ABSTRACT
Bilateral acute depigmentation of the iris (BADI) and bilateral acute iris transillumination (BAIT) are relatively new clinical entities characterized by acute pigment dispersion from the iris stroma or iris pigment epithelium, respectively. While BADI presents with diffuse or geographic areas of iris stromal depigmentation without transillumination, BAIT cases typically develop diffuse iris transillumination and mydriatic atonic pupils. Prolonged pigment dispersion and ocular hypertension are more common in BAIT. Although the exact etiopathogenesis is still unknown, moxifloxacin toxicity appears to be a probable/likely cause. The underlying cause of BADI or BAIT in patients who were not exposed to fluoroquinolone antibiotics remains unexplained. Systemic viral infections, including coronavirus disease 2019, may be the triggering event in several cases.
Keywords:
Bilateral acute depigmentation of the iris, bilateral acute iris transillumination, ocular hypertension, moxifloxacin, pigment dispersion
Introduction
Bilateral acute depigmentation of the iris (BADI) and bilateral acute iris transillumination (BAIT) are peculiar pigment dispersion syndromes first described in the early 2000s.1,2 While these two entities have distinct clinical phenotypes and disease course, they may belong to the same spectrum, although the etiopathogenesis remains unclear.
Conclusion
Although BADI and BAIT have the common feature of sudden-onset symptomatic pigment dispersion in both eyes, iris stromal depigmentation with a benign course is seen in BADI, whereas BAIT is characterized by iris pigment epithelial depigmentation and has a more protracted course with persistent mydriasis and potentially severe OHT. There are recent reports of atypical unilateral cases as well as reports of both phenotypes being found in the same eye or both eyes of the same patient. Oral moxifloxacin intake has been held responsible for several cases of BAIT, and there are recent reports of unilateral BAIT-like syndrome after intracameral moxifloxacin injection. Yet there are still reports of patients without any history of antibiotic treatment, including those who developed BADI or BAIT following COVID-19 infection. An increased awareness of the presentation patterns of BADI and BAIT will ensure timely diagnosis and avoid unnecessary investigations. Ophthalmologists should remain vigilant when history-taking to avoid missing a history of past or present systemic illness and medication use which might be the trigger of acute pigment dispersion. Fluoroquinolone antibiotics should be avoided in patients with a history of BADI or BAIT, as a rechallenge may potentially exacerbate pigment dispersion.
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