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delayed subretinal uid absorption (Hilton et al. 1990). Among these, new retinal break formation is a relatively common complication (incidence of 13%) with a favourable outcome (Hilton et al. 1990). It is believed to be the major reason for the lower initial success rate associated with pneumatic retinopexy (Hilton et al. 1990; Holz & Mieler 2003). By contrast, new giant retinal tear is a serious, vision-threatening complication and is exceedingly rare after pneumatic retinopexy. Partly detached posterior vitreous is believed to be responsible for giant tear formation (Holz & Mieler 2003). Our patients young age suggests incomplete liquefaction and detachment of the posterior vitreous preoperatively. Because of its small initial volume, the intraocular gas may inadvertently migrate into the retro- hyaloid space. With subsequent expansion, it may lead to further dissection of the interface between the posterior vitreous and the internal limiting membrane of the retina (Freeman et al. 1988; Holz & Mieler 2003). This may produce excessive vitreoretinal traction leading to giant retinal tear formation, as in our case. Giant retinal tear is a serious complication and remains a surgical challenge because of the high incidence of proliferative vitreoretinopathy and re-detachment with which it is associated (Ghosh et al. 2004). Vitrectomy combined with scleral buckling, peruorocarbon liquid, laser, cryopexy, and gas or silicone oil is the mainstay of management (Ghosh et al. 2004). Preoperative assessment for the presence of posterior vitreous detachment, avoidance of injection of intraocular gas into retro-hyaloid space and frequent postoperative examination for new retinal breaks are important precautions. Prior to the procedure, patients should be informed that giant retinal tear is a remote but possible serious complication of pneumatic retinopexy.

Ghosh YK, Banerjee S, Savant V et al. (2004): Surgical treatment and outcome of patients with giant retinal tears. Eye 18: 9961000. Hilton GF, Tornambe PE, Brinton DA et al. (1990): The complications of pneumatic retinopexy. Trans Am Ophthalmol Soc 88: 191207. Holz ER & Mieler WF (2003): The case for pneumatic retinopexy. Br J Ophthalmol 87: 787789. Wilkinson CP & Rice T (1997): Michels retinal detachment. St Louis, MI: CV Mosby 654656.

Correspondence: David T. L. Liu FRCS Department of Ophthalmology and Visual Sciences Chinese University of Hong Kong University Eye Centre Hong Kong Eye Hospital 147K Argyle Street Hong Kong Tel: + 852 2632 2878 Fax: + 852 2648 2943 Email: david_tlliu@yahoo.com

Bilateral iris cyst secondary to topical latanoprost

Sudha Pruthi, Shahram Kashani and Simon Ruben Department of Ophthalmology, Queens Hospital, Romford, UK doi: 10.1111/j.1600-0420.2007.01028.x

The optic discs appeared cupped (0.6 RE and 0.75 LE) with thinning of the left neuroretinal rim inferiorly. Humphrey (24-2) visual elds showed a left superior nasal step. Previous medical history included atrial brillation which had been treated with warfarin and bisoprolol tablets. As her phasing test failed to demonstrate raised IOPs, the subject was diagnosed with normal-tension glaucoma and started on topical latanoprost. On a routine clinic review 18 months later, slit-lamp examination showed bilateral iris pigment epithelial cysts inferotemporally through an undilated pupil, which were more prominent in the right eye (Fig. 1A, B). The iris appeared to bow forwards between the 4 and 6 oclock positions and open angles were seen on gonioscopy. The posterior pole was otherwise normal and there were no signs of ocular inammation. Ultrasound biomicroscopy (UBM) (Fig. 2) conrmed bilateral inferotemporal quadrant iris pigment epithelial cysts. The patient was diagnosed with secondary iris cysts following latanoprost treatment. The treatment was changed to topical Trusopt TDS (MSD, Hoddesdon, UK) bilaterally. On review 6 weeks later, the cyst in the left eye was seen to have completely

Editor, 75-year-old woman was referred by her optician to the eye clinic with asymmetrical intraocular pressure (IOP) (20 mmHg in the right eye [RE] and 25 mmHg in the left [LE]) and a left visual eld defect. She was asymptomatic. Careful anterior segment examination was unremarkable with no translumination defects, pseudoexfoliative change or signs of cysts or tumours. The subjects vision was normal, IOP was 19 mmHg RE and 21 mmHg LE (in clinic), and gonioscopy demonstrated normal angle morphology. Central corneal thickness was 519 mm RE and 525 mm LE.

References
Freeman WR, Lipson BK, Morgan CM & Liggett PE (1988): New posteriorly located retinal breaks after pneumatic retinopexy. Ophthalmology 95: 1418.

B
Fig. 1. (A) Iris cyst in the right eye. (B) Iris cyst in the left eye.

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The cysts can take any length of time from 3 weeks (Krohn & Hove 1999) to 5 months (Lai et al. 2003) to disappear, although this seems to depend on the time they take to develop. Generally, treatment involves changing latanoprost to an agent with a different mechanism of action, although more radical measures such as laser treatment or surgery might be required, particularly if there is associated secondary angle closure. All the cases reported in the literature describe unilateral iris cysts in association with latanoprost treatment. Our patient was noted to have developed bilateral iris epithelial cysts. As far as we know, this is the rst case of bilateral iris cyst following latanoprost treatment to be reported.

B
Fig. 2. Ultrasound biomicroscopy in (A) the right eye (2.7 mm 3.3 mm 1.1 mm) and (B) the left eye (3.2 mm 3.8 mm 1.0 mm).

References
Browning DJ, Perkins SL & Lark KK (2003): Iris cyst secondary to latanoprost mimicking iris melanoma. Am J Ophthalmol 135: 419421. Krohn J & Hove VK (1999): Iris cyst associated with topical administration of latanoprost. Am J Ophthalmol 127: 9193. Lai I, Kuo M & Teng L (2003): Iris pigment epithelial cyst induced by topical administration of latanoprost. Br J Ophthalmol 87: 366. Sodhi PK (2003): Iris cyst secondary to latanoprost mimicking iris melanoma. Am J Ophthalmol 136: 780.

resolved, whereas that in the right eye remained but had decreased in size. Common side-effects of latanoprost therapy include conjunctival hyperaemia, increased pigmentation of periocular skin, iris hyperchromia, increased length of eye lashes, uveitis and cystoid macular oedema. However, other rare side-effects, such as secondary iris epithelial cyst have been reported in the literature (Krohn & Hove 1999; Browning et al. 2003; Lai et al. 2003). Secondary iris epithelial cysts occur after trauma, intraocular surgery or inammation. Drug-related iris pigment epithelial cysts have been reported to occur with the use of miotics (pilocarpine) (Krohn & Hove 1999) as well as topical latanoprost.

The exact mechanism for the development of drug-induced iris cysts is unclear. Miotics such as pilocarpine are thought to form iris cysts by inducing proliferation of melanocytes (Sodhi 2003). Latanoprost does not have this effect, but a possible theory is that it increases uveoscleral outow, which leads to an enhanced aqueous ow through the ciliary muscle and the intraepithelial space of the posterior iris (Browning et al. 2003). Such iris cysts can develop at anytime from as early as 5 weeks (Krohn & Hove 1999) to as late as 9 months (Lai et al. 2003). In our case, the iris cysts took 18 months to develop although this fact was difcult to establish as our patient was followed up at long intervals.

Correspondence: Shahram Kashani BSc, MRCP, MRCOphth Queens Hospital Rom Valley Way Romford RM7 OAG UK Tel: + 44 845 1304204 Fax: + 44 1708 435108 Email: shahdoc@hotmail.com

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