A 50-Year-Old Patient's Left Eye Gradually Changes Color

Clinical Presentation

A 50-year-old man was referred for uveitis and cataract in his left eye. The patient reported slowly progressive loss of vision in that eye, with intermittent pain, photophobia, and redness that partially improved with topical steroids and cycloplegic drops. Family members noted that over the past 2 months, his normally amber-colored left eye turned darker and more brownish. Routine vision testing conducted to renew his driver's license 1 year ago documented 20/20 acuity in both eyes without correction.

The patient was a construction worker, during which he used high-powered tools (eg, nail gun) but often did not use protective eyewear; as a result, his ocular history was significant for prior corneal abrasions and superficial foreign bodies in both eyes. He recalled experiencing an eye injury a few months ago, but was unsure which eye was involved. His medical history was significant for chronic back pain due to an injury incurred by falling from a ladder at work, for which he frequently used oral nonsteroidal anti-inflammatory drugs.

The family history was unremarkable. The social history included smoking two packs of cigarettes daily for 20 years. Review of systems was negative for rashes, fevers, infections, anhidrosis, tuberculosis exposure, toxic medications, foreign travel, night blindness, or tick/mosquito bites.

Visual acuity was 20/20 in the right eye and hand motion in the left eye, with no improvement on manifest refraction. Amsler grid testing and confrontational visual fields were normal in the right eye and could not be performed in the left eye. Color vision using Ishihara plates was 12/12 in the right eye and 0/12 in the left eye. Pupil examination revealed anisocoria with a briskly reactive 4-mm pupil in the right eye, and an unreactive 6-mm pupil with a reverse relative afferent pupillary defect in the left eye. Both eyelids were normal.

Anterior segment examination of the right eye was significant for a 4-mm vertically oriented corneal scar centered at the 9 o'clock position and located 4 mm from the limbus. The iris in the right eye was amber to light brown in color, with a normal anterior chamber and clear lens (Figure 1). Anterior segment examination of the left eye revealed a slight granular appearance to the corneal stroma with rare cell and +1 flare in the anterior chamber.

There was a small, barely visible, 1-mm corneal stromal scar parallel to the limbus at the 11 o'clock position. The iris in the left eye was a comparatively darker brown color, with posterior synechiae and patchy, clumpy pigmentation in a ring shape on the anterior lens capsule (Figure 2). The left lens was cataractous, with a dense nuclear and posterior subcapsular component. Intraocular pressure was 12 mm Hg in the right eye and 24 mm Hg in the left eye.

Gonioscopic examination revealed open angles in both eyes, with increased pigmentation of the trabecular meshwork in the left eye. Fundus and optic disc examination in the right eye was within normal limits. There was a poor view of the fundus in the left eye; it appeared to have pigmentary changes and a pale optic nerve.

Figure 1. Anterior segment slit-lamp photos of the right eye, with hazel to light brown iris and temporal corneal scar (arrow).

Figure 2. Anterior segment slit-lamp photos of the left eye, with darker brown iris, patchy pigment on the anterior lens capsule, dense cataract, and small corneal scar at the 11 o'clock position (arrow).

Ultrasonography of the left eye was performed, using both B scan and high-frequency ultrasound biomicroscopy (UBM). The B scan found no retinal detachment, and UBM revealed a normal ciliary body in all quadrants without angle recession or masses. There was an echo-dense opacity with surrounding debris at the pars plicata superotemporally in the left eye (Figure 3). Electroretinography (ERG) was normal in the right eye and showed flattening of both the a-wave and b-wave amplitudes in the left eye (Figure 4).

Figure 3. Ultrasound biomicroscopy of the left eye, revealing a normal ciliary body in all quadrants without tumor or anterior chamber foreign body. There was an echo-dense opacity (arrow) with surrounding debris at the pars plicata superotemporally.

Figure 4. Full-field electroretinography, which was normal in the right eye (a) and revealed a marked decrease in a- and b-wave amplitudes in the left eye (b).

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