Brimonidine-induced uveitis: The inflammatory aftermath of treatment

We report a rare case of late onset brimonidine-associated granulomatous anterior uveitis in a patient with primary open angle glaucoma (POAG). A 57-year-old female presented with insidious onset blurring of vision, redness, glare, and pain in the right eye for 2 months. She was a known case of bilateral POAG for 2 years, controlled on topical brimonidine and timolol. Her right eye workup revealed signs of granulomatous anterior uveitis with an intraocular pressure (IOP) of 20 and a cup–disc ratio (CDR) of 0.8. Systemic tests for tuberculosis (TB), sarcoidosis, HIV, and syphilis were negative, which led to suspicion of brimonidine-associated AAU. Brimonidine was withheld for a week without initiating steroids. At 1 week follow-up, the mutton fat keratic precipitates (KPs) reduced dramatically and IOP reduced to 12 mm Hg. The KPs showed complete resolution at 3 weeks, with no recurrence at 1.5-year follow-up. To summarize, patients on long-term brimonidine can rarely present with features of granulomatous anterior uveitis, which is completely reversible after cessation of the offending drug. Such patients often do well without long-term treatment with steroids.