Fungal iris cyst after sub-Tenon triamcinolone injection in a patient with treatment-resistant uveitis

This case report highlights the complex medical journey of a 69-year-old male with no significant medical history, who presented with recurring episodes of uveitis in his left eye, which did not respond to standard treatment. The patient underwent various medical interventions, including sub-Tenon triamcinolone injection, only to develop an iris cyst associated with fungal endophthalmitis, raising questions about the initial diagnosis. Case Report The patient initially suffered from recurrent treatment-resistant uveitis in his left eye. Standard treatment with prednisolone acetate eye drops every two hours proved ineffective. Subsequently, the patient received a sub-Tenon injection of Trigon depot, but three weeks later, he developed a subconjunctival abscess. Surgical debridement and a scleroconjunctival biopsy revealed scleromalacia with Candida and Actinomyces fungal elements. Antifungal treatment was initiated (voriconazole 2% eye drops daily dosage every four hours, oral voriconazole loading dose of 400 mg twice a day for 48 hours, followed by a regular 200 mg maintenance regimen) and after 1 month, the infection and uveitis partially remitted. Two months after surgical debridement, the patient's condition worsened, with sudden-onset ocular pain, intense redness, and decreased visual acuity (20/100). During slit-lamp examination, a white iris cyst was detected in the iridocorneal angle of his left eye [Fig. 1a and b]. This finding was confirmed through anterior segment optical coherence tomography (AS-OCT) [Fig. 2a–c]. Fine-needle aspiration biopsy (FNAB) with cyst excision and adjuvant photocoagulation revealed fungal material (Purpureacillium lilacium). Previous antifungal treatment was restarted, and three intravitreal injections of voriconazole were administered at one-week intervals. Gradual improvement in inflammation and vision (20/50) was observed after several months of topical and systemic long-term treatment.Figure 1: (a and b) Slit-lamp examination images of the left eye iris cyst. Oval-shaped cyst, whitish hue, and solid and firm texture. Also, it is immobile, raised, and features uneven edgesFigure 2: (a–c) AS-OCT images. Left eye iris cyst in inferior temporal iridocorneal angle. Dense consistency and thick walls. Size of 2.5 × 2 × 1 mm. Scanning from top to bottom. AS-OCT = anterior segment optical coherence tomographyDiscussion Iris cysts are rare space-occupying lesions within the eye, classified into primary and secondary cysts.[1] Secondary cysts can be caused by various factors, including uveitis.[1] Diagnosis relies on clinical evaluation and imaging techniques such as ultrasound biomicroscopy (UBM) or AS-OCT.[2] Treatment options encompass a spectrum of approaches, starting with clinical observation and extending to fine-needle aspiration biopsy, either with or without the use of sclerosing agents such as mitomycin-C or 5-fluorouracil.[1,2] In addition, treatments may include laser photocoagulation–photodisruption or complete surgical excision.[3] In this case, the patient's uveitis was initially refractory, leading to the question of whether it was of infectious origin or triggered by the sub-Tenon triamcinolone injection. The subsequent development of an iris cyst associated with fungal endophthalmitis added complexity to the case. Conclusion This case underscores the challenges in diagnosing and treating uveitis, especially when it is refractory. The development of an iris cyst associated with fungal endophthalmitis raises questions about the initial diagnosis and the role of medical interventions in its progression. Clinicians should exercise caution and consider potential infectious etiologies in challenging cases of uveitis. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship: Nil. Conflicts of interest: There are no conflicts of interest.