A 68-year-old female patient was referred to our ophthalmic outpatient department complaining of a burning, itching, and reddened right eye with sticky eyelids in the morning, associated with a visual deterioration for approximately five days. She stated that she had no other symptoms aside from the eye. The day before the onset of the symptoms, she had received her first intravenous infusion of zoledronic acid for the treatment of osteoporosis. The patient had annual ophthalmic follow-ups but had no notable ophthalmic history and had never had these symptoms before. She also reported that there was no inflammation, headache, fever, or surgery in the past and did not suffer from any rheumatologic conditions. She denied taking any further concomitant drugs, except for a supplement of Calcium and Cholecalciferol. She had ovarian cancer one year ago, which was treated with neoadjuvant chemotherapy and surgery.
At her initial consultation (day-0), her best-corrected visual acuity (BCVA) was 6/24 and 6/6 (Snellen) to her right and left eye, respectively. Intraocular pressure was 11 mmHg in the right and 17 mmHg in the left eye. Slit-lamp examination of her right eye revealed hyperemia of the conjunctiva and chemosis (Fig. 1A). The cornea showed Descemet's folds (Fig. 1B, yellow arrow) and fine corneal precipitates inferiorly. The anterior chamber was deep and showed fibrinous strands with coagulated blood (Fig. 1A), a positive Tyndall effect, and cell grade of 2+ (according to the SUN working group anatomic classification of uveitis6). The pupil was distorted due to an onset of circular posterior synechiae (Fig. 1A and 1B) and circular hyperemic iris vessels were noticeable (Fig. 1D, white arrow). As expected, taking the age of the patient into account, the lens had a slight opacification. Due to the severity of the anterior chamber findings, detailed fundoscopy was not possible. Ultrasonographic examination (A-scan and B-scan) of the eye revealed no involvement of the vitreous body (Fig. 1C and 1E). No relative afferent pupillary defect (RAPD) was seen. Spectral-domain optic coherence tomography (SD-OCT) examination of the right eye excluded intra- and subretinal fluid. The examination of the left eye showed no pathologic changes, especially no signs of uveitis.
We immediately suspected acute zoledronic acid associated unilateral anterior uveitis and local therapy to the right eye was started with prednisolone 1.0 % (Pred Forte® gtt opht 1 % 5 ml, Allergan AG) eye drops hourly, prednisolone eye ointment (Ultracortenol® eye ointment. AGEPHA PHARMA s.r.o.) at night, and scopolamine 0.25 % (SCOPOLAMINE Dispersa® Gtt Opht 0.25 %, Omnivision AG) eye drops twice daily. A complete synechiolysis with tropicamide 0.5 % (Mydriaticum Dispersa Gtt Opth 0.5 %, OmniVision AG, Puchheim, Germany) and phenylephrine 5.0 % (Neosynephrin-POS 5.0 % Gtt Opth, Ursapharm GmbH, Saarbrücken, Germany) was not possible.
At the follow-up visit the next day (day-1), the patient already reported an improvement of the pain and redness and she confirmed she had used the therapy as prescribed. Clinical examination showed no significant changes in the findings at this time and the BCVA remained 6/24 in the right eye, therefore Dexamethasone (MEPHAMESON® injection solution 4 mg/ml, Mepha Pharma AG) was injected subconjunctivally. The existing topical therapy was continued. Tropicamide (0.5 %) and phenylephrine (5.0 %) eye drops were applied at 10-minute intervals for a total of 30 minutes to initiate resolution of the posterior synechiae.
The following day (day-2) showed further subjective improvement. The patient reported no more pain. The BCVA improved to 6/19 in the affected eye. Clinically, there was a mild decrease of the fibrinous structure and coagulated blood, and the posterior synechiae had greatly improved. Dexamethasone was again injected subconjunctivally.
On day-5, BCVA was already 6/12 in the right eye. The fibrin in the anterior chamber had completely regressed (Fig. 2B) and the cell grade had decreased to 1+. We also noted a decrease in conjunctival hyperemia (Fig. 2A). Based on the significant improvement of the findings, Scopolamine (0.25 %) was stopped and Prednisolone (1.0 %) was reduced to five times daily.
At the follow-up on day-16, the patient reported significant subjective improvement in visual acuity. The BCVA was 6/7.5 in her right eye. The anterior chamber no longer showed signs of irritation with +0.5 pigmented cells. The fibrinous strands and coagulated blood were no longer present. At this time, topical therapy consisted of prednisolone (1.0%) three times daily and continued to be tapered weekly according to the regimen.
No retinal or vitreous involvement was identified at any time point.