A floating ball inside the eye in smartphone slit-lamp imaging: A case report of a pediatric vitreous cyst and a literature review

Abstract

An 8-year-old male patient was presented with a chief complaint of visual perception of a spherical object located in the visual field of his right eye. According to the patient’s prior medical records, they exhibited a sole incident of minor visual impairment in the right eye, characterized by blurred vision (best-corrected visual acuity: 8/10), which first manifested during preschool assessments at the age of 5 years. During the fundoscopic examination of the patient, a pigmented, lobulated, and mobile vitreous cyst was observed in the right eye, whereas the examination of the patient’s left eye revealed no abnormalities. A video of a smartphone slit-lamp imaging was also captured to facilitate subsequent examinations and patient follow-up.

Introduction

Vitreous cysts are infrequent ocular observations, ¹ exhibiting diverse spherical, oval, and lobulated configurations in individuals ranging from 5 to 68 years of age. ² The cysts often exhibit unilateral presentation, lack pigmentation, and have limited mobility as they adhere to the optic disk’s surface. However, there have been documented instances of bilateral occurrence, particularly in cases of retinitis pigmentosa.^1,3 In the majority of instances, individuals exhibit no symptoms and do not require any clinical intervention, unless they begin to cause visual disturbances such as impaired vision or the presence of floaters in the visual field. ⁴ Treatment options for patients experiencing these symptoms include argon or Neodymium-Yttrium Aluminum Garnet (Nd:YAG) laser photocystotomy or pars plana vitrectomy. ⁵ Pigmented cysts can be classified as either congenital or acquired in nature. If present from birth, these structures represent remnants of the hyaloid artery system, specifically the Bergmeister’s papilla and Mittendorf dot. ⁶ The etiology of acquired ones is believed to be associated with various factors, including trauma, inflammatory disorders such as toxoplasmosis, degenerative diseases of the retina, or a potential complication of retinal detachment procedures. ⁷ Previous studies have shown the presence of vitreous cysts in pediatric patients, and it has been discovered that this condition is often associated with a notable level of amblyopia. ⁸ In this article, the ophthalmic characteristics of a pigmented, lobulated, and freely floating vitreous cyst in a boy with mild amblyopia are described, and smartphone slit-lamp imaging is introduced as a noninvasive and suitable method for patient documentation and subsequent patient follow-up.

Case presentation

An 8-year-old male patient in a healthy state presented at Farabi Eye Hospital with the primary concern of perceiving a floating object within his right eye. At the age of 5 years, during preschool assessments conducted at a different location, he received a diagnosis of non-progressive, mild amblyopia. The patient did not experience any noticeable impairment to his vision until a period of 6 months before the present. After that time, the patient experienced an abrupt manifestation of floaters in his right eye. The patient characterizes his floaters as a spherical object exhibiting unguided motion inside his field of vision. There is no documented evidence of any previous trauma to the eyes, and no signs of intraocular inflammation were observed. Furthermore, it should be noted that the individual in question has not previously undergone any ophthalmic surgical interventions or procedures. The patient’s best-corrected visual acuity in the right and left eyes was recorded as 8/10 and 10/10, respectively. The refractive error of the right eye was measured to be +0.25, whereas the left eye exhibited a refractive error of +0.50. The slit-lamp examination did not detect any cataracts, and the evaluations of the anterior segment of both eyes were unremarkable. The fundus examination revealed the presence of a pigmented, lobulated, and mobile cystic structure with an uneven surface in the right eye (Figure 1(a–d)). Furthermore, there were no indications of bleeding, prepapillary atrophy, or posterior vitreous detachment observed during the examination of both eyes. The patient’s fundus examination was also performed with a 90° lens, and no prominent peripheral lesion such as lattice degeneration was found on the peripheral retinal exam. The cyst exhibits movement in response to the patient’s sustained gaze. The cyst exhibited a diameter of around 3 by 3 mm. The presence of a black dot on its surface, as depicted in Figure 1(a), indicated the location of its previous attachment site. The sudden appearance of this floater can be attributed to the dissociation of the cyst from an intraocular structure and its subsequent displacement into the vitreous cavity. No significant findings were observed in the other clinical or laboratory assessments. The diagnostic procedures employed in this study encompassed a comprehensive blood analysis, specifically the complete blood count and erythrocyte sedimentation rate, and additionally, serological testing and stool exams were conducted to definitively rule out the potential infection of Toxoplasma gondii, Toxocara canis, cysticercosis, and echinococcus which can cause similar conditions to vitreous cysts. The ultimate diagnosis indicated a primary (idiopathic) pigmented vitreous cyst. Based on the patient’s favorable visual acuity, it was recommended that periodic observation be conducted. A video of smartphone slit-lamp imaging is included in the supplementary material section (smartphone slit-lamp video is available in Supplementary Material 1).

