Introduction

Iris cysts can be either primary or sec-ondary (Rizzuti 1955; Srivastava et al.1982; Hoh & Menage 1993; Marigoet al. 1998), depending on their causeand pathogenesis. Secondary trau-matic inclusion cysts are more com-monly encountered in clinical practice,especially after penetrating injury orcataract and keratoplasty surgery. Theclinical spectrum of the post-traumatic

inclusion cyst is diverse, as is itsresponse to various modes of treat-ment. Although the diagnosis in thesecases is clinical, ultrasound biomicros-copy (UBM) has made it possible tostudy some of the features of thesecysts, such as consistency and area ofinvolvement, especially in cases withoverlying corneal opacification. It alsohas important clinical implications interms of choice of treatment andpossible complications during or after

treatment. Earlier studies have quotedvariable results with different treat-ment modalities for traumatic cysts.Most of these studies were retrospec-tive, with analysis carried out on theoutcome on a retrospective basis. Wedescribe the clinical profiles of 11cases of iris implantation cysts, andtheir UBM features, along with aprospective analysis of the final surgi-cal outcomes with various therapeuticapproaches.

Materials and Methods

Eleven cases of post-traumatic irisinclusion cysts presenting at our out-patient department were evaluated.Examinations included best correctedSnellen visual acuity (VA), applana-tion tonometry and UBM. Dependingon the extent of involvement of theeye at initial presentation and thetreatments administered previously,patients were treated either withNd:YAG laser iridotomy or surgery.Specimens collected during surgerywere sent for histopathological study.

These patients were followed upregularly after treatment on an outpa-tient basis and prospective analysis oftheir outcomes was performed. All exa-minations were repeated in the event ofrecurrence and repeat surgery or lasertreatment was undertaken, dependingon the clinical presentation duringfollow-up. Any complications thatoccurred in the postoperative periodwere noted and treated appropriately.

Post-traumatic inclusion cysts ofthe iris: a longterm prospectivecase series

Viney Gupta, Aparna Rao, Ankur Sinha, Neena Kumar andRamanjit Sihota

Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of MedicalSciences, New Delhi, India

ABSTRACT.

Purpose: Post-traumatic cysts of the iris pose a diagnostic and therapeutic

challenge for ophthalmic surgeons. This prospective case series highlights the

clinical spectrum and longterm outcomes of different modes of treatment in

these cases.

Methods: Eleven cases of post-traumatic iris inclusion cysts, treated with

Nd:YAG laser and ⁄or surgical excision were evaluated prospectively over peri-

ods ranging from 6 months to 3 years. Ultrasound biomicroscopy features and

postoperative outcomes in each were evaluated.

Results: Laser iridotomy of the cyst offers a non-invasive method of therapy

in these cases but has a high rate of recurrence. The outcomes in most cases

were poor, with worse results and more complications encountered in younger

age groups.

Conclusions: Iris inclusion cysts have overall poor surgical outcomes as the

result of the extensive proliferation of epithelial cells, which may explain why

the condition takes a rapid course in younger patients and why severe compli-

cations are encountered postoperatively in this age group.

Key words: iris cyst – implantation cyst – inclusion cyst – ultrasound biomicroscopy – surgical

excision

Acta Ophthalmol. Scand. 2007: 85: 893–896ª 2007 The Authors

Journal compilation ª 2007 Acta Ophthalmol Scand

doi: 10.1111/j.1600-0420.2007.00975.x

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Statistical evaluation was carriedout using spss Version 10. Associa-tions between risk factors and finaloutcomes with regard to VA and cystresolution were analysed using thechi-square test and non-parametricMann–Whitney U-test.

Results

Most of our patients were male(male : female ratio 8 : 3) (Table 1).All age groups were affected, althoughyounger age groups (< 12 years, n ¼4) showed more extensive involvementof the eye, with poorer VA at initialpresentation (p ¼ 0.006). A history ofpenetrating trauma was the incitingfactor in eight cases. Two cases pre-sented after cataract surgery. No his-tory of trauma or surgery was elicitedin one case. Two patients in whomglass had been the object of injury(cases 10 and 11) were noted to havepoor visual outcome at the last fol-low-up (Table 2).

The time lags between trauma andclinical presentation of the cyst ran-ged from 6 months to 20 years andthe initial best corrected VA rangedfrom 6 ⁄ 12 to hand movement close toface (HMCF). The majority ofpatients presented with symptoms ofreduced vision, redness, pain andwatering of the eye. Only one patient(case 11) had raised intraocular pres-sure (IOP) at initial presentation.Details of the clinical profile andprospective follow-up of these patientsare given in Tables 1 and 2. The his-topathological features of case 10where the cyst was excised are alsodescribed (Fig. 1).

All the cases in our series involvedserous cysts (Fig. 2A, B) except onethat was found to be a pearl cyst on

clinical examination, which was con-firmed by UBM (Fig. 3A, B).

