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Sir,

Ah-Fat and Canning1 have described a patient with recurrent visual loss related to spontaneous hyphaema. The source of the hyphaema was thought to be an iris microhaemangioma at the pupil margin and was preceded by ocular pain and amaurosis fugax. We describe a patient with spontaneous hyphaema from a similar vascular iris lesion but without any preceding ocular symptoms.

Case report

A 74-year-old lady presented with a 6-h history of sudden loss of vision in her right eye. There was no history of trauma. Visual acuity was ‘hand movements’. There was a total hyphaema with no anterior chamber details visible. Applanation tonometry showed an intraocular pressure of 72 mmHg. The left eye was unremarkable. Her general health was good apart from systemic hypertension, which was well controlled on oral atenolol. She had no previous ocular complaints.

The lady was admitted and commenced on oral acetazolamide, topical beta-blockers and fluoromethalone. A full-blood count and clotting screen were normal. The intraocular pressure decreased steadily and was 14 mmHg by the following morning.

The hyphaema also resolved, and as the clot retracted a fleshy red vascular tuft became visible on the iris at the pupillary margin. It was about the size of a pinhead (Figure 1) and was situated at 1 o'clock position. The lady was reviewed in outpatients 4 days later. The hyphaema had resolved and vision had improved to 6/9. The vascular iris lesion had remained unchanged. Gonioscopy showed an open angle and no abnormality. The right fundus showed a hyperaemic disc with a splinter haemorrhage, and tortuous veins. The disc appeared normal 6 weeks later. All topical medication was stopped and her condition remains unchanged.

Figure 1
figure 1

Vascular tuft at 1 o'clock position on pupillary margin.

Full size image

Comment

We feel that this is a case of iris microhaemangioma similar to the one described by Ah-Fat and Canning.1 However, unlike their case, our patient never had any preceding visual symptoms such as amaurosis fugax. Similar vascular iris lesions have been described in association with systemic conditions such as hereditary haemorrhagic telangiectasis2 and myotonic dystrophy.3 The treatment of these vascular lesions is not clear. Apart from a single report of an iris tuft successfully treated with laser,4 there is not much literature dealing with the treatment of such lesions, and clearly the rarity of these patients limits the development of a management protocol.