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   Table of Contents      
BRIEF REPORT
Year : 2006  |  Volume : 54  |  Issue : 2  |  Page : 118-120

Spontaneous onset corneoscleral hematic cyst


Cornea and Anterior Segment Services, L. V. Prasad Eye Institute, L. V. Prasad Marg, Hyderabad - 500 034, AP, India

Correspondence Address:
V S Sangwan
L. V. Prasad Eye Institute, L. V. Prasad Marg, Hyderabad - 500 034, AP
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0301-4738.25834

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  Abstract 

Corneoscleral cysts are a rare entity. We report a case of spontaneous corneoscleral hematic cyst, which was treated by cyst excision and lamellar corneal patch graft. No recurrence of cyst was noticed during the 6 years of followup.

Keywords: Corneoscleral cyst, spontaneous cyst, hematic cyst


How to cite this article:
Shah S G, Matalia H P, Sangwan V S. Spontaneous onset corneoscleral hematic cyst. Indian J Ophthalmol 2006;54:118-20

How to cite this URL:
Shah S G, Matalia H P, Sangwan V S. Spontaneous onset corneoscleral hematic cyst. Indian J Ophthalmol [serial online] 2006 [cited 2019 Nov 21];54:118-20. Available from: http://www.ijo.in/text.asp?2006/54/2/118/25834

Spontaneous onset corneoscleral cyst, although a known entity, is rare. They usually present during early years of life, without any previous history of surgery or trauma. Treatment modalities include aspiration of cyst contents, excision of the anterior cyst wall with chemical cauterization or cryotherapy to its posterior wall[1],[2] and excision of cyst with lamellar keratoplasty.[3] We report a case of spontaneous onset corneoscleral hematic cyst.


  Case Report Top


A 14 year old girl presented to us with complaints of a growth in her left eye, that was increasing in size for past 14 months. She was otherwise asymptomatic. There was no history of any ocular trauma or surgery.

On examination, her visual acuity in the right eye was 20/20, N6 (unaided) and 20/20, N6 in the left eye with correction (-1.50 DC x 140 degrees). Slitlamp examination of the right eye was within normal limits, whereas the left eye showed a subconjunctival cyst extending into the anterior corneal stroma on the nasal side, from 7 to 11 o'clock hour position. The cyst contained clear fluid along with clotted blood [Figure - 1]A. Rest of the ocular examination was within normal limits.

Ultrasound biomicroscopy (UBM) of the left eye showed a fluid filled cystic lesion involving the cornea, with no communication with the anterior chamber. The cyst contents were aspirated under anesthesia using a 26 G needle attached to a 2cc syringe. The cyst totally flattened, ruling out any communication with the anterior chamber. There was no refilling of the cyst in next 3 hours.

At one month followup, her uncorrected visual acuity was 20/20 P in the left eye. On slitlamp examination, there was reappearance of the cyst [Figure - 1]B. UBM revealed significant corneal thinning. Bleeding time and clotting time were within normal limits.

She underwent cyst excision with lamellar corneal patch grafting and amniotic membrane grafting, under general anesthesia. After anterior chamber paracentesis, conjunctiva around the outer border of the cyst was dissected. Saline was injected to separate the conjunctiva and the anterior cyst wall. The cyst wall was perforated, followed by its excision. A very small, full thickness scleral defect, was noted near the limbus at the 7 o'clock position. No communication with the anterior chamber was noted. Cauterization was done to the scleral bed. A lamellar corneal patch graft was placed on the sclera covering the scleral perforation and secured with 10-0 nylon interrupted sutures. Amniotic membrane was used to cover the bare sclera.

On first postoperative day, the patch graft and amniotic membrane were in place. She was advised Betamethasone (0.1%) and Ciprofloxacin (0.3%) eye drops, along with Ciprofloxacin tablets only. Histopathological examination of the brownish cyst contents showed plenty of large polygonal cells, many of which had no visible nuclei, suggestive of ghost cells [Figure - 1]C. They contained PAS (periodic acid schiff) positive material in their cytoplasm. Few stratified squamous cells were also seen. The picture was suggestive of hematic cyst. Microbiological evaluation of cyst contents revealed no organisms.

At the intermediary follow up at 21 months following the surgery, her unaided visual acuity in the left eye was 20/20 P, N6. The patch graft was in place with no evidence of any recurrence. At the final follow up at 6 years following surgery, her unaided visual acuity was 20/20, N6 for distance and near respectively, without any evidence of recurrence [Figure - 2].


