Conjunctival inclusion cysts following small incision cataract surgery

In India, survival rates of patients with retinoblastoma are getting better. This is observed by the fact that now we are seeing the second generation of the survivors of germinal type of retinoblastoma. The child’s father was also one such survivor and hence the tumor was picked up in this child very early in life. In spite of being diagnosed early (at five days of life), immediate chemotherapy could not be started because of physiological jaundice. Brachytherapy although available at our center, was not utilized due to our inexperience in doing it in newborns and also it would have taken at least two to three weeks for the I125 seeds to be prepared. Moreover, there were multiple tumors. On second follow-up at Day 16 when the bilirubin levels were still high, we decided to give half-dose carboplatin (9.3 mg/kg instead of 18.6 mg/kg). However, this did not work and by Day 35 the tumor volume had grown about four times. Volume of the tumor was calculated using the formula for ellipsoid 4/3 ∏ abc where ∏ = 22/7, a and b are radii of basal diameters and c is radius of height. Basal diameters were measured on Retcam images using the software while the height was measured by B scan imaging. Area of tumor base was also calculated on Retcam images using the software. Fortunately, full-dose chemotherapy could be started as the bilirubin levels had returned to normal by that time.


Discussion
In India, survival rates of patients with retinoblastoma are getting better.This is observed by the fact that now we are seeing the second generation of the survivors of germinal type of retinoblastoma.The child's father was also one such survivor and hence the tumor was picked up in this child very early in life.In spite of being diagnosed early (at five days of life), immediate chemotherapy could not be started because of physiological jaundice.Brachytherapy although available at our center, was not utilized due to our inexperience in doing it in newborns and also it would have taken at least two to three weeks for the I 125 seeds to be prepared.Moreover, there were multiple tumors.On second follow-up at Day 16 when the bilirubin levels were still high, we decided to give half-dose carboplatin (9.3 mg/kg instead of 18.6 mg/kg).However, this did not work and by Day 35 the tumor volume had grown about four times.Volume of the tumor was calculated using the formula for ellipsoid 4/3 ∏ abc where ∏ = 22/7, a and b are radii of basal diameters and c is radius of height.Basal diameters were measured on Retcam images using the software while the height was measured by B scan imaging.Area of tumor base was also calculated on Retcam images using the software.Fortunately, full-dose chemotherapy could be started as the bilirubin levels had returned to normal by that time.
This delay in treatment gave some time to study the tumor growth.On Day 16 there was a 1.7 times increase in tumor volume and by Day 35 there was 3.9 times increase.We agree with Abramson et al. [2] that the tumor doubling time for retinoblastoma must be around 15 days.However, as they mentioned, we also urge caution in assuming that 15 days is the doubling time for all retinoblastomas since the child was very young and was also treated with half-dose carboplatin midway.Phase transit time in the retinal progenitor cells in this young child is likely to be shorter. [2]In general, in young developing organisms only those tumors with very short doubling time are likely to exist and survive, where as, later during a period of weakening cell-cell cooperation, cancer types with longer doubling times can thrive. [2,3]us the clinical measure of this rapid growth is important and emphasizes the need to start immediate treatment once retinoblastoma is diagnosed.
Conjunctival inclusion cysts are benign cysts filled with clear serous fluid containing shed cells or gelatinous mucous material. [1]They can be congenital or acquired. [2]Acquired cysts occur following traumatic or surgical implantation of conjunctival epithelium, and are much more common. [3]We report two cases of conjunctival inclusion cysts following manual small incision cataract surgery (SICS).To our knowledge, this complication of manual SICS has not been reported previously.

Case Reports
Case 1 A 65-year-old man came with complaints of a swelling in the left eye noticed since one month.It was painless and gradually increasing in size.He had undergone manual SICS with posterior chamber intraocular lens (PCIOL) implantation in Left Eye (LE) two years ago.On examination both eyes had best corrected visual acuity (BCVA) of 20/40 and were pseudophakic with PCIOLs.A solitary cystic swelling was present at the superior limbus in the LE, overlying the previous scleral tunnel incision, measuring 8 X 8 mm and containing clear fluid [Fig. 1 A].The remainder of the ophthalmic examination was unremarkable.He was posted for surgical excision of the cyst under local anesthesia.The conjunctiva around the cyst was separated by blunt dissection, the cyst ruptured while excising it from the base.The sclera underneath was cauterized.The conjunctiva was re-approximated to the limbus.The excised cyst was subjected to histopathological examination, which revealed a cyst lined by non-keratinized stratified squamous epithelium suggestive of a conjunctival inclusion cyst [Fig. 1 B].He has been followed up for three months, without any signs of recurrence.

