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 Table of Contents  
Year : 2018  |  Volume : 19  |  Issue : 1  |  Page : 24-29

Ultrasound biomicroscopy as a guideline for management of secondary iris cysts: a case series study

Department of Ophthalmology, Faculty of Medicine, Tanta University, Tanta, Egypt

Date of Submission30-Jun-2017
Date of Acceptance18-Oct-2017
Date of Web Publication1-Feb-2018

Correspondence Address:
Rabab M El-Seht
Department of Ophthalmology, Faculty of Medicine, Tanta University Hospital, 31527 Tanta
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/DJO.DJO_45_17

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The aim of this study was to evaluate the role of ultrasound biomicroscopy (UBM) in diagnosis, decision of intervention, and follow-up monitoring of secondary iris cysts.
Patients and methods
This case series study included 17 patients diagnosed clinically of having secondary iris cysts. History and full ophthalmological examination included visual acuity testing and slit lamp examination. UBM and B-scan ultrasound were performed for all cases. The study cases were divided into two groups according to the management plan (surgical management group and follow-up group). The follow-up period was 1 year.
The study included 17 cases with unilateral secondary iris cysts. They were five females and 12 males, with age range from 3.0 to 44 years and a mean of 9.01±10.76 years. The clinical presentations such as blurring of vision, uveitis, red eye, ocular pain, or disfiguring intraocular swelling were insignificantly related to the different management groups (P>0.05). Angle closure and corneal touch (detected by UBM) were significantly present in the surgically managed cases, with P values of 0.003 and 0.009, respectively. The cyst size dimensions and its relation to the visual axis were detected with an insignificant difference between both groups.
UBM had a great value in the diagnosis of secondary iris cysts. Certain UBM findings were very important in deciding the different management plans and follow-up monitoring.

Keywords: inclusion cysts, monitoring of iris cyst growth, pearl cysts, penetrating ocular trauma, serous cysts

How to cite this article:
El-Seht RM. Ultrasound biomicroscopy as a guideline for management of secondary iris cysts: a case series study. Delta J Ophthalmol 2018;19:24-9

How to cite this URL:
El-Seht RM. Ultrasound biomicroscopy as a guideline for management of secondary iris cysts: a case series study. Delta J Ophthalmol [serial online] 2018 [cited 2019 Mar 18];19:24-9. Available from: http://www.djo.eg.net/text.asp?2018/19/1/24/224569

  Introduction Top

Secondary iris cysts develop because of ocular trauma or intraocular surgery or in cases with prolonged use of some topical drugs [1],[2],[3]. The delay in iris cyst diagnosis may result in intractable deprivation amblyopia in children or secondary glaucoma and visual affection in adults [4]. Traumatic iris cysts are difficult to manage and may have a poor visual outcome in cases associated with postoperative complications or recurrence [5]. Iris cyst excision usually needs meticulous surgical maneuvers depending on the size and the site of the iris cyst [6].

The aim of this study was to evaluate the role of ultrasound biomicroscopy (UBM) as an objective tool in proper and accurate diagnosis of secondary iris cysts to avoid unnecessary surgical intervention.

  Patients and methods Top

This case series study included 17 patients with unilateral secondary iris cysts who attended the Ultrasound Unit at Tanta University Eye Hospital during the period from August 2013 to August 2015. This study was adherent to the principles of the Declaration of Helsinki and has been approved by the Institutional Ethical Committee. All patients signed a written informed consent to participate in the study. Patients with primary iris cysts or iris tumors and those with recurrent iris cysts following previous surgical excision were excluded from the study. All patients were subjected to full history taking including different eye complains and full ophthalmological examination including measurement of uncorrected distance visual acuity and corrected distance visual acuity (CDVA) by Snellen’s E chart or Allen’s cards in preschool children, detailed slit lamp anterior segment examination, dilated fundus examination, and intraocular pressure measurement.

All cases were examined by high-frequency UBM (50 MHz VuMAX; Sonomed Escalon, USA). B-scan ultrasonography was performed in cases with opaque media. The UBM reports in each group included qualitative and quantitative assessment as follows:
  1. Full description of the iris cyst.
  2. The size was measured in three dimensions in radial and transverse scans.
  3. The site of the cyst and its relation to the visual axis.
  4. The relationship to the surrounding anterior segment structures.
  5. The cornea, the anterior chamber depth, and the anterior chamber angle.

Cases were divided into two groups according to the UBM findings.

Group I: surgical management group (n=12): cases were planned for total excision of the iris cyst.
Group II: follow-up management group (n=5): cases were planned for follow-up at 4-month intervals without surgical intervention.

Statistical analysis

It was performed using statistical package for the social sciences software (version 17.0; SPSS Inc., Chicago, Illinois, USA). Qualitative data were summarized in percentage, and nonparametric tests of significance, such as Fisher’s exact test, were used to compare two proportions. The P value was two tailed, and statistical significance was set at 0.05.

