/6. Autorefractometer (AR) also reported a refractive error of -3.25 DS (Figure 1). Color vision and near visual acuity was normal in both eyes. Both anterior and posterior segment of both eyes were normal. Keeping in mind the possible diagnosis of ciliary spasm, patient was Department of Ophthalomogy, Armed Forces Institute of Ophthalmology, Rawalpindi. Correspondence: Dr. Asad Habib, Armed Forces Institute of Ophthalmology, Mall Road, Military Hospital, Rawalpindi. E-mail: [email protected] Received: May 26, 2017; Accepted: December 03, 2017. Figure 1: Autorefractometer showing refractive error before and after treatment. S56 Journal of the College of Physicians and Surgeons Pakistan 2018, Vol. 28 (Special Supplement 1 of Case Reports): S56-S57 Cyclitis induced myopia to continue topical medication and review after two In our opinion, the cycloplegics (cyclopentolate, atropine) weeks for repeat anterior chamber OCT, which revealed did not relieve his myopia, initially because there was a an open angle of 49.3 degrees in the right eye (Figure 2). persistent edema of the ciliary body which was further Vision improved to 6/6 and anterior chamber was quiet. relaxing the zonular fibers, making the lens more Patient was discharged after follow-up and advised to globular. As soon as the patient was started on steroids, come back for consultation, if symptoms reappear. the ciliary edema subsided, the ciliary muscles assumed their normal position, and the pseudomyopia was relieved. In conclusion, acute unilateral iridocyclitis can present as pseudomyopia. To the best of our knowledge, this was the first case in our setting which presented as pseudomyopia in a backdrop of acute iridocyclitis, and Figure 2: Anterior segment OCT showing angle measurements before treatment. such a rare presentation of this disease has never been reported before. In contrast to treatment by cycloplegics only, this disease entity responds well to the routine acute anterior uveitis treatment. REFERENCES 1. Herbort CP, Papadia M, Neri P. Myopia and inflammation. J Ophthalmic Vis Res. 2011; 6:270-83. Figure 3: Anterior segment OCT showing angle measurements after treatment. 2. Panday VA, Rhee DJ. Review of sulfonamide-induced acute myopia and acute bilateral angle-closure glaucoma. Compr DISCUSSION Ophthalmol Update 2006; 8:271-6. Pseudomyopia may be defined as the sporadic and 3. Bhattacharyya KB, Basu S. Acute myopia induced by temporary shift of the refractive power of the eye topiramate: report of a case and review of the literature. Neurol towards myopia. It may occur alone as a sporadic entity India 2005; 53:108. or it may manifest as the spasm of synkinetic reflex, i.e. 4. Brandão MN, Fernandes IC, Barradas FF, Machado JF, with pupil constriction and convergent strabismus. The Oliveira MT. Acute myopia and angle closure glaucoma aetiology of this condition varies from organic, traumatic, associated with topiramate use in a young patient: case report. iatrogenic causes to functional and drug-related causes.8,9 Arq Bras Oftalmol 2009; 72:103-5. Pseudomyopia has also been documented in inflammatory 5. Rapoport Y, Benegas N, Kuchtey RW, Joos KM. Acute myopia conditions like sclero-choroidal inflammation and multifocal and angle closure glaucoma from topiramate in a seven-year- choroiditis, though its manifestation in iridocyclitis has old: a case report and review of the literature. BMC Pediatr never been documented.10 2014; 14:96. When this patient presented to the outpatient department 6. Boonyaleephan S. Bilateral acute onset myopia and angle for the first time with blurred vision in right eye, he was closure glaucoma after oral topiramate: a case report. J Med suspected as a case of simple accommodative spasm Assoc Thai 2008; 91:1904. due to increase in refractive power of the eye and 7. Mantovani A, Resta A, Herbort CP, El Asrar AA, Kawaguchi T, absence of any organic pathology, after going through Mochizuki M, et al. Work-up, diagnosis and management of an extensive history and examination protocol. acute Vogt-Koyanagi-Harada disease. Int Ophthalmol 2007; Therefore, he was prescribed cycloplegic eye drops 27:105-15. initially and was called for follow-up. On subsequent 8. Stratos AA, Peponis VG, Portaliou DM, Stroubini TE, Skouriotis S, visits, the myopic shift kept on increasing and initial Kymionis GD. Secondary pseudomyopia induced by signs of acute anterior uveitis started to appear. Further amisulpride. Optom Vis Sci 2011; 88:1380-2. investigations and imaging results were consistent with 9. Chan RP, Trobe JD. Spasm of accommodation associated with narrow angle, possibly secondary to cyclitis. The patient closed head trauma. J Neuro-ophthalmol 2002; 22:15-7. was then started on topical and oral steroids, to which he 10. Herbort CP, Papadia M, Neri P. Myopia and inflammation. responded effectively and his vision returned to normal. J Ophthalmic Vis Res. 2011; 6:270-83. Journal of the College of Physicians and Surgeons Pakistan 2018, Vol. 28 (Special Supplement 1 of Case Reports): S56-S57 S57.