Figure 1.

A dilated fundus examination revealed a pigmented (a), lobulated (b), and freely floating vitreous cyst which moved when the patient kept staring (c and d). Notice the dark dot which is obvious in Figures (a) and (c). This probably represents the former attachment of the vitreous cyst.

In the 1-year follow-up, complete ophthalmological examinations and imaging such as infrared (IR) and anterior segment optical coherence tomography (Figure 2), IR video (IR video is available in Supplemental Material 2), and B-scan (B-scan video is available in Supplemental Material 3) were performed, and the size of the lesion was reported to be the same (3 × 3 mm). Therefore, it was recommended to follow up again in the next year to check the size of the lesion, the patient’s subjective symptoms, and the need to change the treatment plan.

Figure 2.

Anterior segment optical coherence tomography of the patient in a 1-year follow-up, which shows the vitreous cyst of the right eye with the exact size (a), the infrared image in a 1-year follow-up of the right eye showing the same findings (b).

Discussion

Vitreous cysts, whether acquired or congenital, are infrequently encountered occurrences that may exhibit an absence of symptoms in certain instances. ⁹ Our patient did not mention any history of trauma or systemic disease, so the congenital background of the vitreous cyst was considered and the most probable origin of our patient’s vitreous cyst is the remnants of the hyaloid artery system. On the other hand, the cyst was floating in the vitreous of the patient, and it was not connected to a specific point. It was located outside the patient’s visual center, so it did not cause severe amblyopia for the patient. The sudden and acute onset of this type of floater, similar to our patient’s complaint, is unique, although other patients have reported seeing an object like a round ball in the visual field, and the definitive diagnosis of a vitreous cyst.^10–12

The recommended interventions for these instances encompass photocystotomy employing argon or Nd:YAG laser for cysts measuring between 3 and 4 mm in diameter, and cyst drainage through surgical techniques such as pars plana vitrectomy for larger cysts. ¹³ Not all vitreous cysts necessitate intervention, and in cases where there are few clinical manifestations, a watchful approach may be appropriate. However, if the patient experiences bothersome symptoms such as floaters, therapy becomes important.

An essential aspect concerning this patient entails conducting smartphone slit-lamp imaging to properly record and document the patient’s examination. Given the widespread accessibility of this methodology, it holds significant potential in supporting telemedicine by facilitating the documentation of patients’ records, enabling more comprehensive monitoring, and facilitating consultations with specialized facilities located at considerable distances. Based on the available evidence, this study represents the initial instance of utilizing smartphone slit-lamp imaging in a patient diagnosed with a vitreous cyst.

PubMed and Google Scholar searches were performed with the keyword “Vitreous Cyst” and all cases under 18 years of age were added as “pediatric vitreous cyst” in Table 1. The purpose of the literature review was to investigate the manifestations of vitreous cysts in people under 18 years of age and to evaluate the treatment plan considered for these patients, in which most observation was used for these patients. However, in one case, a pars plana vitrectomy was performed for a 15-year-old girl. ¹⁴

Table 1.

Literature review of pediatrics vitreous cysts (under 18 years old patients).

