Surgical management of post-traumatic iris cyst: A case report

Abstract

Introduction and importance

Cysts of the iridociliary complex could be primary or secondary. Small and asymptomatic iris cysts can be monitored, whereas larger cysts require treatment as they can cause severe complications. Treatment modalities can range from minimally invasive techniques to aggressive surgical procedures.

Case presentation

We report the case of an 11-year-old child who applied to our department with blurred vision. The anterior segment examination of the right eye revealed an oval, light brown, semi translucid cyst, located in the iris extending to corneal endothelium. The iris cyst was managed surgically. A pigment magma on the anterior surface of the lens was observed and was respected in order not to induce a cataract. Surgical treatment consisted of total removal of the external cyst layer.

Clinical discussion

There are numerous different methods for treating iris cysts. The main goal of treatment is to be as little intrusive as possible. Cysts that are small, stable, and asymptomatic can be observed. To avoid major issues, larger cysts may need to be treated. When less intrusive treatments have failed, surgery is always the final option. In our case, the post-traumatic iris cyst was immediately treated surgically by aspiration followed by excision of its wall, because of the significant visual disturbance, the age of the patient, and the corneal endothelial touch.

Conclusion

Surgical intervention remains the last option, especially when less invasive options did not reveal to be successful due to the extensive nature of the lesion.

Highlights

• •Describe our team's experience in front of a secondary iris cyst in a child
• •Detail the surgical management of an iris cyst, step by step
• •Report the therapeutic options described in literature in the management of iris cysts and its different incomes

1. Introduction

Cysts of the iridociliary complex could be primary or secondary, and their appearance may occasionally mimic a pigmented tumor. Secondary iridociliary cysts are usually secondary to trauma or anterior segment surgery. Traumatic iris cysts can be divided into two types: solid-looking cysts with stratified or cubical epithelium that aligns with the cyst wall and serous cysts. Small and asymptomatic iris cysts can be monitored, whereas larger cysts require treatment as they can cause pupillary block, secondary glaucoma, uveitis, cataract, and corneal decompensation.

Treatment modalities can range from minimally invasive techniques such as aspiration and laser therapy, to aggressive surgical procedures [1].

High-frequency ultrasound biomicroscopy (UBM) clarifies the diagnosis and guides therapy [2].

We report a case of an 11-year-old patient with a traumatic iris cyst treated with surgical excision.

This case report has been reported in line with the SCARE Criteria [3].

2. Presentation of a case

We report a case of an 11-year-old boy with a history of a minor right ocular blunt trauma, who consulted us for visual blur associated with irritative signs of the right eye evolving for 1 month. The ophthalmological examination revealed in the right eye a visual acuity limited to a luminous perception, a large multilobed brown iridal cyst from 3 o'clock to 7 o'clock position with an inferonasal base occupying 2/3 of the anterior chamber with minimal corneal contact and obscuring the visual axis (Fig. 1). In the left eye, the best corrected visual acuity (BCVA) was 20/20 with an unremarkable anterior segment examination. The intraocular pressure was normal in both eyes.

Fig. 1.

Anterior segment photo showing clear pigmented iris cyst in front view.

Ultrasound of the posterior pole of the right eye did not show any abnormalities. Optical coherence tomography of the anterior segment (SA-OCT) confirmed the contact of the outer layer with the corneal endothelium (Fig. 2) but did not allow the evaluation of the pigment epithelium or the ciliary body. An UBM revealed acoustically empty contents confirming the benign nature of the cyst (Fig. 3). The patient was managed surgically. The surgical technique consisted, under general anesthesia, of two corneal incisions calibrated at 2.2 mm and located at 12 o'clock (Fig. 4A) and 14 o'clock (Fig. 4B) positions, intracameral injection of viscoelastic, the release of the iris cyst from the posterior aspect of the cornea using a capsulorhexis forceps, puncture of the cyst and its dissection using Vannas capsulotomy scissors (Fig. 5A) and removal of the cyst wall (Fig. 5B) which was sent for anatomopathological examination. A pigment magma on the anterior surface of the lens was observed and was respected in order not to induce a cataract. At the end of the procedure, a viscoelastic washout and an anterior chamber air injection were performed (Fig. 6). The corneal incisions were closed by stromal hydration and by 2 corneal stitches with 10/0 monofilament.

Fig. 2.

Anterior segment optical coherence tomography (SA-OCT) showing the contact of the iris cyst with the corneal endothelium.

Fig. 3.

Ultrasound biomicroscopy of the iris cyst. The cyst wall is hyperechoic while the interior is hypoechoic.

Fig. 4.

A: corneal incision calibrated at 2.2 mm located at 12 o'clock position.

B: corneal incision calibrated at 2.2 mm located at 14 o'clock position.

Fig. 5.

A Release of the iris cyst from the posterior aspect of the cornea.

B Dissection of the cyst using a Vannas capsulotomy scissors.

Fig. 6.

Viscoelastic washout and anterior chamber air injection. The corneal incisions were closed by hydrosuture and by 2 corneal stitches with 10/0 monofilament.