In all cases, UBM was used to ana-lyse the extent of the cyst and to iden-tify the thinnest segment of the cystwall when Nd:YAG laser puncturewas planned. Non-invasive laser treat-ment was performed in eight subjects.Cyst excision, keratoplasty with cystexcision and iris reconstruction wereperformed in one case each. Trabecul-ectomy alone was performed in oneeye (case 11), which had undergoneprevious laser iridotomies and inwhich the condition was associatedwith intractable glaucoma.

The overall outcomes in thesepatients were poor. Only two patientsregained good vision after treatmentwithout any recurrence in the subse-quent 2 years. In both these patientsthe cyst involved the anterior stromaof the iris, whereas in the rest the pos-terior pigment epithelium was seen tobe involved on UBM. Severe compli-cations such as postoperative cataractand glaucoma were more common inyoung subjects, which precluded agood visual outcome in these patients.Case 10 demonstrated a conjunctivalcyst continuous with the anteriorchamber cyst on follow-up after non-invasive laser treatment. Ultrasoundbiomicroscopy in this patient revealedmultiloculated cysts extending to thepars plana region (Fig. 4).

No difference in final outcomes wasseen in terms of VA and cyst resolu-tion after laser treatment or surgery.Final outcome in terms of complica-tions was somewhat related to age atinitial presentation (p ¼ 0.01) andthe extent of involvement of the eye(p ¼ 0.015), although a larger samplesize would be required to identifythese as independent risk factors.

There was no association between theduration of the disease process or theperiod of follow-up and incidence ofcomplications in our study (p ¼ 0.3and p ¼ 0.8, respectively).

Discussion

Post-traumatic inclusion cysts aremost commonly seen after penetratinginjury or after cataract or keratoplastysurgery. Their pathogenesis beginswith the entry of epithelial cells intothe anterior chamber following pene-trating injury (Rizzuti 1955; Marigoet al. 1998). Consequently, intraocularimplantation depends upon a favour-able environment in the eye, which isprovided by the vascular iris. The epi-thelial cells proliferate and extend intothe adjacent ocular structures, spread-ing anteriorly over the angle andposteriorly into the ciliary body andbeyond. This proliferation can takethe form of a serous cyst, a pearl cyst(Sitchevska & Payne 1951) or epitheli-alization of the anterior chamber(Terry et al. 1939; Maumenee & Shan-non 1956). Characteristically, thesecysts are lined with stratified squa-mous epithelium and contain fluidand ⁄or inflammatory cells (Fig. 1).The general features of these cysts onUBM have been extensively described(Finger et al. 1995; Zhou et al. 2006).The majority of studies advocate sur-gical methods over laser treatmentand quote fair outcomes (Okun &Mandell 1974; Bruner et al. 1981;Naumann & Rummelt 1992). How-ever, none of these studies comparedthe disease course in patients afterlaser treatment with that in patientsafter surgical treatment.

In this series no specific age groupwas predominantly affected, although

Table 1. Clinical profiles of patients with iris inclusion cysts.

Case Age (years) Sex Type of injury Presentation after trauma Previous surgery

1 30 Male Penetrating injury (iron) 1 year Corneal perforation repair

2 20 Male Penetrating injury (iron) 5 years Corneal perforation repair

3 40 Male Penetrating injury (iron) 20 years Corneal perforation repair

4 6 Male Penetrating injury (iron) 2 years Laser treatment three times

5 38 Male No trauma ⁄ surgery – Excision ⁄ aspiration twice

6 60 Female Cataract surgery 8 years Cataract extraction

7 42 Female Cataract surgery 8 years Cataract extraction

8 28 Male Penetrating injury (iron) 6 years Perforation repair

9 8 Male Penetrating injury

(wooden splinter)

2 years Limbal perforation repair

and iris repositioning

10 11 Female Penetrating injury (glass) 1 year Perforation repair

11 8 Male Penetrating injury (glass) 1 year Nd:YAG laser three times

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younger age groups showed moresevere signs of the disease process atinitial presentation. We also observedthat younger patients presented at anearlier stage than patients in the olderage group. The rapid debu in youngerpatients possibly reflects a more aggres-sive disease course in this group.

In our series, UBM was used toidentify the thinnest section of the cystwall for Nd:YAG laser puncture.Such a strategy helps to minimize thecomplications that are likely to occurwhen trying to puncture a thicker seg-ment of the wall and thereby usingmore energy. Using UBM in case 3helped us to view the entire cyst,which then contributed towards plan-ning the keratoplasty and anteriorsegment reconstruction. The limits of

the cyst and the relatively thinner wallof the cyst were defined despite impro-per visualization, which facilitatedease of laser treatment while waitingfor keratoplasty.