Author/year	Gender/age (years)	Best-corrected visual acuity	Size	Treatment	Description
Tansley a /1899	Male/17	20/70	1-disc diameter	Observation	The presence of the pigment upon its capsule indicates an inflammatory process in the past.
Scarlett b /1929	Female/8	6/30	3/2-disc diameter	Observation	Because of the pigment spots, a diagnosis of a congenital uveal cyst was made.
Steinmetz et al. c /1990	Female/10	20/40	2 × 2 × 4 mm	Observation	Its surface was a speckled brown, and internally it was optically clear and a bilobed posterior vitreous cyst was noted.
	Female/14	20/20	3 × 3 × 5 mm	Observation	It had thin and translucent walls and appeared brown and was optically clear with direct illumination.
Flynn and Carlson d /1994	Female/13	15/20	1.9 mm diameter	Observation	A vertical transverse B-scan echogram at the equator shows the cyst in the vitreous cavity.
Bianchi et al. e /1997	Male/6	20/20	2.5 mm diameter	Observation	Its movements occasionally affected the visual axis, causing only transient and sporadic blurring of vision.
Chang and Brosnahan f /2003	Female/15 months	–	3-disc diameter	Just lensectomy for cataract	Left intermittent exotropia and cataracts were present. B-scan echogram showing cystic lesion at the posterior pole.
Taranath and Flaherity g /2007	Female/6	2/60	–	Observation	Brown-pigmented, semitranslucent cyst in the anterior vitreous. A history of bilateral cryotherapy for horseshoe retinal tears at 16 months.
Lally et al. h /2008	Male/8	20/20	4 mm diameter	Observation	Ultrasonography confirmed a cystic vitreous mass.
Missotten and Van Calster i /2011	Female/11	20/20	2.8 mm diameter	Observation	The cyst was pigmented and at some places translucent. It made frequent movements, sometimes occluding the visual axis.
Brue et al. j /2012	Male/14	20/40	2.6 mm maximal diameter	Observation	History of receiving a knock on the left side of his head a few days before the visual discomfort.
Moreno-Arrones and Jiménez-Parras k /2012	Male/12	9/10	3.2 × 4.3 mm	Observation	Magnetic resonance showed a low intense image in T1, and a B-scan ultrasound confirmed a hypoechogenic cyst.
Rathore et al. l /2014	Female/9	1/60	2 × 1.5 mm in both eyes	Observation	Posterior embryotoxon was present in both eyes. A spherical, translucent, smooth cyst covered with a brown pigment was noted in the posterior vitreous, in both eyes.
Štěpánková et al. m /2017	Female/3	20/20	⩽0.4 mm (each cyst)	Observation	Five spherical, translucent, but slightly pigmented cysts on the right eye and four similar ones on the left.
Majumder et al. n /2017	Female/10	6/9	4 mm in diameter	Observation	Free-floating pigmented cyst in vitreous.
Salman o /2017	Male/12	20/35	3/2-disc diameter	Observation	A hyperechogenic spherical body floating in the middle of the vitreous
Robben et al. p /2020	Female/15	20/60	4.1 mm in diameter	Pars plana vitrectomy	Oval, pigmented, translucent cyst with no apparent attachments. The B-scan showed a hyperechogenic, spherical cyst.
	Male/15 months	20/120 (at 3 years old)	2/3-disc diameter	Observation	Round, whitish, vascularized prepapillary structure without transillumination with an attachment to the optic nerve.
Zheng et al. q /2023	Male/6	20/40	–	Observation	Pigmented epithelium cyst

^aTansley ¹⁵ .

^bScarlett ¹⁶ .

^cSteinmetz et al. ¹⁷

^dFlynn and Carlson ¹⁸ .

^eBianchi et al. ¹⁹

^fChang and Brosnahan. ²⁰

^gTaranath and Flaherity. ²¹

^hLally et al. ²²

ⁱMissotten and Van Calster. ²³

^jBrue et al. ²⁴

^kMoreno-Arrones and Jiménez-Parras. ²⁵

^lRathore et al. ²⁶

^mŠtěpánková et al. ²⁷

ⁿMajumder et al. ²⁸

^oSalman. ⁸

^pRobben et al. ¹⁴

^qZheng et al. ²⁹

Since the initial publication in 1899 by Dr. Tansley at the American Academy of Ophthalmology, ¹⁵ the primary objective has been to ascertain the source of vitreous cysts. The etiology of vitreous cysts has been the subject of numerous hypotheses, as indicated by the clinical and pathological investigations conducted on these cysts. Based on the presence of melanosomes in pigmented cells, two potential sources can be identified: the ciliary pigment epithelium and the retinal pigment epithelial (RPE) layer. ³⁰ The electron microscope observations occasionally provide insights into the source of the cyst from the ciliary epithelium. However, in certain instances, the identification of lattice degeneration during funduscopic examination implies that the RPE is the origin of the cyst.^5,30 In this particular instance, the precise etiology of the cyst cannot be definitively ascertained due to the inherent limitations in studying the pathology and the absence of notable abnormalities in the routine examination.

As evident from the literature review table (Table 1), observation emerges as the prevailing therapy modality for individuals with similar characteristics to our case. One noteworthy aspect of our case is that, in contrast to numerous other cases, the cyst’s location was likely beyond the patient’s visual axis and had been detached from its point of attachment approximately 6 months prior. Consequently, it did not induce significant amblyopia.

It appears that the specific clinical conditions of the patient should be taken into account when deciding on the course of treatment for each patient, whether surgery or observation. If there is a risk of severe amblyopia, annoying symptoms, and the large size of the cyst, a surgical approach is a suitable option. Otherwise, observation will be suitable.

Determining the nature and origin of vitreous cysts was one of the limitations of our study. The reasons were the lack of surgery and access to its pathology and the lack of consent of the patient’s parents to the examination under general anesthesia. On the other hand, the patient did not cooperate to perform ultrasound biomicroscopy. Therefore, the authors could not present definite hypotheses to determine the origin of vitreous cysts.

Conclusion

Pediatrics vitreous cysts are infrequent visual conditions within the field of ophthalmology that have been the subject of discussion for a century. Important care in children is to evaluate the possibility of amblyopia and to intervene at the right time. Smartphone slit-lamp imaging is a very simple and accessible method for the evaluation and follow-up of these patients, especially children, considering their non-cooperation for examination. However, the optimal approach for treating these ocular anomalies remains a topic of debate.