Massive Epithelium-lined Inclusion Cysts After Scleral Buckling

doi:10.1016/S0002-9394(14)76169-0

American Journal of Ophthalmology

Volume 113, Issue 4, April 1992, Pages 439-442

https://doi.org/10.1016/S0002-9394(14)76169-0 Get rights and content

Two patients with massive epithelium-lined inclusion cysts of the orbit became symptomatic five and 16 years after scleral buckling. Each patient described diplopia and displacement of the previously treated eye. An orbitotomy in the first patient disclosed a loculated epithelium-lined inclusion cyst that extended posteriorly from the insertion of the inferior rectus muscle nearly to the apex of the orbit. In the second patient, a loculated epithelium-lined inclusion cyst extended into the superior nasal portion of the orbit from its origin near the insertions of the superior and medial recti muscles. We speculated that epithelial cells of the conjunctiva were shed at the time of scleral buckling and became lodged in the exposed sulcus created by the surgical retraction of Tenon's capsule. Here they proliferated and formed the large epithelium-lined cysts. In each patient, removal of the cyst was followed by a decrease in diplopia as the displaced globe returned toward its normal position.

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Cited by (24)

Giant conjunctival inclusion cyst mimicking an orbital tumor
2023, Journal Francais d'Ophtalmologie
Long-term results of surgical excision of conjunctival retention cyst using trypan blue with methylcellulose
2019, American Journal of Ophthalmology Case Reports
Citation Excerpt :
Secondary conjunctival cysts are usually acquired due to conjunctival inflammation such as trachoma and vernal keratoconjunctivitis6,7 or trauma. Cysts can result from conjunctival surgery8 such as for pterygium9, strabismus, scleral buckling10, and pars plana vitrectomy.11 Conjunctival inclusion cysts can be solitary as in the first and the third patient3 or multiple as in the second patient who had a bipartite cyst).
Conjunctival retention cysts may recur if not completely removed. However, the cyst wall often ruptures during surgical excision, making complete removal difficult. In order to ensure complete cyst excision, we used a method of staining the inner cyst wall using trypan blue augmented by Methyl cellulose.
Interventional study. Staining was performed by injecting trypan blue using an insulin needle. Then the needle was kept in place and methyl cellulose was injected to make the cyst content viscous to avoid its collapse after removing the needle. By using this technique, it was possible to excise the lesion as a whole. Three patients were included (unilateral). Two patients had cysts that were secondary to trachoma and were followed for up to 2 years without recurrence. A third patient had a conjunctival cyst following strabismus surgery was not successfully removed.
This method is simple and effective for complete excision of conjunctival retention cysts exception for cysts post strabismus surgery.
Removal of conjunctival cyst with high-frequency radio-wave electrosurgery
2015, Canadian Journal of Ophthalmology
Citation Excerpt :
Formation of conjunctival cysts occurs as a result of implantation of conjunctival epithelium underneath the stroma after injury or surgery.13 Their formation has been reported after various surgeries, such as enucleation,14–16 strabismus surgery,9,17,18 vitreoretinal surgery, including sclera buckling,19,20 sclera tunnel phacoemulsification,13 pterygium excision,10 and sub-Tenon’s injection.13 It is believed that conjunctival cysts can occur in the conjunctiva after the stagnation of mucus in epithelial spaces, formed by amalgamations of conjunctival folds that result from irregularly elevated surface epithelium in inflammatory conditions.10,21
To introduce a new simple surgical approach for removal of conjunctival cysts with high-frequency radio-wave electrosurgery.
Retrospective, noncomparative, interventional case series analysis.
Twenty-one eyes of 21 patients.
Symptomatic conjunctival cysts, which did not show improvement despite conventional medical management or other surgical procedures were included. The conjunctival cysts were treated using a high-frequency radio-wave electrosurgical unit (Ellman Surgitron; Ellman International Inc, Oceanside, N.Y.). The conjunctiva surrounding the conjunctival cyst was grasped and lifted up using a smooth forcep and a fine-needle electrode (Ellman Insulated Needle Electrodes D6A; Ellman International Inc) was inserted into the cyst. A power setting of 0.5 to 1 was used for coagulation of cysts, without charring the tissue.
After surgery, none of the patients had recurrence of conjunctival cysts during the follow-up period of 6 months, and symptoms also disappeared. The surgery did not exceed 5 minutes in all cases, and subconjunctival hemorrhage was observed in 1 case. Subconjunctival hemorrhage had completely resolved within 2 weeks and no other complications were observed.
A surgical approach with high-frequency radio-wave electrosurgery successfully removed conjunctival cysts and produced improvement in symptoms. High-frequency radio-wave surgical techniques might be a favourable alternative to surgical treatment of conjunctival cysts.
Présenter une nouvelle approche chirurgicale simple pour l’ablation de kystes conjonctivaux par radiochirurgie haute fréquence.
Analyse rétrospective non comparative d’une série de cas d’intervention.
21 yeux de 21 patients.
