Severe sequelae in bilateral acute iris transillumination syndrome secondary to the use of oral moxifloxacin: a case report

Abstract

Background Moxifloxacin is a fourth-generation fluoroquinolone used as a second-line treatment for multiple bacterial infections. Uveitis has been described as an adverse effect related to this medication. Although several case reports have been published describing uveitis and bilateral acute iris transillumination syndrome related to moxifloxacin, we present a unique case of a patient with severe sequelae associated with bilateral acute iris transillumination syndrome secondary to the use of oral moxifloxacin. Case presentation A 45-year-old Colombian hispanic female presented bilateral conjunctival hyperemia, decreased visual acuity, blurred vision, photophobia, and ocular pain after 15 days of treatment with systemic moxifloxacin for an upper tract respiratory infection. The patient presented unilateral anterior chamber pigment dispersion, mydriatic and nonreactive pupils, extensive iris transillumination defects, and secondary glaucoma. Blood and aqueous humor tests were negative for infectious and autoimmune diseases. Moxifloxacin-induced bilateral acute iris transillumination syndrome was diagnosed. Permanent sequelae such as ocular pain, photophobia, and focus difficulty secondary to severe bilateral iridian atrophy and inability of synkinetic reflex were left. Additionally, glaucoma was diagnosed, and Ahmed valve implantation was required. Conclusions We should be aware of the possible association between moxifloxacin and bilateral acute iris transillumination syndrome. A detailed anamnesis, adequate examination, and laboratory tests are necessary to reach an early diagnosis and treatment to avoid unnecessary therapies. Larger studies should be carried out to understand the pathophysiology, diagnosis, management, and sequelae of the disease.

Bilateral acute iris transillumination without prior systemic antibiotics

“…reported one case with BAIT that developed bilateral glaucoma requiring Ahmed glaucoma valve implantation. 13 In former studies, two patients failed to have IOP control with solely topical drops and required peripheral iridectomy in one patient and laser iridoplasty in the other. 14 15 …”

Comment on: Relative efficacy of intracameral moxifloxacin injection methods

“…The correlation in findings with moxifloxacin-induced bilateral acute iris transillumination (BAIT) increases the suspicion that moxifloxacin itself, as opposed to potential impurity in the formulation, may be responsible for these adverse changes. 4 Phakic procedures, including some minimally invasive glaucoma surgeries and, in particular, implantable collamer lens procedures, have gained popularity. As these surgeries become more commonplace, the use of moxifloxacin in such cases deserves special attention.…”

“…5 0 9 1 4 0 Aqueous >1 mg/mL (h) 5 3.5 14 24 Duration of administration IC = intracameral; pseudophakic = newly pseudophakic with an intracapsular posterior chamber IOL For the purpose of this table, the moxifloxacin concentration abatement rate for a newly pseudophakic eye was taken to be the same as we previously calculated (abatement every hour to 0.7866 of the concentration of the preceding hour), whereas for the smaller anterior chamber volume of a phakic eye, it calculates to 0.6188 because of the higher aqueous turnover in a smaller space. 4 If, however, the undiluted antibiotic becomes trapped between the iris and the lens, the turnover will be much slower. The data mentioned above are, therefore, approximate and to be used to illustrate a comparison only.…”

“…3 To our knowledge, the only case secondary to IC administration was reported on April 13, 2016 (ASCRS Cataract/Refractive Eye Connections Digest), by Matthew Runde, MD, but not published until 2019. 4 The article recounted the story of a 45-year-old male patient who suffered from unilateral BAIT after a 0.1-mL bolus of undiluted moxifloxacin (500 mg/0.1 mL) was administered IC into the right phakic eye after vitrectomy for floaters.…”

“…The correlation in findings with moxifloxacin-induced bilateral acute iris transillumination (BAIT) increases the suspicion that moxifloxacin itself, as opposed to potential impurity in the formulation, may be responsible for these adverse changes. 4…”