58-year-old male presented to our clinic for evaluation of an iris lesion, identified after his wife noticed an irregular pupil in the left eye. He had no history of ocular surgery or trauma. His last eye exam, performed elsewhere, occurred at least 10 years prior. Despite the otherwise unremarkable history, he did, however, report a long history of iris heterochromia. 

Upon examination, his visual acuity was 20/15 bilaterally without correction. Intraocular pressure was 20mm Hg OD and 16mm Hg OS. Pupillary, motility and confrontation visual field testing were all within normal limits bilaterally. Slit lamp examination revealed clear corneas and normal anterior chambers. The right iris had a yellowish coloration superonasally near the pupil. Additionally scattered throughout the iris were yellowish “fleshy” spots that likely represent a variant of normal anatomy. There were some prominent and dilated normal iris stromal vessels. The left iris had even more prominent stromal vessels. There was a yellowish nodule at 12 o’clock on the pupillary margin. 

Click image to enlarge.

Inferiorly, there was marked ectropion uvea. At 6 to 7 o’clock, there was an amelanotic nodule with central excavation. No frank neovascularization was noted, though there was some increased vascularity nasal to the lesion. Gonioscopy revealed an open angle ciliary body 360 degrees in both eyes. There were no peripheral anterior synechiae, nor a neovascularization of the angle, noted. 

Dilated fundus examination showed healthy optic nerves bilaterally with 0.1 cup-to-disc ratios. The retinal vasculature and periphery were normal, including no ciliary body or pars plana masses on the scleral indentation exam. 

An ultrasound was obtained, which revealed a cystic-looking irregular structure from 5 to 7 o’clock on the inferior left iris. There was no evidence of ciliary body or posterior masses by ultrasound. A diagnosis was made of congenital iris lesion vs. occult trauma. The lesion was photodocumented and will be followed in six months for change.