Case 2
A 67-year-old man came with complaint of a swelling in his Right Eye (RE) noticed since two months, initially smaller in size, gradually increased to present size and associated with foreign body sensation.He had undergone manual SICS with PCIOL implantation in RE eight months ago.On examination, RE had a BCVA of 20/60, and was pseudophakic with PCIOL.A solitary oval cystic swelling was present at the superior limbus in RE, measuring 11 mm × 9 mm, and containing clear fluid [Fig.2A].The LE had a BCVA of counting fingers 4 meters, with posterior subcapsular cataract.The anterior segment and fundus examination were unremarkable.He was posted for surgical excision of the cyst under topical anesthesia.The conjunctiva overlying the cyst was separated by blunt dissection, the cyst was excised at the base, but as with the previous case it ruptured during excision.The underlying sclera was cauterized.The conjunctiva was re-approximated to the limbus by a subconjunctival injection of 0.5 ml gentamicin.The excised cyst was subjected to histopathological examination, which revealed a cyst lined by non-keratinized stratified squamous epithelium showing occasional apical snouts [Fig.2B], again suggestive of conjunctival inclusion cyst.He also has been followed up for three months without any signs of recurrence.

Discussion
Conjunctival inclusion cysts can be congenital or acquired.Acquired conjunctival inclusion cysts occur following trauma or surgery.They are most common following strabismus surgery, [3] but may also occur following other ophthalmic surgeries such as pars plana vitrectomy, [4] scleral buckling, [5] Ahmed glaucoma valve insertion, [6] and ptosis surgery. [7]While conjunctival inclusion cyst following phacoemulsification surgery has been reported, [8] there are no reports following manual SICS.These cysts are generally asymptomatic, or may cause a mild foreign body sensation or cosmetic concerns.The chief differential diagnosis is a filtering bleb.Possible complications are infection and the rare possibility of epithelial ingrowth through the tunnel wound.These cysts may disappear spontaneously; however, persistent cases require treatment.Surgical excision of the cyst is the best treatment.Thermal cautery under slit-lamp visualization [9] or YAG laser of the cyst can also be performed. [10]om our cases, we note that conjunctival inclusion cysts can occur following manual SICS.The conjuntival tissue may be implanted during the construction of the tunnel wound or due to dragging of conjunctiva during PCIOL implantation.This complication may be prevented by paying careful attention to reflection of the conjunctiva prior to scleral wound construction and by avoiding contact between the IOL and conjunctiva during intraocular lens implantation.

Pukhraj Rishi, Ekta Rishi, Tarun Sharma, Sheshadri Mahajan
Amongst the clinical presentations of retinal artery occlusion, hemi-central retinal artery occlusion (Hemi-CRAO) is rarely described.This case series of four adults aged between Acute retinal arterial obstruction presents as central retinal artery (CRA) obstruction in 57% cases, branch retinal obstruction in 38% and cilioretinal artery obstruction in 5%. [1]t may be related to known preexisting systemic disease or may be an initial manifestation of previously undiagnosed systemic abnormality.In young adults with retinal artery occlusion, associated etiological factors are more often obscure and diverse. [2]Hemi-central retinal artery occlusion (Hemi-CRAO) is an extremely uncommon clinical entity that has hardly been described in the literature.Hereby, we describe systemic and ophthalmologic characteristics of four patients ranging between 22 and 36 years of age, who presented with hemi-central retinal artery occlusion.

Figure 2A :
Figure 2A: Intra-operative clinical photograph of Case 2, showing an oval conjunctival cyst at superior limbus; the overlying conjunctiva has been reflected 22 and 36 years attempts to describe the clinical profile, etiology and management of Hemi-CRAO.Case 1 had an artificial mitral valve implant.Polycythemia and malignant hypertension were noted in Case 2. The third patient had Leiden mutation while the fourth patient had Eisenmenger's syndrome.Clinical examination and fundus fluorescein angiography revealed a bifurcated central retinal artery at emergence from the optic nerve head, in all cases.Color Doppler examination of the central retinal artery confirmed branching of the artery behind the lamina cribrosa.It is hypothesized that bifurcation of central retinal artery behind the lamina cribrosa may predispose these hemi-trunks to develop an acute occlusion if associated with underlying risk factors.The prognosis depends upon arterial recanalisation and etiology of the thromboembolic event.Key words: Central retinal artery occlusion, Eisenmenger's syndrome, embolus, hemi-central artery occlusion, Leiden mutation, malignant hypertension, polycythemia, retinal artery occlusion, thrombosis Indian J Ophthalmol: 2010;58:425-432 DOI: 10.4103/0301-4738.67069PMID: ***