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A clinical study of annular cyclitis.

Purpose: To investigate six cases of annular cyclitis. Methods: All patients with impairment of visual acuity underwent complete ophthalmologic examination, color fundus photography, laboratory tests and fluorescein angiography. Indocyanine green (ICG) angiography and B-scan ultrasonography were also performed in three cases in order to diagnose the disease. Results: All patients presented a unilateral or bilateral granulomatous uveitis, associated with inflammatory annular cyclitis. They had a shallow anterior chamber, a mildly elevated intraocular pressure (under 25 mm Hg) and an annular serous retinal detachment. A resolution was observed after specific therapy associated with systemic prednisolone therapy and antiglaucomatous drops. Conclusion: This is the first description of an observational study of six patients with inflammatory annular cyclitis.


Introduction
Annular cyclitis is a rare, chronic, usually bilateral uveitis, characterized by an infl ammation of the ciliary body along with a low-grade anterior chamber infl ammation and a peripheral retinal detachment, which may last for several years. It can be associated with secondary malignant glaucoma caused by the shallowing of the anterior (axial) chamber, its peripheral fl attening and the increased intraocular pressure (IOP). However, very little is known about the pathology of annular cyclitis.
In our retrospective observational study, six cases of infl ammatory cases of infl ammatory annular cyclitis are described.

Materials and methods
Six patients were referred to the Jules Gonin Eye Hospital for evaluation of impairment of visual acuity (VA). All of them underwent ophthalmologic examination, which included measurement of VA on a standard Snellen chart, tonometry, binocular ophthalmoscopy, slit lamp biomicroscopy with a contact lens, color fundus photography, fl uorescein angiography and laboratory tests. Indocyanine green (ICG) angiography and B-scan ultrasonography were also performed in three cases in order to diagnose the disease. Patients were regularly examined at 1-6-month intervals.
Characteristics and clinical fi ndings for each patient are summarized in Table 1.

Results
Eight eyes of six patients were diagnosed with infl ammatory annular cyclitis. Three (50%) were male and three were female. Their ages ranged from 37 to 64 years (mean 52.11 years). The follow-up period ranged from three to six months (mean 5.4 months). Systemic medical and laboratory work-up was performed in order to diagnose the cause of cyclitis. Chest computed tomography established the diagnosis of systemic sarcoidosis in two patients. Mantoux test was positive (skin lesion Ͼ20 mm) in one patient.
All patients received systemic corticosteroids (1 mg/kg/d) progressively tapered. We describe more extensively one illustrative case.

Discussion
Annular cyclitis is a rare disease, characterized by an infl ammation of the ciliary body and, in some cases, associated with annular chorioretinal detachment. 1 This is the fi rst description, to our knowledge, of an observational case series of six patients with infl ammatory annular cyclitis. It can be complicated with malignant-like  Ophthalmological fi ndings of annular cyclitis glaucoma mainly caused by the shallowing of the anterior chamber due to the annular chorioretinal detachment. The term malignant-like glaucoma has been proposed for cases with similar clinical presentations with the malignant glaucoma but different underlying pathophysiology and causes. In this case series all patients present a potential risk of presenting a malignant-like glaucoma. This can be caused by the shallowing of the central anterior chamber, its peripheral fl attening and the increased IOP. Also all patients were characterized by an absence of papillary block, an absence of suprachoroidal effusion or hemorrhage. The differential diagnosis of annular cyclitis includes tumors of the ciliary body (ring melanomas, cysts), infectious diseases (Lyme, toxocariasis, syphilis, tuberculosis, fungal keratomycosis, Nocardia asteroides), systemic infl ammatory diseases (sarcoidosis, Vogt-Koyanagi-Harada syndrome, rheumatic disease, infl ammatory bowel disease).
Ring melanomas can closely simulate annular cyclitis ophthalmoscopically. In A-scan sonography the malignant melanoma of the ciliary body is characterized by low to medium refl ectivity, whereas annular cyclitis combined with chorioretinal detachment manifests no internal refl ectivity. 2 After having excluded tumoral of infectious diseases, infl ammatory agents should be suspected. Therefore, high dose of steroids should be introduced in order to be treated properly and rapidly. 3