  Results Top

This study included 17 patients with unilateral secondary iris cysts: five females and 12 males. The age of the patients ranged from 3 to 44 years, with a mean of 9.01±10.76 years.

The etiology of iris cysts and the clinical presentations of the cases were not significant guides for different management plans whether surgical or follow-up. Regarding the visual acuity, the difference in the CDVA measured in both groups of management was not significant (P=0.313). It was difficult to measure the visual acuity in seven uncooperative children (41.2%) with age less than 4 years. The CDVA of at least 20/200 was detected in 35.3% of cases and more than 20/200 in 23.5% of cases. The other clinical presentations such as uveitis, red eye, and intraocular disfiguring lesion were not statistically different between the two groups ([Table 1]).
Table 1: The clinical presentations and findings in different management groups

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Regarding the UBM findings detected in both groups of management, the following results were obtained:

The qualitative UBM data detected two types of secondary iris cysts (pearl cyst; 58.8% and serous cyst; 41.2%). The type of iris cyst was not a guiding finding for different management plans (P=0.949). Serous cyst had a thin, hyper-echogenic well-defined wall with a central anechoic pattern. Pearl iris cyst had a three-layered wall (outer thin hyper-reflective well-defined cyst wall, middle less reflective layer, and central anechoic mucus fluid with hyper-echogenic keratin particles) ([Figure 1],[Figure 2],[Figure 3]).
Figure 1: (a) A slit lamp photograph of serous iris cyst. (b) Irregular anterior chamber. (c) Small encapsulated stromal iris cyst. The cyst has a hyper-reflective wall with anechoic material within the cyst. Two dimensions were measured in radial scan (2.24 and 3.06 mm). (d) Corneal touch with edema. (e) The iris cyst was away from the visual axis with an open angle.

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Figure 2: (a) A slit lamp photograph of pearl iris cyst. (b) Intrastromal iris cyst with a thin hyper-reflective wall, moderate reflective middle layer, hyper-reflective particles inside the cyst; three-layers filled with mucous within the cyst (a mantle, mucus content, and keratin particles at the center). (c) Irregular anterior chamber. (d) There was mild lens opacity and rupture of lens zonules. (e) The angle was closed with corneal touch at the lower nasal area.

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Figure 3: Ultrasound biomicroscopy of giant serous iris cyst: (a) hyperechogenic cyst wall in the anterior chamber. (b) The angle is closed. (c) The iris cyst touching the cornea with cloudiness (hyper-reflectivity) with increased corneal thickness and shallow anterior chamber. (d) The iris cyst was at the visual axis and obscures the anterior segment structures.

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The quantitative UBM parameters such as angle closure and corneal touch with or without corneal edema were present in a significantly higher value (83.3 and 75%, respectively) in the surgically managed group compared with the follow-up group (P<0.05). Regarding other UBM parameters such as the site of the iris cyst in relation to the visual axis, it was found that 76.5% of iris cysts away from the visual axis were managed surgically, whereas 100% were managed by follow-up, with nonsignificant difference between both groups (P=0.26). Regarding the cyst size, the giant iris cysts (100%) were managed totally by surgical management, whereas 83.3% of small cysts were managed also surgically, so the cyst size also had a nonsignificant difference between both groups (P=1.000, [Table 2]).
Table 2: The guiding ultrasound biomicroscopy findings in different management groups

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The size of the iris cysts was measured in three dimensions by the UBM as a quantitative function for diagnosis and follow-up. Two giant iris cysts (obscuring the anterior segment structures) were encountered with average dimensions of 7.1, 0.5, and 3.0 mm. Fifteen cases had small sized iris cysts with average dimensions of 2.0, 2.24, and 1.3 mm. During the follow-up period of 1 year after management, in surgically managed group, no recurrence was detected. In the follow-up group, gradual increase in the size was detected in one (20%) case, with increase of 0.18, 1.55, and 0.5 mm in the three dimensions ([Figure 4]).
Figure 4: Ultrasound biomicroscopy showing gradual increase in different iris dimensions (a–c frames) at 4-month interval.

