Sir,

We have read with interest the article of Wefers Bettink-Remeijer et al.,1 who described a case series of five patients presenting an acute iris depigmentation, masquerading as uveitis, following moxifloxacin treatment. They suggest that this new syndrome is multifactorial and that moxifloxacin use is one of the precipitating factors. In our clinic, we have followed up a patient with a similar history who had also a possible additional risk factor.

Case report

A 36-year-old man presented to our department for acute bilateral pain and vision impairment. Ten days earlier he was treated in another institution with topical steroids for a bilateral mild uveitis that occurred 2 weeks after treatment with moxifloxacin (Avelox) for otitis. Symptoms did not improve and the patient was given oral and subconjunctival steroids with a topical beta-blocker. However, the situation continued to get worse and the patient came to our clinic. His visual acuity was 1/10 in both eyes. Slit lamp examination showed fine pigment keratic precipitates, many pigment granules, and few non-pigmented cells in the anterior chamber. Intraocular pressure was 46 mm Hg in both eyes. The angles were open but heavily pigmented. The iris was intensively depigmented (Figure 1). OCT of the angles demonstrated a concave iris (Figure 2). Steroids were stopped, antiglaucomatous therapy and oral acetazolamide were prescribed, but the clinical picture remains uncontrolled. An anterior chamber tap was performed and PCR for herpes viruses was negative. After the tap, the amount of pigment in the anterior chamber decreased significantly but IOP remain elevated despite strong anti-glaucomatous medication. Finally, IOP could be controlled after laser iridoplasty, which normalised the shape of the iris.

Figure 1
figure 1

Anterior chamber color picture demonstrating intense iris depigmentation.

Full size image
Figure 2
figure 2

OCT of the angles before (top) and after (bottom) laser iridoplasty.

Full size image

Comment

As predicted by the authors, our case report further confirms that moxifloxacin can induce the development of a pseudouveitis characterised by an acute depigmentation of the iris. In addition, this case also suggests that a concave shape of the iris could be another triggering element. In this setting, IOP might be dangerously elevated and laser iridoplasty recommended.