Abstract
Primary epithelial iris cysts are benign innocuous lesions, which are mostly bilateral and asymptomatic in nature. They can lead to creeping angle closure, when the angle progressively narrows due to age-associated changes. This photoessay, herewith, signifies the dual importance of identifying minute bumpy elevations in the iris by a thorough slit lamp examination as well as the use of ultrasound biomicroscopy in patients presenting with creeping angle closure, frequently misdiagnosed in the primary angle closure disease spectrum.
Keywords: Iris cysts, open angle, pigment dispersion, ultrasound biomicroscopy
Introduction
A 45-year-old male presented with decrease in near vision. His best-corrected visual acuity was 6/6, N6 with correction. Slit lamp examination revealed multiple bumpy elevation of the peripheral iris in the nasal quadrant of the right eye and in the nasal [Figure 1] and temporal quadrants of the left eye. Rest of the ocular examination revealed no abnormal findings. In both eyes, gonioscopy revealed open angles with localized apposition between the iris and trabecular meshwork noted at the sites of bumpy elevation of the iris [Figures 2 and 3]. Trabecular meshwork pigmentation was 4+. There were broken pigments seen in the temporal angle in the right eye, signifying some degree of intermittent iridotrabecular contact in that quadrant [Figure 2].
Figure 1.
The bumpy elevation in the nasal peripheral iris of the left eye
Figure 2.
Gonioscopic image of the right eye depicting open angles with localized apposition in areas of bumpy elevation and areas of broken pigments. Yellow arrow - Bumpy elevation of iris and localized apposition. Red arrow . Area of broken pigmentation
Figure 3.
Gonioscopic image of the left eye depicting open angles and localized apposition at site of bumpy elevation
A provisional diagnosis of primary pigment epithelial cysts was made, and ultrasound biomicroscopy (UBM) was done to confirm the same. On UBM, multiple cystic spaces were seen behind the peripheral iris and in the ciliary sulcus [Figure 4]. These were seen in all the quadrants and in both eyes. All the cysts were thin walled and had no internal reflectivity with diameter varying from 2 mm to 1 cm. For academic purposes, anterior-segment optical coherence tomography (ASOCT) was done, but no pathological lesion was seen with this mode of investigation [Figure 5]. The angle anatomy, however, varied in different quadrants, with narrow angle width and convex iris configuration in some areas and normal-wide angle width with flat iris insertion in other areas. The bumpy appearance of the peripheral iris was visible with ASOCT similar to that on slit lamp; however, the anterior margin of the cysts was not discernable.
Figure 4.
Ultrasound biomicroscopy image showing the extensive multiple thin-walled, cystic lesions beneath the mid peripheral and peripheral iris causing the bumpy elevation of the iris
Figure 5.
Anterior-segment optical coherence tomography image showing the irregular angle opening in different quadrants
Discussion
The above case describes the importance of a routine slit lamp evaluation in all patients. Further, with age-related changes in the angle and lens, this patient remains more prone to develop angle closure and subsequently glaucoma. UBM permits noninvasive examination of the anterior-segment anatomy at high resolution (40 μm) by using a high-frequency transducer.[1] Kunimatsu et al. performed UBM in eyes of 116 normal subjects and detected a surprisingly high incidence of cysts at 54.3%.[2] Wang and Yao conducted UBM in 727 patients with shallow anterior chambers.[3] They detected primary iris and ciliary body cysts in 34.4% of these patients, with secondary plateau iris configuration in 38%. The cysts larger than 0.8 mm, located at iridociliary sulcus, or multiple and extensive cysts were more inclined to cause angle narrowing or closure
Even though iris cysts are pathologically insignificant, early diagnosis by UBM remains helpful in identifying patients prone to develop angle closure, particularly when they are bilateral and multiple.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
- 1.He M, Wang D, Jiang Y. Overview of ultrasound biomicroscopy. J Curr Glaucoma Pract. 2012;6:25–53. doi: 10.5005/jp-journals-10008-1105. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Kunimatsu S, Araie M, Ohara K, Hamada C. Ultrasound biomicroscopy of ciliary body cysts. Am J Ophthalmol. 1999;127:48–55. doi: 10.1016/s0002-9394(98)00308-0. [DOI] [PubMed] [Google Scholar]
- 3.Wang BH, Yao YF. Effect of primary iris and ciliary body cyst on anterior chamber angle in patients with shallow anterior chamber. J Zhejiang Univ Sci B. 2012;13:723–30. doi: 10.1631/jzus.B1200124. [DOI] [PMC free article] [PubMed] [Google Scholar]