Sir,

Our patient presented with a subconjunctival cyst associated with a pseudohypopyon. She was aphakic after cataract extraction 4 years before. One year later, she underwent encirclement, vitrectomy, cryotherapy, and gas tamponade for a retinal detachment. Two years on, she developed an anterior non-necrotizing scleritis.

The sclera was injected around the encircling band. There was a subconjunctival inclusion cyst with a white fluid level in the superonasal quadrant (Figure 1a). A white retinal detachment resembling the fluid in the cyst (Figure 1b) was seen. Communication between the cyst and subretinal space was confirmed with a B-scan ultrasound (Figure 1c) with secondary retinal incarceration. LogMar acuity was 0.78 in the affected eye.

Figure 1
figure 1

Subconjunctival cyst associated with a pseudohypopyon (a), white retinal detachment (b), and a communication tract between conjunctiva and retina as represented by the arrow on B-scan USG (c).

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Scleritis was considered causal in this fistula formation. Infective, neoplastic, and systemic inflammatory causes were excluded before surgical repair. Transconjunctival cyst aspiration biopsy grew no microorganisms. Papanicoloa staining is shown in Figure 2. She subsequently underwent excision of the conjunctival cyst, removal of the encircling band, scleral patch graft, and vitrectomy. Figure 3 shows histopathology of excised tissue. No suture material was present.

Figure 2
figure 2

Cytological examination of aspirated fluid showing the revealed squamous cells with keratinisation seen in orange and atrophic features with background macrophages and neutrophils. Papanicolaou stain (magnification × 180).

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Figure 3
figure 3

Cyst wall lined with corneoscleral limbus-type epithelium (a), and scleral stroma showing neovascularisation and focal chronic inflammatory infiltrate (b). Histological examination stained with haematoxylin and eosin (magnification × 100).

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Three months later, the fundus showed a reticulated pattern of subretinal debris and pseudosheathing of retinal vessels (Figure 4). Six years later, LogMar VA improved to 0.48 with no trace of debris.

Figure 4
figure 4

Reticulated pattern of subretinal debris and pseudosheathing of blood veseels.

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Most cysts develop postsurgically after enucleation, strabismus surgery, or scleral buckle implantation1 due to the implantation of conjunctival epithelial cells.2 ‘Simple’ conjunctival cysts are usually transparent and lined with non-keratinising epithelium containing goblet cells.1 Keratinisation is unusual but has been described and associated with a pseudohypopyon.3

Surgically-induced necrotising scleritis is a rare complication of ocular surgery4 and is most commonly associated with vasculitis.4 Other causes are infection, excessive cautery, or tissue manipulation. Suture materials may cause scleritis or migrate through sclera.4 Scleral buckles may migrate through the insertion of extraocular muscles causing ischaemic necrosis. Scleral patch grafts for scleral defects are known to work in the cases of thinning related to infection or necrosis.5 The scleral breakdown in our patient presumed to be suture associated as there was focal chronic inflammatory infiltrate at the scleral fragment margin.