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Waking Up With Cloudy Vision

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 63-year-old woman was referred by optometry after waking up with cloudy vision in the left eye and an ache around the left brow. Visual acuity was 20/20 OD and light perception OS. Intraocular pressure (IOP) was 15 mm Hg OD and 54 mm Hg OS. Anterior segment examination of the left eye was remarkable for a large cystic iris stromal lesion from the 2- to 7-o’clock position with iris-cornea touch. The anterior chamber was shallow in the area of the enlarged cystic lesion with a large amount of pigmented cells. The pupil was irregular with blood at the pupillary margin. Her intraocular lens was not visible because of occlusion by a cystic lesion behind the iris (Figure 1). Her ocular history was notable for indiscriminate trauma to her left eye, primary open-angle glaucoma in both eyes treated with dorzolamide hydrochloride and brimonidine tartrate, and pseudophakia in both eyes. Four years prior, an inferior cystic iris stromal lesion was discovered in the left eye that measured approximately 5 × 2 mm in basal dimensions at the slitlamp. Fine-needle aspiration was negative for malignancy, and the lesion was managed by close follow-up.

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Secondary angle-closure glaucoma due to sudden enlargement of a cystic iris stromal lesion

A. YAG laser to perforate the cystic wall

The differential diagnosis for a cystic iris mass includes primary iris stromal and iris pigmented epithelial cysts, as well as secondary cysts related to neoplasia, trauma, inflammation, or medication.14 Ultrasound B-scan and biomicroscopy allow for identification of internal echogenicity and involvement of surrounding structures, which aid in ruling out solid mass lesions.4,5 Primary iris cysts tend to have thin walls and smooth borders, whereas secondary cysts tend to have irregular borders and rough surfaces.6 This surgical history and prior ocular trauma suggest a secondary etiology in this patient.

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Article Information

Corresponding Author: Kay T. Khine, MD, Department of Ophthalmology, Bascom Palmer Eye Institute, 900 NW 17th St, Miami, FL 33136 (kaykhine3@gmail.com).

Published Online: October 28, 2021. doi:10.1001/jamaophthalmol.2021.1461

Conflict of Interest Disclosures: Dr Harbour reported being an advisor for Castle Biosciences Scientific outside the submitted work. No other disclosures were reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
1.
Shields  CL , Kancherla  S , Patel  J ,  et al.  Clinical survey of 3680 iris tumors based on patient age at presentation.   Ophthalmology. 2012;119(2):407-414. doi:10.1016/j.ophtha.2011.07.059PubMedGoogle ScholarCrossref
2.
Shields  JA .  Primary cysts of the iris.   Trans Am Ophthalmol Soc. 1981;79:771-809.PubMedGoogle Scholar
3.
Shields  JA , Kline  MW , Augsburger  JJ .  Primary iris cysts: a review of the literature and report of 62 cases.   Br J Ophthalmol. 1984;68(3):152-166. doi:10.1136/bjo.68.3.152PubMedGoogle ScholarCrossref
4.
Georgalas  I , Petrou  P , Papaconstantinou  D , Brouzas  D , Koutsandrea  C , Kanakis  M .  Iris cysts: a comprehensive review on diagnosis and treatment.   Surv Ophthalmol. 2018;63(3):347-364. doi:10.1016/j.survophthal.2017.08.009PubMedGoogle ScholarCrossref
5.
Verbeek  AM .  Conventional diagnostic ultrasound of iris lesions.   Doc Ophthalmol. 1995;90(1):43-52. doi:10.1007/BF01203293PubMedGoogle ScholarCrossref
6.
Marigo  FA , Esaki  K , Finger  PT ,  et al.  Differential diagnosis of anterior segment cysts by ultrasound biomicroscopy.   Ophthalmology. 1999;106(11):2131-2135. doi:10.1016/S0161-6420(99)90495-5PubMedGoogle ScholarCrossref
7.
Katsimpris  JM , Petropoulos  IK , Sunaric-Mégevand  G .  Ultrasound biomicroscopy evaluation of angle closure in a patient with multiple and bilateral iridociliary cysts.   Klin Monbl Augenheilkd. 2007;224(4):324-327. doi:10.1055/s-2007-962951PubMedGoogle ScholarCrossref
8.
Vela  A , Rieser  JC , Campbell  DG .  The heredity and treatment of angle-closure glaucoma secondary to iris and ciliary body cysts.   Ophthalmology. 1984;91(4):332-337. doi:10.1016/S0161-6420(84)34287-7PubMedGoogle ScholarCrossref
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