|LETTER TO THE EDITOR
|Year : 2011 | Volume
| Issue : 5 | Page : 406-407
Postoperative conjunctival cyst: A masquerade
Bhargavi Pawar, Manjoo Reddy, Sripathi Kamath
Department of Ophthalmology, St. Johns Medical College Hospital, Bangalore, India
|Date of Web Publication||9-Aug-2011|
No. 21, 2nd main, 1st Cross, Domlur 2nd stage, Bangalore 560 071
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Pawar B, Reddy M, Kamath S. Postoperative conjunctival cyst: A masquerade. Indian J Ophthalmol 2011;59:406-7
In response to the article published by Narayanappa et al., we would like to share our experience in the occasional misdiagnosis of such conjunctival cystic swellings. 
A 60 year old male patient presented with diffuse conjunctival swelling and foreign body sensation, 2 months following manual small incision cataract surgery (SICS). His intraoperative and immediate postoperative periods were uneventful and he had completed the scheduled 6-week course of topical steroids. His best-corrected visual acuity was 20/30. On examination, there was a diffuse swelling present in the superior conjunctiva overlying the wound, measuring 16 mm × 13 mm [Figure 1]. Rest of the anterior and posterior segment examination was normal. Intraoperative pressure (IOP) measured 12 mm Hg in both eyes. A provisional diagnosis of postoperative conjunctival inclusion cyst was made and the patient was taken up for cyst needling/puncture with a 26 G needle under aseptic precautions as an outpatient procedure.
On cyst puncture, clear fluid emerged from the cyst with subsequent progressive shallowing of the anterior chamber, indicating a communication between cyst and anterior chamber, similar to filtering blebs. Patient was started on antibiotics, and a pressure was bandage applied for 12 hours. On reopening the bandage, despite the anterior chamber being formed, a leak persisted as evidenced by a positive Seidel's test. The patient was taken up for wound exploration and resuturing under local anesthesia. On exploration, a wound gape (fish mouthing) was found, which was secured by 10-0 nylon interrupted sutures. Postoperatively, a short course of topical steroidantibiotic combination was given. The patient was asymptomatic and had no similar recurrences till the last follow up (6 months).
Filtering blebs or fistulae between the anterior chamber and subconjunctival space are intentionally produced in surgeries such as trabeculectomy, but can occur as a complication of an otherwise uneventful cataract surgery and masquerade as subconjunctival inclusion cyst in the early postoperative period. The reported incidence of inadvertent filtering blebs following cataract surgery ranges from 1% to 7.7%.  With the advent of clear corneal phacoemulsification, the incidence of these cysts has reduced. The most common reason postulated for its occurrence is the poor wound healing response following surgery, with egress of aqueous into deeper portions of the scleral tunnel and subconjunctival space.  Higher incidence of endophthalmitis and hypotony-related complications has been reported in these patients.  The cause for such leaks can be attributed to poorly constructed scleral wounds, large incisions, excess cautery and failure to recognize microleaks intraoperatively. , It may prove useful to investigate these patients for underlying systemic causes associated with scleral thinning and delayed healing. Prompt recognition of such fistulas using gonioscopy and ultra sonography biomicroscopy (UBM) helps in better management. 
A simple procedure such as needling may uncover a deeper problem such as a communicating fistula, and its risks should be kept in mind. We should perhaps, instead, exercise caution by proper wound exploration under sterile precautions and secure the incision with sutures if required to avoid untoward consequences. This letter stresses the importance of ruling out the possibility of filtering bleb encysted or communicating, in cases presenting with postoperative subconjunctival cystic swelling.
| References|| |
Narayanppa S, Dayananda S, Dakshayini M. Conjunctival inclusion cysts following small incision cataract surgery. Indian J Ophthalmol 2010;58:423.
Swan KC, Cambell L. Unintentional filtration following cataract surgery. Arch Ophthalmol 1964;71:43.
Gimbel HV, Sun R, DeBroff BM. Recognition and management of internal wound gape. J Cataract Refract Surg 1995;21:121-4.
Stonecipher KG, Parmley VC, Jensen H, Rowsey JJ. Infectious endophthalmitis following sutureless cataract surgery. Arch Ophthalmol 1991;109:1562-3.
Jain S. Inadvertent filtering bleb following sutureless cataract surgery. Indian J Ophthalmol 2005;53:1968.