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Epithelial iris cyst treatment with intracystic ethanol irrigation
Epithelial Iris Cyst Treatment with Intracystic Ethanol Irrigation Zohreh Behrouzi, MD,1 Aliasghar Khodadoust, MD2 Purpose: To report the therapeutic effects of ethanol (ETOH) irrigation into epithelial iris cysts (EIC). Study Design: Retrospective noncomparative interventional case series. Participants: 102 eyes of 102 patients aged between 4 and 71 years with EIC, with 4 months to 15 years follow-up. Intervention: Under local or general anesthesia, cyst fluid was drained gently via a 27-gauge needle. Without changing the position of the needle, the syringe was replaced with one containing an equal amount of ETOH to the drained cyst fluid, and ETOH was gently irrigated into the cyst. The ETOH was left inside until the cyst wall turned white (about one minute). The ETOH was aspirated and the needle removed. After the irrigation, patients were treated with atropine 1% and dexamethasone 5 ml eye drops. Results: Pretreatment findings suggest that the bases of all the cysts were connected either to incisions made during previous operations or to sites of laceration from penetrating trauma. Three types of cysts were identified: single in 88 patients, double in 11 patients, and triple in 3 patients. The cyst wall contained keratic precipitates in three cases, and was vascularized in two cases. Of the 102 cases, 3 were excluded from the study because the EIC was connected to the anterior chamber. Follow-up indicated that 93 cysts resolved after the first irrigation, 3 after the second irrigation and 2 after the third irrigation and 1 case did not respond after third irrigation. The cysts clinically shrank in 78 cases by 1 day after ETOH irrigation and in 20 cases by 2 weeks after ETOH irrigation. Anterior chamber reaction was observed the day after ETOH irrigation in two cases, probably as a result of ETOH leakage, and in nine cases without apparent ETOH leakage. All were treated with dexamethasone 10 ml eye drop for 2 weeks. Intraocular pressure (IOP) normalized in 11 out of 21 cases who had IOP⬎20 mmHg before ETOH irrigation. Conclusion: Ethanol irrigation is a cost-effective and safe procedure, and we recommend consideration of the procedure for treatment of iris epithelial cysts. Ophthalmology 2003;110:1601–1605 © 2003 by the American Academy of Ophthalmology.
Epithelial invasion of the iris stroma is a rare but potentially blinding complication of penetrating anterior segment trauma or surgery. The origin of the cysts is not always known but they may be the result of trauma or surgical implantation of epithelium, iris incarceration, or poor wound closure during cataract surgery. Histologically, the cysts are lined by a multilayered epithelium resembling cornea or conjunctival epithelium, which may even contain goblet cells. The cysts generally contain clear fluid. They may become large and cause visual problems by covering the pupil, and in some cases they may occlude the angle and cause secondary angle-closure glaucoma.1,2 Many techniques have been devised to treat EICs, such as surgical excision of the cyst and surrounding iris tissues,3,4
aspiration of the cyst, photocoagulation, and injection of chemicals into the cyst such as iodine 1%, pure carbonic acid, and trichloroacetic acid 10%.4 Surgical excision, aspiration,5 laser therapy, and photocoagulation6, 7 are invasive techniques with potentially serious complications such as bleeding, endophthalmitis, cataract, and cyst rupture with conversion to the sheet form of epithelial ingrowth. The success rate and the side effects of methods using chemical compounds are not well documented. Recurrence of EICs has followed many previous surgical therapies, presumably due to incomplete excision. The rationale for ethanol (ETOH) use is that this chemical inflames the cyst wall and destroys the lining epithelium. The large number of cases reviewed in this manuscript also provides an opportunity to consider probable etiology, structure, contents, and types of EICs.
Originally received: October 15, 2001. Accepted: January 18, 2003. Manuscript no. 210509 1 Department of Ophthalmology, Emam Hossein Hospital, Shahid Beheshti University School of Medicine, Tehran, Iran. 2 Department of Ophthalmology, Yale University School of Medicine, New Haven, Connecticut. Presented at the American Academy of Ophthalmology Annual Meeting, New Orleans, Louisiana, November 2001. Reprint requests to Zohreh Behrouzi, MD, 9th FL, DRS BLDG, Royan Alley, Keshavarz BLVD, Tehran 14159, Iran.
