CASE REPORT

Atypical iris cyst after trauma and cataract surgery masquerading as iris tumor

Chokesuwattanaskul, Susama MD, PhD; Tansanguan, Sasiwimon MD; Tananuvat, Napaporn MD

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doi: 10.1097/j.jcro.0000000000000044
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Abstract

Iris cysts can be classified as primary or secondary. Primary iris cysts originate from the iris epithelium or stroma. Secondary iris cysts have more heterogeneous causes including posttraumatic or postsurgical, drug induced, parasitic, uveitic, or neoplasm.1 After penetrating eye injuries, stratified squamous epithelium from the conjunctiva or cornea could be implanted through the wound and proliferate on any intraocular tissue. The migrated epithelial cells might form cysts that produce secretions, most commonly serous fluid or sometimes solid content that appears as pearl cysts.2–4

Management of iris cysts ranges from simple observation to more invasive interventions including fine-needle aspiration, intracystic injection of sclerosing or antimitotic agents, laser, and surgical excision. However, a stepwise conservative approach is preferred because of the risk for complications and high recurrence.1 In this study, we report an atypical case of iris cyst, masquerading as an iris tumor, developed after open globe injury and subsequent cataract surgery.

CASE REPORT

A 22-year-old man was referred to our tertiary care for gradually blurred vision in his left eye over 1 month, with a history of repairing corneal laceration 2 years prior (Figure 1, A). Subsequently, he underwent cataract surgery with intraocular lens implantation 1 year later. The ocular findings of the affected eye included visual acuity of 6/24 and a large whitish mass involving the superior part of the iris obscuring the pupil (Figure 1, B). The intraocular pressure was 13 mm Hg, and the fundus examination was unremarkable.

Figure 1.
Figure 1.:
Clinical findings of the iris cyst. The color photographs of the left eye: (A) after the surgical repair of traumatic ruptured cornea; (B) with the presence of the whitish mass at the upper segment of the iris, obscuring the pupil. C: The anterior segment optical coherence tomography shows the iris cyst with mostly solidified contents occupying approximately one third of the anterior chamber, approaching the posterior cornea. The linear hyperreflective line at the cornea (arrow) indicates the scar from a previous lacerated wound. D: The color photograph of the left eye after the surgical removal of the cyst shows a large iris defect at the previously located lesion.

The anterior segment optical coherence tomography (AS-OCT; Casia SS-1000, Tomey Corp.) demonstrated a large solidified iris cyst occupying approximately one third of the anterior chamber, approaching the posterior cornea (Figure 1, C). Thus, diagnostic and therapeutic surgical removal was advised.

Intraoperatively, the aspiration of the contents was attempted to deflate the cyst but was unsuccessful. The stalk of the cyst was approached through a superior corneoscleral incision, and then, the cyst wall was opened to evacuate the thick whitish content. Iridectomies were performed to remove the entire lesion (Supplemental Digital Content, Video 1, available at http://links.lww.com/JC9/A348). A histopathological study of the resected tissue revealed that the iris cyst wall was lined by stratified squamous epithelium (Figure 2, A and B).

Figure 2.
Figure 2.:
Histopathological findings of the resected iris cyst: (A) the cyst wall was lined by stratified squamous epithelial cells (arrow) with the adjacent iris pigment epithelium containing melanin pigments (arrow head) (hematoxylin and eosin, ×100); (B) larger magnification (hematoxylin and eosin, ×200).

At 12-month postoperative follow-up, the corrected distance visual acuity of the affected eye was 6/12, with normal intraocular pressure and no signs of iris cyst recurrence (Figure 1, D).

DISCUSSION

Iris implantation cysts can have variable presentations. They often have a destructive nature associated with poor functional outcomes, giving the clinician both diagnostic and therapeutic challenges. In our case, although the clinical history suggested the mechanism of iris cyst as postpenetrating eye trauma/postcataract surgery, the characteristic of the cyst itself was inconclusive because of its mostly solidified content, mimicking the iris tumor.5 AS-OCT was helpful for visualizing the contour and the extension of the cyst and its relation to other structures. Surgery was unavoidable because of the proximity of the cyst to the posterior cornea and the pupil obscuration. The histopathological results confirmed the origins of the cyst as stratified squamous epithelial cell implantation. The solid content of the cyst could be attributed to the precipitates of keratin and inflammatory debris. The implanted epithelial cells were likely to have derived during the previous surgery because the stalk of the iris cyst adhered to the superior limbus where the cataract incision was located.

A posttraumatic/postsurgical iris cyst can be masqueraded as an iris tumor. Noninvasive imaging tools such as the AS-OCT are helpful for both diagnosis and management. Surgery is indicated if the vision is threatened and to provide the histopathological diagnosis. Careful and complete cyst excision is required to prevent its recurrence and minimize the complications. In addition, in a solidified iris cyst, evacuation of cyst content might be necessary.

WHAT WAS KNOWN

  • Secondary iris cyst after penetrating eye injuries, with stratified squamous epithelium from the conjunctiva or cornea, could be implanted through the wound and proliferate on any intraocular tissue.
  • A surgical removal is indicated if the vision is threatened and to provide a definite histopathological diagnosis.
  • Careful and complete cyst excision is required to prevent its recurrence and minimize the complications.

WHAT THIS PAPER ADDS

  • Secondary iris cyst, from epithelial downgrowth, which occurs after trauma and cataract surgery, can atypically has solidified contents, thus masquerading as an iris tumor.
  • Evacuation of cyst content is essential to remove the solidified iris cyst.

REFERENCES

1. Georgalas I, Petrou P, Papaconstantinou D, Brouzas D, Koutsandrea C, Kanakis M. Iris cysts: a comprehensive review on diagnosis and treatment. Surv Ophthalmol 2018;63:347–364
2. Sahu S, Puri LR, Singh SK. Intraocular eyelashes and iris cyst in anterior chamber following penetrating eye injury: a case report. Inter Med Case Rep J 2017;10:105–107
3. Philip SS, John DR, Ninan F, John SS. Surgical management of post-traumatic iris cyst. Open Ophthalmol J 2015;9:164–166
4. Venkateswaran N, Ching SS, Fischer W, Lee F, Yeaney G, Hindman HB. The diagnostic and therapeutic challenges of posttraumatic iris implantation cysts: illustrative case presentations and a review of the literature. Case Rep Ophthalmol Med 2015;2015:375947
5. Shields CL, Shields PW, Manalac J, Jumroendararasame C, Shields JA. Review of cystic and solid tumors of the iris. Oman J Ophthalmol 2013;6:159–164

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