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Presentation spectrum and management of iris cysts
Iris cysts can be primary or secondary, with primary being divided into epithelial and stromal types.
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Iris cysts are benign lesions that arise from iris tissue and are seen clinically in cyst or elevated form. They can be primary, with no etiological cause, or secondary, with etiological cause. Primary iris cysts are divided into epithelial and stromal types, depending upon their clinical characteristics. Epithelial cysts arise between the pigmented epithelial layers of the iris. They can be central, peripheral and middle in relation to the pupil. Stromal cysts arise within the stroma and are not in straight connection with the posterior epithelium. They apparently arise from ectopic surface epithelium, which is trapped in the iris during embryologic development. Secondary iris cysts often arise after ocular trauma or surgery.
Spectrum of presentations
Recurrent cyst in child: A 3-year-old child with decreased vision since childhood was diagnosed to have an iris cyst on examination under anesthesia. She underwent cystotomy twice and had a recurrence after each procedure. On ultrasound biomicroscopy (UBM), the cyst measured about 5 mm by 6 mm. There was corneal adhesion and scar formation. The lens was cataractous and tilted due to mechanical pressure from the overlying iris cyst. The patient underwent cystectomy with lensectomy and en bloc iridectomy under general anesthesia (Figures 1a to 1f). A glued IOL was implanted. Keratoplasty may be needed in the future if corneal decompensation sets in. The postoperative period showed mild corneal edema with a nicely centered glued IOL.
Iris cyst causing IOL tilt: A 60-year-old patient presented with blurred vision for the past 6 months. He gave a history of cataract surgery 3 years prior. On examination, he had a large iris cyst arising from the epithelium. There was endothelial encroachment, and corneal edema was present (Figure 2). The cyst was pressing on the posterior chamber IOL, and there was induced IOL tilt, as seen on OCT. The patient underwent cystectomy under local anesthesia.
Images: Kumar DA, Agarwal A
Post-keratoplasty iris cyst: An 18-year-old patient presented with a history of blurred vision. She had optical penetrating keratoplasty done at the age of 10 years for keratoconus. On examination, her best corrected visual acuity was 20/30 in the right eye and 20/80 in the left eye. The patient’s previous records showed that her BCVA was 20/40 in the left eye about 6 months prior. There was an inferior iris cyst seen with graft corneal endothelial touch and mild corneal edema (Figure 3). Nd:YAG cystotomy was performed, and the patient was administered oral steroids for 2 weeks. Topical steroids and lubricants were continued for 1 month. At 2 months after surgery, there was clear cornea with BCVA of 20/40.
Asymptomatic iris cyst: Iris cysts can be present for a long period without any patient symptoms. Patients who undergo routine work-ups for refractive or cataract surgery have been observed to have asymptomatic cysts (Figure 4). However, such iris cysts need not be intervened. Iris cysts can be large and present in a horseshoe shape (Figure 5). Large “kissing” cysts can at times induce pinhole effect. Iris arising from the posterior pigment epithelium can mimic melanoma.
Diagnosis and complications
Clinically, iris cysts can be well seen on the slit lamp. However, confirmation is always required with imaging modalities such as UBM or anterior segment OCT. UBM shows thick walls that are hyperechoic due to pigmented epithelium or hypoechoic depending on the inner fluid content. UBM is superior to OCT in such cases because the infrared light cannot pass through the iris epithelium. Iris cysts can be in an initial silent phase and then induce iridocyclitis and glaucoma (angle closure). Chronic iris cysts induce endothelial decompensation due to corneal touch and cause corneal opacification. In cases of suspicious lesions, MRI may be advised. Early diagnosis and observation in asymptomatic cases may help; however, when vision-threatening complications set in, surgical removal or laser cystotomy is recommended.
- References:
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- Kuchenbecker J, et al. Am J Ophthalmol. 2000;doi:10.1016/S0002-9394(99)00392-X.
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- For more information:
- Amar Agarwal, MS, FRCS, FRCOphth, is director of Dr. Agarwal’s Eye Hospital and Eye Research Centre. Agarwal is the author of several books published by SLACK Incorporated, publisher of Ocular Surgery News, including Phaco Nightmares: Conquering Cataract Catastrophes, Bimanual Phaco: Mastering the Phakonit/MICS Technique, Dry Eye: A Practical Guide to Ocular Surface Disorders and Stem Cell Surgery and Presbyopia: A Surgical Textbook. He can be reached at 19 Cathedral Road, Chennai 600 086, India; email: dragarwal@vsnl.com; website: www.dragarwal.com.
Disclosure: Agarwal reports he is a consultant for STAAR Surgical. Kumar reports no relevant financial disclosures.