Bilateral severe iatrogenic pigmentary glaucoma following laser treatment for cosmetic iris color change

PURPOSE: We report a case of bilateral severe pigmentary glaucoma and paracentral acute middle maculopathy (PAMM) following laser treatment for iris color change. OBSERVATIONS: A 32-year-old female presented to our emergency clinic after having undergone 4 sessions of bilateral cosmetic iris laser treatment in Turkey to lighten the color of her dark brown irides. Visual acuity was 20/150 in the right eye (OD) and counting fingers in the left eye (OS) at presentation. Intraocular pressures (IOP) were 50 mmHg in the right eye and 42 mmHg in the left eye, with 4+ free-floating pigmented cells in the anterior chamber. The fundus exam revealed cup-to-disc ratios of 0.5 in the right eye and 0.35 in the left eye and scattered intraretinal hemorrhages in both eyes. The diagnoses of bilateral severe iatrogenic pigmentary glaucoma and PAMM were established. Urgent bilateral fornix-based trabeculectomies with mitomycin C (MMC) 0.05% were performed with an attempt to wash out as much pigment from the anterior chamber as possible. Post-operatively, despite well-controlled IOP and cessation of all glaucoma medications, the patient remains with visual field defects and significant glare. CONCLUSIONS AND IMPORTANCE: Photoablative iridoplasty is rarely encountered as a cause of iatrogenic pigmentary glaucoma in North American due to strict regulations against this procedure. However, physicians must be aware of its devastating and life-changing visual sequelae and elicit a careful history in patients with a similar presentation. Our patient demonstrated acute, severe glaucomatous damage from pigmentary dispersion along with PAMM, a newly described complication of this procedure. We strongly advise against this medically unnecessary practice.