A 71-year-old Caucasian gentleman presented with blurry vision and uncomfortable eyes. His visual acuities were 6/24 in both eyes. He complained his visual had been deteriorating a fortnight ago. He was started on travoprost 2 months ago. The treatment was added to dorzolamide to improve the intraocular pressure (IOP) control. He had bilateral glaucomatous optic neuropathy, more marked in the left eye. The IOPs were 34 mmHg in the right eye and 45 mmHg in the left when he was seen in the eye emergency clinic.
He was usually fit and well. He suffered from poor hearing since 2 years ago. He was on lisinopril for hypertension and atorvastatin. He had been taking Systane for dysfunctional tear syndrome twice to four times daily over the past 2 years. There were no other symptoms or signs to elicit.
There were mutton-fat keratic precipitates and 3+ cells in the anterior chambers with posterior synechiae. Dilated fundoscopy revealed mild vitritis but no signs of posterior uveitis. The patient was started on intense topical steroid and mydrilate. The travoprost was switched to a fixed combination of brinzolamide and timolol. Oral acetazolamide was prescribed.
The eyes were quieter after 3 days, and the IOPs were 23 mmHg in both eyes. A week later, the eyes were quiet, and there were less mutton-fat keratic precipitates. The IOPs were 12 and 14 mmHg. He was advised to stop the acetazolamide.
The inflammatory markers were normal. The haemoglobin was slightly below normal at 12.5 g/dL, however, the rest of the full blood count was normal. The results for immunological screen, inflammatory markers, syphilis, tuberculosis, toxoplasma, Lyme disease, angiotensin converting enzyme, and calcium profile were unremarkable. The chest X-ray was normal.
A month from the initial presentation, his eyes were quiet on topical steroid three times daily. The IOPs were 17 and 18 mmHg on topical brinzolamide and timolol. The possibility of the granulomatous anterior uveitis secondary to travoprost was considered. The steroid was stopped. The patient agreed to a rechallenge with travoprost in the right eye only. Both eyes were quiet in the first week; however, the right eye developed 2+ cells in the anterior chamber a fortnight later. The left eye remained quiet. Travoprost was stopped. In the subsequent visits, the uveitis resolved without any topical steroid. The patient's eyes had been quiet over the past 3 months on the fixed brinzolamide and timolol combination topical treatment.