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Adolescent Medicine

Gravitational Shifting of a Pigmented Iris Lesion in a Young Boy

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

1 Credit CME

JAMA Ophthalmology

Published Online: September 14, 2023

JAMA Ophthalmology Clinical Challenge

Article Information and Disclosures

Kevin R. Card, BS¹;

Matthew R. Barke, MD¹;

Carol L. Shields, MD¹

Author Affiliations

¹Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania

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A 13-year-old boy with a history of sports-related blunt trauma to the left eye was referred for evaluation of an asymptomatic, pigmented iris lesion in the left eye. On examination, his best-corrected visual acuity was 20/20 OU, and intraocular pressures were normal in both eyes. Results of slitlamp examination of the right eye were unremarkable. Slitlamp examination of the left eye revealed a round, pigmented lesion measuring 3 × 3 mm in basal dimension and with gravitational shifting within the anterior chamber fluid with patient head tilt (Video). There was no corneal guttatae or edema. Anterior segment optical coherence tomography depicted the lesion in the anterior chamber angle abutting the corneal endothelium and resting on the iris stroma with no internal fluid level and no solid component. Ultrasound biomicroscopy confirmed the lesion to be cystic with a thickness of 1.6 mm. Dilated fundus examination revealed normal findings in both eyes.

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A 13-year-old boy with a history of sports-related blunt trauma to the left eye was referred for evaluation of an asymptomatic, pigmented iris lesion in the left eye. On examination, his best-corrected visual acuity was 20/20 OU, and intraocular pressures were normal in both eyes. Results of slitlamp examination of the right eye were unremarkable. Slitlamp examination of the left eye revealed a round, pigmented lesion measuring 3 × 3 mm in basal dimension and with gravitational shifting within the anterior chamber fluid with patient head tilt (Video). There was no corneal guttatae or edema. Anterior segment optical coherence tomography depicted the lesion in the anterior chamber angle abutting the corneal endothelium and resting on the iris stroma with no internal fluid level and no solid component. Ultrasound biomicroscopy confirmed the lesion to be cystic with a thickness of 1.6 mm. Dilated fundus examination revealed normal findings in both eyes.

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Article Information

Corresponding Author: Carol L. Shields, MD, Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, 840 Walnut St, Ste 1440, Philadelphia, PA 19107 (carolshields@gmail.com).

Published Online: September 14, 2023. doi:10.1001/jamaophthalmol.2023.4019

Conflict of Interest Disclosures: Dr Shields is supported in part by the Eye Tumor Research Foundation. No other disclosures were reported.

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

References

Shields CL , Shields PW , Manalac J , Jumroendararasame C , Shields JA . Review of cystic and solid tumors of the iris. Oman J Ophthalmol. 2013;6(3):159-164. doi:10.4103/0974-620X.122269 PubMed Google Scholar Crossref

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.2011.07.059 PubMed Google Scholar Crossref

Bianciotto C , Shields CL , Guzman JM , et al. Assessment of anterior segment tumors with ultrasound biomicroscopy versus anterior segment optical coherence tomography in 200 cases. Ophthalmology. 2011;118(7):1297-1302. doi:10.1016/j.ophtha.2010.11.011 PubMed Google Scholar Crossref

Singh G , Narendran K , Saravanan VR , Narendran V . Pigmented free-floating iris cysts. Br J Ophthalmol. 2007;91(8):1037. doi:10.1136/bjo.2007.126078 PubMed Google Scholar Crossref

Rotsos T , Bagikos G , Christou S , et al. Free-floating iris pigmented epithelial cyst in the anterior chamber. Case Rep Ophthalmol Med. 2016;2016:4731037. doi:10.1155/2016/4731037 PubMed Google Scholar Crossref

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 credit toward the CME [and Self-Assessment requirements] of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.