Conjunctival inclusion cyst following manual small incision cataract surgery

Conjunctival inclusion cysts are benign, fluid-filled thin-walled sac-like swellings of congenital or acquired origin. They comprise 6%–13% of conjunctival lesions and about 80% of cystic conjunctival lesions.[1] Inclusion cysts in conjunctiva may occur following trauma, strabismus surgery,[2] pars plana vitrectomy,[3] ptosis surgery,[4] and manual small incision cataract surgery.[5] Manual small incision cataract surgery is still widely performed in developing countries like India. Though rare, literature search revealed some reports of conjunctival cysts following this surgery. The etiopathogenesis of the condition involves implantation of conjunctival epithelial cells deep into the scleral tunnel wound. Unintended deeper scleral dissection and excessive cautery application over scleral vessels can lead to delay in wound healing. In this case series, we report two cases of conjunctival implantation cysts which developed following otherwise uneventful manual small incision cataract surgery. Case History Case 1 A 63-year-old male patient presented to us with a painless swelling in the right eye since 2 months which was progressively increasing in size. He gave history of undergoing small incision cataract surgery 4 months ago. There were no complications in the intraoperative or postoperative period. On examination, a solitary, thin-walled, cystic swelling measuring 14 × 8 mm was seen arising from the scleral tunnel incision site at the superior limbus as seen in Fig. 1. The rest of the ophthalmic examination was unremarkable.Figure 1: A single, thin-walled, cystic swelling measuring 14 × 8 mm was seen arising from the scleral tunnel incision site at the superior limbus in case 1Case 2 A 56-year-old female patient presented with complaints of irritation and foreign body sensation under the left eyelid since 6 months. She gave history of undergoing uneventful small incision cataract surgery with PCIOL implantation 2 years ago. On examination, a single conjunctival cyst measuring 5 × 6 mm was seen arising from the tunnel incision at the superior limbus as seen in Fig. 2.Figure 2: A single conjunctival cyst measuring 5 × 6 mm was seen arising from the tunnel incision at the superior limbus in case 2In both the cases, the cysts were excised after infiltrating the surrounding conjunctiva with 2 ml of 2% xylocaine. Incision was made around the cyst. Careful dissection was carried out all around after holding the cyst firmly [Fig. 3].Figure 3: Surgical excision of cyst in totoCyst was separated from all sides taking care not to rupture the thin wall. After complete excision in each case, the specimen was sent for histopathological examination to confirm the diagnosis [Fig. 4].Figure 4: Histopathological examination showing conjunctival cyst lined by stratified squamous epithelium filled with desquamated cells and proteinaceous materialHistopathological examination showed conjunctival cyst lined by stratified squamous epithelium filled with desquamated cells and proteinaceous material. Postoperatively, the wound healed well as seen in Fig. 5 without any recurrence over a period of 6 months.Figure 5: Postoperative appearance in case 1 after excision of cystDiscussion Acquired conjunctival cysts have been reported following small incision cataract surgery. Sequestration of conjunctival epithelial cells into deeper layers during either wound construction or dragging of conjunctival tissue at the time of intraocular lens insertion contributes to the pathogenesis of the cyst. Meticulous dissection of the overlying conjunctiva with separation from the underlying Tenon’s capsule before proceeding to scleral incision is thought to prevent the formation of conjunctival cyst.[6] Careful insertion of intraocular lens with minimal conjunctiva manipulation is proposed to avoid implantation of epithelial cells into the incision site, thereby minimizing the chance of cyst formation later on.[7] Patients usually present with painless cystic swelling or foreign body sensation under the eyelid at the site of sclerocorneal incision wound after a few months of surgery. An important differential diagnosis for this finding includes the formation of unintentional filtering bleb. In trabeculectomy surgery, bleb is created intentionally to allow aqueous drainage from the anterior chamber to subconjunctival space, thereby reducing high intraocular pressure. Krishnacharya[7] has reported the formation of cystic bleb which had communication with the anterior chamber, seen as fish mouthing of its internal lip on gonioscopy. Such an overfiltering bleb may lead to hypotony and its complications. Hence, careful preoperative evaluation like tonometry, visual acuity assessment, and gonioscopy must be performed to rule out a bleb. Careful surgical excision should be done without rupturing the cyst wall to prevent any recurrence. Conclusion This case series emphasizes the importance of diligent wound construction in small incision cataract surgery. Avoiding overuse of cautery and unnecessary conjunctival tissue handling during surgery can prevent the formation of postoperative inclusion cyst of the conjunctiva. However, upon formation of such a cyst, filtering bleb should be ruled out by vigilant examination at slit lamp to prevent vision threatening complications due to hypotony. The surgical excision should be done very patiently to avoid accidental rupture of the cyst.[8] Follow-up visits should be done to look for any recurrence. Authors’ contributions Dr Vinaya Mallya- Concept, definition of intellectual content, literature search, data analysis, manuscript preparation, manuscript editing and manuscript review. Dr Shashikala P – Concept, design, definition of intellectual content, data acquisition, manuscript editing and manuscript 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 his/her/their consent for his/her/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.