Excision of post small incision cataract surgery conjunctival inclusion cyst.

Dear Editor,

We read with great interest the article by Narayanappa et al.[1] Authors have presented a rare entity of post small incision cataract surgery (SICS) conjunctival inclusion cyst and managed both the cases beautifully without recurrence. But in both the cases, the cyst was ruptured during excision.[1] Acquired conjunctival inclusion cysts occur following traumatic or surgical implantation of conjunctival epithelium.[23] They are thin walled, difficult to excise and rupture is common. Complete excision is recommended for big cysts to prevent recurrences.[45] We would like to share suggestions to excise cysts without rupture. We managed two cases of conjunctival inclusion cyst following SICS without rupture and recurrence.

Both the patients were males, aged 57 and 62 years. They came 6 and 15 months, respectively, after SICS, with complaints of foreign body sensation and small growth in the left eye. Growth was increasing in size. On examination, case 1 had best corrected visual acuity (BCVA) in right eye (RE) 20/40 with nuclear cataract; left eye (LE) was psuedophakic with BCVA 20/30. Conjunctival cyst of 6×8 mm was present on nasal side of limbus at 10 o' clock position [Fig. 1a, b]. Case 2 had pseudophakia with BCVA 20/30 in both eyes. Conjunctival cyst of 7 ×6 mm was present at 12 o'clock at limbus in the left eye [Fig. 2].

Figure 1

(a) Case 1 left eye conjunctival inclusion cyst nasal side at 10 o'clock position; (b) case 1 close-up of conjunctival inclusion cyst

Figure 2

Case 2 left eye conjunctival inclusion cyst at 12 o' clock position

Both cases were operated under subconjunctival anesthesia by injecting 2 ml of 2% xylocain around the cyst. Incision was given around the cyst with 15 number blade [Fig. 3]. Conjunctiva above the cyst was kept intact, which helped to hold the cyst firmly, while blunt dissection was carried out. Care was taken to keep the tip of the corneal scissors away from the cyst. After separating the cyst from all sides [Fig. 4], its base was dissected out very carefully as it is the commonest side for rupture. Conjunctiva above the cyst was pulled in the opposite direction of the dissection area, so that fibrous attachments at the base of the cyst were stretched and became easily visible [Fig. 5]. They could be cut under direct visualization. It was easy to separate sides and base of the cyst and to remove it without rupture. Conjunctiva was re-positioned at limbus. Excised cysts were examined histopathologically to confirm the diagnosis [Figs. 6, 7]. They were proved to be conjunctival cyst, lined by stratified squamous epithelium and filled with desquamated cells and proteinaceous material inside. Follow-up in case 1 was 18 months [Fig. 8]and in case 2 it was 5 months [Fig. 9] without recurrence.

Figure 3

Incision around the cyst

Figure 4

Cyst separated from all sides, intact conjunctiva is seen on the cyst

Figure 5

Conjunctiva above the cyst pulled in opposite direction to visualize fibrous attachments at base

Figure 6

Histopathology of case 1 conjunctival cyst. (H and E, ×40). Showing cyst lined by stratified squamous epithelium and filled with desquamated cells and proteinaceous material

Figure 7

Histopathology of case 2 conjunctival cyst. (H and E, ×40).Showing cyst lined by stratified squamous epithelium and filled with desquamated cells and proteinaceous material

Figure 8

Case 1 follow-up after 12 months

Figure 9

Case 2 follow-up after 4 months

To conclude, following four things are suggested for excision of conjunctival inclusion cyst without rupture.

Conjunctiva above the cyst is kept attached to cyst. It provides firm hold to dissect.

Tip of corneal scissors is kept away from cyst.

To dissect base under direct visualization, conjunctiva above the cyst is pulled in opposite direction of dissection area.

It requires patience to excise the delicate cyst.