L’étude a porté sur des cas de traitement de kystes conjonctivaux avec symptômes ne présentant pas d’amélioration malgré une gestion médicale classique ou d’autres interventions chirurgicales. Les kystes ont été traités au moyen d’un appareil de radiochirurgie haute fréquence (Ellman Surgitron®; Ellman International Inc., Oceanside, New York, États-Unis). Après avoir saisi et soulevé la partie de la conjonctive entourant le kyste au moyen d’une pince à bout arrondi, on a inséré une électrode à aiguille fine (électrode aiguille isolée D6A; Ellman International Inc., Oceanside, New York, États-Unis) dans le kyste. Une puissance de 0,5 à 1 a été utilisée pour la coagulation du kyste, sans carbonisation des tissus.
Après l’intervention, il n’y a eu aucun cas de récurrence de kystes conjonctivaux pendant la période de suivi de six mois, et les symptômes ont aussi disparu. Aucune intervention n’a duré plus de 5 minutes, et il y a eu un cas d’hémorragie sous-conjonctivale. Cette dernière s’est complètement résorbée à l’intérieur de deux semaines, et aucune autre complication n’a été observée.
Une approche faisant appel à la radiochirurgie haute fréquence s’est révélée efficace pour l’ablation de kystes conjonctivaux et a donné lieu à une amélioration des symptômes. Des techniques utilisant la radiochirurgie haute fréquence pourraient constituer de bonnes solutions de rechange au traitement chirurgical des kystes conjonctivaux.
Conjunctival cysts of the orbit
1998, Ophthalmology
This study reviews functionally and anatomically disruptive features of simple conjunctival orbital cysts.
A case series review from four oculoplastic practices over 6 years.
Eleven patients with simple conjunctival cysts of the orbit were identified.
All cysts were excised and evaluated histopathologically.
Assessment was made of the length of time from inciting event to presentation, preoperative and postoperative refractive state and ocular motility, the presence or absence of discomfort, and radiographic or clinical evidence of bone remodeling.
Six of 11 cysts were presumed to be primary, unrelated to antecedent surgery or trauma. Four of 11 cysts were associated with pain or tenderness, 5 cysts induced ocular motility disturbance, 6 cysts caused observable globe distortion or refractive error change, and 6 cysts remodeled bone.
Simple conjunctival cysts of the orbit, traditionally regarded as low-pressure lesions with minimal structural impact, may induce considerable anatomic and functional disruption.
Epithelial Implantation Cysts of the Upper Eyelid after Lid-lowering Procedures
1993, Ophthalmology
Purpose: Epithelial inclusion cysts are benign lesions that have been described after intraocular and intraorbital surgery or trauma. The authors determine the rate of occurrence and characteristics of epithelial implantation cysts after upper eyelid-lowering procedures using a posterior conjunctival incision.
Method: The records of 109 upper eyelid-lowering cases over a 9-year period that had an internal incision were reviewed retrospectively. Any cysts removed were sent for histopathologic examination.
Results: The incidence of cyst development was found to be 2.75%. The cysts were small and remained under 4 mm over time. Histopathologic findings of the two epithelial cysts removed suggested a conjunctival origin. The development of cysts did not correlate with length and difficulty of the procedure.
Conclusion: Epithelial implantation cysts of the eyelid after posterior approach levator recession procedures are rare (2.75% incidence). However, they often require surgical excision due to their conspicuous location. Their origin is probably the conjunctival epithelium implanted while manipulating the conjunctival incision edge.
Invasive Squamous Cell Carcinoma Arising from Asymptomatic Choristomatous Cysts of the Orbit: Two Cases and a Review of the Literature
1993, Ophthalmology
Background: Epithelial choristomatous cysts are common orbital lesions, the most frequent of which are dermoid or epidermoid tumors. Massive enlargement or extraorbital extension of these benign lesions may occur. Malignant transformation of the epithelial lining of epidermoid cysts is rarely reported.
Methods: Two patients are presented in whom the epithelial lining of a previously asymptomatic choristomatous cyst of the orbit underwent malignant transformation to produce invasive squamous cell carcinoma. The unusual origin and clinical presentation of the lesions caused a delay in the diagnosis and therapy in both patients. Metastatic workup was negative in both patients, who underwent resection of their tumors via orbital exenteration with craniofacial resection. Reported cases of malignant transformation in analogous choristomatous cysts elsewhere in the cranium are reviewed.
Results: One patient is alive and well without recurrent disease 40 months postoperatively. The second patient died of a pulmonary embolus 2 months postoperatively. Autopsy showed no residual tumor. Overall, only 3 of 18 reported patients with epidermoid choristoma of the head and orbit with malignant transformation were alive when reported.
Conclusions: Malignant squamous metaplasia is believed to be a rare complication of orbital dermoid or epidermoid cysts, with only two previously reported cases. However, malignant transformation is relatively frequent in analogous epidermoid cysts found elsewhere in the cranial vault, especially after incomplete excision. These reports encourage the complete removal of epithelial choristomas of the orbit.

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This study was supported in part by an unrestricted grant from Research to Prevent Blindness, Inc., New York, New York; and by Mayo Foundation.

Reprint requests to George B. Bartley, M.D., Department of Ophthalmology, Mayo Clinic, 200 First St. S.W., Rochester, MN 55905.

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Massive Epithelium-lined Inclusion Cysts After Scleral Buckling

Am. J. Ophthalmol.

Am. J. Ophthalmol.

Ophthalmology

Am. J. Ophthalmol.

A large implantation cyst of the conjunctiva

Proc. R. Soc. Med.

Large orbital conjunctival cyst after enucleation

Am. J. Ophthalmol.