Commentary: Iris nodules in infants and children- A challenging dilemma.

We commend the authors for an excellent descriptive article of a diagnostic dilemma of iris nodules in a child.[1] The anterior segment examination showed deep corneal vascularization, mutton fat keratic precipitates, anterior chamber reaction, Busacca nodules, and rubeosis iridis with festooned pupil. Vitreous echoes suggest a granulomatous panuveitis. Positive Mantoux with QuantiFERON Gold TB test with changes in high-resolution computed tomography of the chest coupled with a positive polymerase chain reaction testing for mannose binding protein-64 (MPB64) genome suggest a diagnosis of tuberculosis in the child. Gupta et al.[2] have proposed a classification of intraocular tuberculosis and this patient would fall into a category of confirmed intraocular tuberculosis. Mantoux and QuantiFERON quantifications would add value to the article. Testing or knowing the HIV status is preferable before starting the systemic steroids. The fact that the child responded well to antituberculous treatment with systemic steroids augments the diagnosis. We presume that topical steroids were continued as well along with the systemic medication which led to a better outcome.

Infants and children may present with features of chronic uveitis with band keratopathy which is often unilateral. This may lead the clinician to a diagnosis of juvenile idiopathic arthritis. This may prompt the ophthalmologists to start the child on steroids as was done by the initial ophthalmologist by giving sub-Tenon injection. A thorough work up is necessary before initiating the treatment. Possible considerations for iris nodules would be juvenile xanthogranuloma (JXG) and malignancies like retinoblastoma, medulloepithelioma, and leukemia, trauma, trematode granulomas, and blood dyscrasias.

JXG is a rare benign non-Langerhans' histiocytic skin disorder mainly seen during infancy and childhood. This case of a six year old child is on the upper limit for JXG presentation.[1]

Ocular manifestations of JXG are seen in less than 1% of the cases, where in secondary glaucoma can result in severe and blinding eye disease.[3] While the majority of the cases present as a solitary cutaneous nodular lesion, eye is the most frequent extracutaneous site of JXG and iris is the most commonly affected.[4]

Most often than not when iris nodules seen in primary or secondary eye care setting, they may be started on topical steroid therapy. If this is found ineffective, the patients may be referred to a higher center. Systemic examination for cutaneous lesions may not always be present. Masquerades also need to be kept in line of thinking to consider possible cytological examination with needle aspiration biopsy. History of bathing in the pond in the rural sitting will give us a clue to suspect trematode granuloma in case of anterior uveitis with iris granuloma in a child and aspiration with HPE of the nodule will help us to confirm the diagnosis.[5]