Case Report

A 25-year-old Hispanic woman traveled to Panama and underwent simultaneous bilateral eye surgery to change the color of her irides with non-FDA-approved anterior chamber cosmetic iris diaphragm implants (NewColorIris) ( Figure , Top row). Since the week following the surgery she complained of bilateral blurry vision, redness, tearing, and light sensitivity. Topical steroids for chronic iritis and IOP-lowering drops were prescribed by her surgeon during numerous postoperative visits back to Panama. Three months later, she consulted an ophthalmologist in the United States who recommended immediate explantation of the iris implants, but she did not follow this advice.

Cosmetic iris implant and consequences. (Top row) Schematic diagram of cosmetic iris implant and profile view of position in the anterior chamber. (Second row) Subsequent bilateral surgical aniridia, (Third row) bilateral central retinal vein occlusion, and (Bottom row) neovascular glaucoma with corresponding optical coherence tomography and visual field loss.

About 16 months after the implants were placed, the patient noticed a rapid decline of vision in both eyes and returned to Panama, where she was diagnosed with glaucoma and underwent removal of the implants by the original surgeon. A month later her best-corrected visual acuity (BCVA) had decreased to hand motion (HM) in the right and 20/400 in the left eye. IOP was 22 mm Hg in the right eye and 30 mm Hg in the left eye on latanoprost ophthalmic solution once at night (Xalatan 0.005%; Pfizer Inc, New York, New York, USA), brinzolamide ophthalmic suspension twice per day (Azopt 1%; Alcon Laboratories, Fort Worth, Texas, USA), and brimonidine ophthalmic solution twice per day (Alphagan P 0.1%; Allergan Inc, Irvine, California, USA) in both eyes. There was bilateral low-grade iritis, surgical aniridia ( Figure , Second row), and 1+ nuclear sclerosis. Gonioscopy revealed peripheral anterior synechiae and neovascularization of the angle and an inferior retracted hyphema. Fundoscopic examination showed minimal vitreous hemorrhage, advanced to end-stage glaucomatous optic neuropathy (right eye vertical cup-to-disc ratio 0.95, left eye 0.85), engorged retinal veins, macular edema, and numerous intraretinal hemorrhages throughout the fundus ( Figure , third row). She was diagnosed with bilateral central retinal vein occlusion and neovascular glaucoma at the referring practice and treated with intravitreal bevacizumab (Avastin; Genentech, San Francisco, California, USA) followed by panretinal photocoagulation (PRP). She was started on oral acetazolamide 500 mg twice a day for 5 days and referred to our glaucoma service when her IOP increased to 48 mm Hg in the right eye and 40 mm Hg in the left eye. There was mild corneal stromal edema with central corneal thicknesses of 602 μm in the right eye and 686 μm in the left eye, respectively. Endothelial counts by specular microscopy were 557 in the right eye and unobtainable in the left eye. Extensive thinning of the peripapillary retinal nerve fiber layer was confirmed by optical coherence tomography ( Figure , Bottom row) using Stratus OCT (Carl Zeiss Meditec, Dublin, California, USA). After informed consent, an Ahmed glaucoma drainage implant (New World Medical Inc, Rancho Cucamonga, California, USA) was urgently placed in the left eye, followed by the same procedure in the right eye within 1 week. Difluprednate ophthalmic suspension 4 times per day (Durezol 0.05%; Sirion Therapeutics, Tampa, Florida, USA) and brinzolamide ophthalmic suspension 3 times per day (Azopt 1%; Alcon Laboratories) were needed for three months after glaucoma drainage device implantation. Further PRP was added in both eyes to control neovascularization. After resolution of macular edema, her BCVA was hand motion in the right and 20/150 in the left eye with IOP in the mid teens bilaterally. Visual field analysis (HFA II model 750 operating system 12.6; Carl Zeiss Meditec, Jena, Germany) was unobtainable in the right eye and showed a small paracentral island in the left eye ( Figure , Bottom row).