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  Discussion Top

Secondary iris cysts represent a great challenge for ophthalmologists. Many cases in this study including children presented with disfiguring or growing cystic swelling inside the eye with no other obvious eye complaints. However, other cases of secondary iris cysts showed different clinical presentations and eye complaints such as red eye, recurrent attacks of uveitis, and high intraocular pressure. The study performed by Venkateswaran et al. [7] documented that iris inclusion cysts usually present to ophthalmologists with different diagnostic challenges. Similarly, in the present study, the clinical presentations of cases with secondary iris cysts were inadequate to have a proper decision of management. Venkateswaran et al. [7] recommended the need for anterior segment optical coherence tomography, UBM, and histopathology to facilitate timely and accurate diagnosis and to review the range of available therapeutic modalities. UBM had distinctive and well-descriptive criteria for secondary implantation cysts. These criteria could differentiate them into many subtypes [8],[9]. In this study, UBM exploration was essential to determine the mass characteristics if cystic or solid. It allows the evaluation of the lesions that cannot be assessed clinically especially those at the retropupillary areas and opaque media in uncooperative children with no obvious eye complaint. The therapeutic challenges had the same importance as the diagnostic ones. Many studies documented that the complications associated with the iris cysts were infrequent than those associated after the surgical removal, which frequently had a destructive nature to the anterior segment structures [10]. Iris inclusion cysts have overall poor surgical outcome owing to the extensive proliferation of epithelial cells, which may explain why the condition takes a rapid course in younger patients and why severe complications are encountered postoperatively [5]. In general, the treatment of all anterior segment masses needs great experience for preservation of ocular structures [11],[12],[13],[14]. In many studies, the treatment of these lesions remains controversial, without proper decision-making criteria for management. In the present study, not all cases with iris cysts were managed surgically as 29.4% of the cases were managed by follow-up without intervention. The decision of management was guided by certain UBM findings. The UBM findings and the descriptive criteria had a significant value in guiding the plan of management especially in cases that did not need surgical interference; their absence was a significant guideline for follow-up with no surgical interference. These findings included angle closure, corneal touch, size, site of the cyst, and its relation to the visual axis or to the anterior segment structures. Other studies reported in addition that UBM was useful for objective follow-up and monitoring of the lesion [15],[16],[17]. In the current study, UBM documented increase in the size of the cyst in one case that was managed without surgical intervention. No recurrence occurred in surgically managed cases as UBM acts as a good monitoring tool. Aguilar et al. [10] documented that the possibility of recurrence of iris cysts after aspiration or partial removal is high.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Politzer G. The etiology of spontaneous epithelial cysts of the iris. Albrecht Von Graefes Arch Ophthalmol 1953; 153:497–503.  Back to cited text no. 1
Hvidberg-Hansen J, Larsen FE. Congenital iris cyst. A case studied by light and electron microscopy. Acta Ophthalmol 1972; 50:501–514.  Back to cited text no. 2
Hunter WS. Aberrant intra-ocular lacrimal gland tissue. Br J Ophthalmol 1960; 44:619–625.  Back to cited text no. 3
Shields JA. Primary cysts of the iris. Trans Am Ophthalmol Soc 1981; 79:771–809.  Back to cited text no. 4
Gupta V, Rao A, Sinha A, Kumar N, Sihota R. Post-traumatic inclusion cysts of the iris: a long-term prospective case series. Acta Ophthalmol Scand 2007; 85:893–896.  Back to cited text no. 5
Rishi P, Rishi E, Biswas J, Nandi K. Clinical and histopathological features of post traumatic iris cyst. Indian J Ophthalmol 2008; 56:518–521.  Back to cited text no. 6
Venkateswaran N, Ching ST, Fischer W, Lee F, Yeaney G, Hindman HB. The diagnostic and therapeutic challenges of post-traumatic iris implantation cysts: illustrative case presentations and a review of the literature. Case Rep Ophthalmol Med 2015; 2015:375947.  Back to cited text no. 7
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Finge PT, McCormick SA, Lombardo J, Tello C, Ritch R. Epithelial inclusion cyst of the iris. Arch Ophthalmol 1995; 113:777–780.  Back to cited text no. 9
Aguilar LP, Cata CF, Seres MP. Ultrasound provides important information about cyst characteristics and constitutes an important tool to differentiate neoplastic lesions. Arch Soc Esp Oftalmol 2016; 91:81–85.  Back to cited text no. 10
Shin SY, Stark WJ, Haller J, Green WR. Surgical management of recurrent iris stromal cyst. Am J Ophthalmol 2000; 130:122–123.  Back to cited text no. 11
Haller JA, Stark WJ, Azab A, Thomsen RW, Gottsch JD. Surgical approaches to the management of epithelial cysts. Am J Ophthalmol 2003; 135:309–313.  Back to cited text no. 12
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Tsai JC, Arrindell EL, O’Day DM. Needle aspiration and endo diathermy treatment of epithelial inclusion cyst of the iris. Am J Ophthalmol 2001; 131:263–265.  Back to cited text no. 14
Marigo FA, Esaki K, Finger PT, Ishikawa H, Greenfield DS, Liebmann JM et al. Differential diagnosis of anterior segment cysts by ultrasound bio-microscopy. Ophthalmology 1999; 106:2131–2135.  Back to cited text no. 15
Pavlin CJ, Harasiewicz K, Sherar MD, Foster FS. Clinical use of ultrasound biomicroscopy. Ophthalmology 1991; 98:287–295.8.  Back to cited text no. 16
Ishikawa H, Schuman JS. Anterior segment imaging: ultrasound biomicroscopy. Ophthalmol Clin North Am 2004; 17:7–20.  Back to cited text no. 17


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1], [Table 2]


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