  Discussion Top


Corneoscleral cysts may be spontaneous in onset or may occur following trauma or surgery. Our patient had a spontaneous onset hematic cyst without any history of previous trauma or surgery. Simple aspiration of these cysts may result in recurrence,[1] as happened in our patient. However, surgical excision of the cyst with lamellar patch grafting proved to be an effective modality of treatment. The young age of presentation of our patient, along with the absence of any history of trauma or surgery, points to a developmental origin of the cyst. Although no connection with the anterior chamber or Schlemm's canal was noted, a defect in the perilimbal sclera strengthens the possibilty of sequestration of conjunctival epithelium within the scleral defect as the possible origin of the cyst.

The presence of a fluid level within the cyst, has been noted by various authors.[1],[2],[4] This has been described as desquamated debris that settles down. Presence of brownish looking tissue within the cyst which was histopathologically proven to be lacrimal tissue, has also been reported.[2] In our case, presence of ghost cells on histopathology, suggests bleeding within the cyst. The possible origin of the bleeding is from a break in an adjoining conjunctival blood vessel. Spontaneous onset intracorneal hematoma has been described by Kachi and Hirano[5] in an elderly lady with ghost vessels and corneal opacity. The causes of intracorneal hematoma as proposed by Muenzler[6] include intraocular surgery, ocular trauma, inflammatory corneal disease like corneal ulcer and contact lens wear. None of these factors were present in our patient.

UBM is a useful tool in the management of these cystic lesions. It may help in assessing the posterior extent, as well as the contents of the cyst. The typical description on UBM, is of a cystic lesion with high reflective wall, with low reflective internal echoes.[7] Presence of blood within the cyst can give rise to high reflective internal echoes.[5]

Visual impairment and unacceptable cosmesis form the main indications for treatment. As it presents in the early years of life, it may be amblyogenic, when it involves the visual axis or causes significant alterations of the corneal curvature. Although spontaneous resolution of a corneal cyst by spontaneous drainage of the cyst into the anterior chamber, has been described,[1] the cysts usually require surgical intervention. Aspiration of the cyst contents has been known to fail.[1],[4] Reed and Dohlman[1] tried aspiration in two cases, both of which recurred within a short period of time. Other surgical modalities like incision on the anterior cyst wall,[1],[8] excision of the cyst wall with or without chemical or electrocautery,[1] has been tried with variable success. In their series of three cases, Rao et al[2] have excised the anterior wall, cauterized the posterior wall with 20% Tricholoracetic acid and reported no recurrence at the end of 6 months. Sano et al[3] have tried excision of the cyst with lamellar keratoplasty with frozen corneal tissue and also did not report any recurrence. Aspiration of the cyst contents failed in our case too and the cyst recurred within one month. Excision of the cyst with a patch graft to cover the scleral defect and amniotic membrane grafting without any chemical cautery, was effective in preventing recurrence in our case. Use of an amniotic membrane in this case was to enhance epithelial healing and reduce fibrosis and need not be used in all cases.

 
  References Top

1.
Reed JW, Dohlman CH. Corneal cysts. Arch Ophthalmol 1971;86:648-52.  Back to cited text no. 1
[PUBMED]    
2.
Rao SK, Fogla R, Biswas J, Padmanabhan P. Corneoscleral epithelial cysts: Evidence of developmental etiology. Cornea 1998;17:446-50.  Back to cited text no. 2
[PUBMED]  [FULLTEXT]  
3.
Sano Y, Okamoto S, Nishida K, Sotozono C, Kinoshita S. Peripheral lamellar keratoplasty for corneoscleral cyst: Three case reports. Cornea 1999;18:233-6.  Back to cited text no. 3
[PUBMED]  [FULLTEXT]  
4.
Liakos GM. Intracorneal and sclerocorneal cysts. Br J Ophthalmol 1978;62:155-8.  Back to cited text no. 4
[PUBMED]    
5.
Kachi S, Hirano K. Ultrasonographic biomicroscopic study of an intracorneal hematoma. Cornea 2002;21:421-3.  Back to cited text no. 5
[PUBMED]  [FULLTEXT]  
6.
Muenzler WS. Intracorneal hemorrhage. Am J Ophthalmol 1973;76:440-2.  Back to cited text no. 6
[PUBMED]    
7.
Rao SK, Padmanabhan P, Fogla R, Bhende MP. Ultrasound biomicroscopy of an intracorneal epithelial cyst. Cornea 2000;19:249-50.  Back to cited text no. 7
[PUBMED]  [FULLTEXT]  
8.
Ruedemann AD Jr. A corneoscleral epithelial inclusion cyst, a rarely described clinieopathological entity. Am J Ophthalmol 1956;41:316-7.  Back to cited text no. 8
[PUBMED]    


    Figures

  [Figure - 1], [Figure - 2]



 

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