Histopathological examination revealed the aspect of a pigmented posterior epithelial iris cyst in its peripheral variant (Fig. 7). The postoperative course was unremarkable, and there was no sign of inflammation. The 6-month follow up revealed a 20/20 visual acuity and no signs of a recurrence, glaucoma, or inflammation (Fig. 8).

Fig. 7.

Histological slide of the iris pigment epithelium cyst, peripheral type: Low-power magnification showing a cystic lesion (blue line); at high-power magnification, the cyst is lined by cuboidal cells (arrows) that contain little to no pigment: hematoxylin and eosin stain.

Fig. 8.

Anterior segment photo 3 months after the iris cyst excision showing no signs of inflammation.

This case report has been reported in line with the SCARE Criteria [3].

3. Discussion

Cysts of the iridociliary complex are rare in children. They can be primary or secondary, congenital, or acquired, pigmented or non-pigmented and their appearance can mimic a pigmented tumor [1].

Secondary cysts can be classified into implantation cysts, drug-induced cysts [4], uveitic cysts, tumoral cysts, or cysts in association systemic disorders, based on their pathogenic mechanism [5].

Implantation cysts are the most frequent type. They result from the inclusion of epithelial, corneal, or conjunctival cells in the anterior chamber, either during a surgical procedure or during a traumatic corneoscleral perforation [6].

The ability of epithelial cells to multiply is high. They start to grow and cover the intraocular structures as soon as they come to a source of nourishment. A perfect framework for proliferation can be found in the iris due its rich vascularization.

Because of their tendency to spread and invade ocular structures, secondary cysts can be responsible for a variety of complications, ranging from iritis/uveitis to visual axis obstruction, secondary glaucoma, intraocular lens subluxation, or complicated cataract.

UBM continues to be the gold standard in the diagnosis of iris cyst [7]. It enables the identification of the internal echogenicity and thin ultrastructure of the cyst. UBM is more effective than conventional ultrasound B scan (USB) in the detection of small cysts, and in the specification of anatomical relationship with other organs (cornea, lens).

The choice of treatment for iris cyst depends on the age of the patient, the size of the cyst, its location, its extent, and whether it is recurrent or nor [8].

There are numerous different methods for treating iris cysts. The main goal of treatment is to be as little intrusive as possible [5]. Cysts that are small, stable, and asymptomatic can be observed. To avoid major issues including pupillary obstruction, secondary glaucoma, iridocyclitis, corneal decompensation, loss of vision, and excruciating pain, larger cysts may need to be treated [9].

Methods of treatment include fine-needle aspiration, intracystic injection of absolute alcohol, [10] intracystic administration of mitomycin C, Nd:YAG (neodymium-doped yttrium aluminium garnet) laser iridocystotomy, a cyst aspiration followed by laser photocoagulation of the cyst wall, argon laser photocoagulation and Nd: YAG laser cystotomy, or bloc resection of the cyst and surrounding tissue [5].

When less intrusive treatments have failed or are unlikely to be effective due to the extent or form of the lesion, or in cases of malignant or potentially malignant lesions, surgery is always the final option. [11] Sector iridectomy, iridectomy with corneal curettage, excision plus posterior corneal lamellar resection, iridectomy plus cryotherapy, iridocyclectomy, and penetrating keratoplasty combined with iridocyclectomy are a few examples of surgical excision procedures.

Important vision impairments, a cyst's size increasing significantly over a short period of time, recurrent iridocyclitis, secondary glaucoma, or corneal endothelial are all indications for surgical therapy [12].

In our case, the post-traumatic iris cyst was immediately treated surgically by aspiration followed by excision of its wall, because of the significant visual disturbance, the age of the patient, and the corneal endothelial touch by the cyst visualized by the UBM. The pigment magma on the anterior surface of the lens observed during surgery was respected in order not to induce a cataract.

4. Conclusion

Iris cysts are a rare condition that can be acquired or congenital. Implantation cysts are the most common type. UBM continues to be the gold standard in the diagnosis of iris cyst. Regarding the management of iris cysts, there are numerous different strategies. The main rule for treating iris cysts is to be as minimally invasive as possible. When less intrusive treatment alternatives have failed or are unlikely to be effective, surgery is always the last choice.

Consent

Written informed consent was obtained from the patient's parents/legal guardian for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

State

The work has been reported in line with the SCARE 2020 criteria [3].

Ethical approval

Ethical approval was provided/waived by the authors institution.

Funding

N/A.

Guarantor

Atf Ben Abderrazek atf.benabderrazek@gmail.com.

Research registration number

N/A.

CRediT authorship contribution statement

• Ahmed Mahjoub: Reviewing

• Nadia Ben Abdesslem: Reviewing

• Arij Jouini: Management of case and supervision

• Atf Ben Abderrazek: Writing original draft and data collection

• Mohamed Ghorbel: Revision of article and final approval of the version to be submitted

• Hachemi Mahjoub: Revision of article and final approval of the version to be submitted.

Conflicts of interest

N/A.