Clinical, Diagnostic, And Therapeutic Challenges Of Iridoschisis In 2 Clinical Cases"

Iridoschisis is a rare condition characterized by the progressive separation of anterior iridian stromal fibers from the posterior ones. It typically manifests in middle to late adulthood, affecting both eyes bilaterally and asymmetrically. Various etiopathogenic mechanisms, including genetic predisposition, have been proposed. We present two clinical cases of this condition, highlighting the multidisciplinary ophthalmological management required to address its complications and the diagnostic and therapeutic challenges it presents. 

Both cases were diagnosed and managed by the Ophtalmology department at Vall d'Hebron University Hospital in Barcelona, Spain.

The first case involves a 72-year-old patient with a metastatic parotid neoplasm who presented with left eye pain persisting for several days. Initially suspected as herpetic keratitis, the patient was eventually diagnosed with bilateral, albeit asymmetric, iridoschisis, bilateral endothelial cell loss, and suspicion of primary angle closure syndrome (PACS) in both eyes. Phacoemulsification cataract surgery and intraocular lens implantation were performed on the left eye. Due to posterior endothelial decompensation, the patient required Descemet's Stripping Automated Endothelial Keratoplasty (DSAEK) with satisfactory clinical outcomes. Given the worsening of the underlying condition, YAG laser iridotomy was performed in the right eye as part of PACS treatment.

The second case involves a 64-year-old patient who complain of vision loss in the right eye. Initially, severe primary angle-closure glaucoma was suspected, with an intraocular pressure of 40 mmHg and PACS in the left eye. Subsequent evaluation confirmed bilateral iridoschisis, with predominant involvement observed in the right eye, presenting as secondary narrow-angle glaucoma. Topical hypotensive treatment was initiated in the right eye, resulting in effective intraocular pressure control and preservation of visual field stability. Laser iridoplasty was performed in the left eye, achieving satisfactory intraocular pressure control without evidence of glaucomatous progression to date.

Iridoschisis is an uncommon clinical entity that represents a diagnostic and therapeutic challenge. The differential diagnosis should include iridocorneoendothelial syndrome (ICE), Azenfeld Rieger syndrome, and primary angle-closure glaucoma. Diagnostic assessment should involve examining family members and conducting serological testing to rule out latent infections. The presence of iridian stromal fibers in the anterior chamber poses a risk of developing secondary angle-closure glaucoma and endothelial decompensation.