One patient, in whom an inclusioncyst was confined to the anteriorchamber preoperatively (case 10),developed recurrence after laser treat-ment, with cystic involvement of thelimbus continuous with the anterior

chamber cyst at follow-up. Ultra-sound biomicroscopy revealed thispatient to have multiloculated cystsextending up to the pars plana region.This supports the theory that epithe-lial invasion and multiplication is anongoing process that involves all the

Table 2. Treatment and outcomes of patients with iris inclusion cysts.

Case Procedure

BCVA IOP (mmHg)

Complications Recurrence ⁄ repeat procedure Follow-upPreop Postop Preop Postop

1 Laser iridotomy* 6 ⁄ 12 6 ⁄ 6 14 12 – – 6 months

2 Laser iridotomy 6 ⁄ 60 6 ⁄ 9 12 12 – – 2 years

3 Keratoplasty with

cyst excision and

iris reconstruction

HMCF – 18 – – Lost to follow-up

4 Laser iridotomy 6 ⁄ 24 6 ⁄ 36 12 34 Glaucoma and

ciliary staphyloma

+ ⁄Trabeculectomy 6 months

5 Laser iridotomy 6 ⁄ 18 6 ⁄ 18 14 12 – + ⁄ – 3 years

6 Cyst excision 5 ⁄ 60 3 ⁄ 60 20 – – + ⁄ – 1 year

7 Laser iridotomy FC 1m FCCF 18 20 – + ⁄ – 2 years

8 Laser iridotomy 6 ⁄ 60 6 ⁄ 60 12 14 Cataract – ⁄ – 3 years

9 Laser iridotomy 2 ⁄ 60 FCCF 14 18 – + ⁄ – 1 year

10 Laser iridotomy HMCF HMCF 13 28 Glaucoma,

conjunctival and

ciliary body cysts

+ ⁄PPV +

lensectomy

cyst excision

1 year

11 Trabeculectomy 6 ⁄ 24 HMCF 24 10 Multiple ciliary

staphyloma

+ ⁄ – 2 years

* Laser treatment with frequency doubled Nd:YAG laser, 3.5–4.5 mJ, 100 lm, 5–10 spots.

BCVA ¼ best corrected visual acuity; IOP ¼ intraocular pressure; FCCF ¼ finger counting close to face; HMCF ¼ hand movement close to face;

+¼ present; –¼ absent; PPV ¼ pars plana vitrectomy.

(A)

(B)

Fig. 2. Case 2. (A) A well defined iris

inclusion cyst. (B) Ultrasound biomicroscopy

shows clear serous contents.

(A)

(B)

Fig. 3. Case 3. (A) Clinical photography

shows a well defined iris cyst partially occlu-

ded by corneal opacity. (B) Ultrasound bio-

microscopy shows the solid content of the

cyst, confirming it as a pearl cyst.

Fig. 1. Histopathological photograph of an

inclusion cyst removed in case 10. The long

arrow points towards the stratified squamous

epithelium lining the cyst and the short

arrows point to the iris tissue.

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structures of the eye. This may not beclinically evident at initial presenta-tion, as the ongoing process of epithe-lial sliding may be expected to occuron an ultrastructural level (similar to‘malignant seeding’) and may beresponsible for recurrence after treat-ment and also for overall poor out-comes after surgery.

Most previous reports on iris inclu-sion cysts involve retrospective casestudies (Rizzuti 1955; Finger et al.1995; Marigo et al. 1998). None ofthese studies quote the final outcomesof such cases in terms of longitudinalcourse or prospective follow-up.

We prefer to use a conservativeapproach where laser treatment repre-sents the primary treatment modalitybefore the patient is referred for surgi-cal excision. However, the rate ofrecurrence with both these procedureshas been high. The overall outcome inthe cases described here was poor:

only two patients showed an improve-ment in VA and no recurrence.

Surgical interventions also producedpoor outcomes, especially in theyounger age groups. Postoperativeglaucoma and cataract were morecommon among younger patients.This may result from the stronginflammatory response seen in theseeyes postoperatively. In our experi-ence, other poor prognosticatorsinclude inclusion cysts formed afterpenetrating injury with glass objects,those which are diffuse at presentationand those that involve the pigmentepithelium of the iris.

Given the high recurrence rates andgenerally poor outcomes, especially inyoung subjects, guarded prognosesshould be given to patients with post-traumatic inclusion cysts. Further,prevention in the form of betterwound management in the repair oftraumatic perforations is advisable.

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Received on January 13th, 2007.

Accepted on May 13th, 2007.

Correspondence:

Viney Gupta MD

Assistant Professor of Ophthalmology

Dr Rajendra Prasad Centre for

Ophthalmic Sciences

All India Institute of Medical Sciences

New Delhi 110029

India

Tel: + 91 11 2659 3003

Fax: + 91 11 2658 8919

Email: gupta_v20032000@yahoo.com

Fig. 4. Case 10. Clinical photography shows

cystic involvement of the limbus continuous

with the anterior chamber cyst.

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