Giant iris cyst secondary to closed globe injury

A 19-year-old young otherwise healthy male patient presented with a sudden onset, painless, progressive diminution of vision in the left eye for the past 6 months. The patient reported a history of injury to the left eye with a cricket ball, following which he developed symptoms. The best corrected distant visual acuity in the right eye was 20/20, and the left eye was finger counting close to the face. The intraocular pressure in the right eye was 14 mm Hg, and the left eye was 26 mm Hg. Slit lamp examination of the left eye [Fig. 1a] revealed an edematous cornea, a large brownish cyst with clear fluid, encompassing almost three-fourth of the anterior chamber, with a clear lens. The posterior extent of the cyst was not visible, obscuring the view for fundus examination. The right eye examination was unremarkable. The anterior segment optical coherence tomography [Fig. 1b] showed an edematous cornea with a large iris cyst in the anterior chamber. Ultrasound biomicroscopy [Fig. 1c] revealed a large fluid-filled cyst of iris encompassing the entire anterior chamber which did not extend beyond the anterior chamber. A diagnosis of left eye iris cyst secondary to closed globe injury was made, and planned for surgical excision of iris cyst after a short course of steroids and antiglaucoma medications to control the intraocular pressure. Surgical excision of the large cyst in toto was done using fluid aspiration followed by removal with internal limiting membrane forceps and vitrectomy cutter. The procedure was uneventful. After the cyst excision, the patient was managed with frequent high potency topical steroids and oral steroids for 4 weeks. The corneal edema and anterior chamber inflammation subsided with subsequent improvement in visual acuity to 20/80 in the left eye. However, the risk of recurrence of cyst and need for second surgical intervention was clearly explained to patient and kept on long term follow-up.Figure 1: (a) Slit lamp photography showing brown colored cystic lesion of the iris encompassing almost three-fourths of the anterior chamber. (b) Anterior segment optical coherence tomography showing an iris cyst as a fluid-filled sac in the anterior chamber. (c) Ultrasound biomicroscopy of the lesion showing large, round cysts with clear fluid not extending beyond the irisDiscussion Post-traumatic iris cysts are complex to manage due to the high risk of recurrence and difficulty in complete surgical excision.[1] Secondary iris cyst can result from open globe injury, closed globe injury, surgery, uveitis, drug induced, tumor associated, systemic disorder, and iatrogenic.[2,3] Post-traumatic iris cysts are more commonly associated with open globe injury than closed globe injury although the possibility of latter cannot be ruled out. It is hypothesized that a closed globe injury causes iris cyst due to altered iris pigment epithelium.[4,5] Management of such post-traumatic iris cyst poses challenges due to high risk of recurrence, inflammation and intractable secondary glaucoma, especially in younger age group. Treatment options include conservative management of inflammation and raised intraocular pressure, fine needle aspiration with or without anti-mitotics, laser iridotomy and surgical excision.[1] Complications such as secondary corneal decompensation, recurrence, cataract, and intractable glaucoma often result in poor prognosis in these cases.[6] Authors’ contributions Akshaya Balaji: Concept, manuscript editing, and review. Devashree Moktan: Manuscript preparation and literature search. Tanuj Dada: Manuscript editing and review. Shorya Vardhan Azad: Manuscript editing and review. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published, and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship: Nil. Conflicts of interest: There are no conflicts of interest.