Material and Methods
© 2003 by the American Academy of Ophthalmology Published by Elsevier Inc.
Patients During the last 18 years (1982–2000), 102 consecutive patients (102 eyes) with EIC, 35 female and 67 male, aged between 4 and 71 years were referred to our center (Emam Hossein Hospital). All referred patients with this diagnosis were included in the study, excluding only those whose EICs were connected to the anterior chamber. Institutional review board approval was obtained from ISSN 0161-6420/03/$–see front matter doi:10.1016/S0161-6420(03)00543-8
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Ophthalmology Volume 110, Number 8, August 2003
Figure 2. Double iris cyst.
Figure 1. Steps taken to irrigate ethanol in epithelial iris cysts.
the local ethics committee and certified by the Vice-Chancellor for Research Affairs of the university. Before the treatment, a complete eye examination was done in all patients and their vision checked a using a Snellen chart. Their intraocular pressure (IOP) was recorded with applanation tonometry (Haag Streit, Koeniz, Switzerland). The status of the cornea, endothelium, lens, anterior chamber reaction, and anterior vitreous was examined with a silt lamp. The angle was evaluated using a Goldmann or Zeiss gonioscope. Echography was performed on those patients in whom a connection between the EIC and the posterior segment was suspected. Inflammation and elevated IOP were controlled before irrigation. Three of the patients were excluded from the study because their EICs were connected to the anterior chamber. Decrease in anterior chamber depth during aspirations of EIC fluid indicated anterior chamber connection. The patients’ medical records were reviewed regarding their history of previous trauma or surgeries. Institutional review board approval was obtained.
(Fig 1D). The ETOH was left inside the cyst for approximately 1 minute or until the cyst wall turned white, a sign of destruction of the lining epithelium. The ETOH was drained and the needle removed (Fig 1E). Because the risk of ETOH leakage into the anterior chamber was presumed higher for those patients who had previously undergone laser therapy, the duration of the ETOH irrigation in these cases was shortened because of concern that the wall of the cyst could be easily ruptured. Typically, the volume of alcohol for each irrigation was in the range of 0.05 cc to 0.18 cc and was felt to be the same volume as that of the cyst fluid that had been drained. After irrigation, patients were treated with that of atropine 1% four times per day for 4 to 5 days to dilate the pupil and help the deflated cyst walls stick together. Dexamethasone 5 ml eye drops (Sina Daro Drug Co., Tehran, Iran) were also prescribed to control the possible reaction of the anterior chamber and were maintained until the inflammation subsided. Patients were examined on the day of the irrigation, the next day, at 2 weeks and after 1 month. The patients were then referred to their own centers for further follow-up. The cyst normally collapsed and scarred after 2 to 4 weeks. The statistical tests used in this study were mean scores and percentages. The follow-up period was 4 months to 15 years (mean ⫾ SD ⫽ 3.85⫾4.1). In fact, most patients did not return to their original centers because treatment had been successful.
Ethanol Irrigation Procedure The procedure was done under local or general anesthesia depending on patient cooperation. Depending on the location of the EIC, the eye was stabilized with a superior rectus or inferior rectus traction suture (4 – 0 silk). A 27-gauge needle was inserted into the base of the cyst from approximately 2 mm posterior to the limbus, using a microscope with high magnification (Fig 1A, B) and the cyst fluid was gently aspirated. In cases of double or triple cysts (Fig 2), before draining the fluid the cysts were joined to each other by the tip of the needle. The process of drainage was terminated if the depth of the anterior chamber decreased. This decrease was an indication of the connection of the anterior chamber with the EIC, which meant a high risk of ETOH (96.2%) leakage into the chamber. After drainage of the fluid and the consequent shrinkage of the cyst, without changing the position of the needle the syringe was replaced with one containing an equal amount of ETOH (medical grade absolute ethyl alcohol) to the drained cyst fluid (Fig 1C). Ethanol was steadily irrigated into the cyst until it reinflated
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Figure 3. Precipitate level in epithelial iris cyst.
Zohreh and Asghar 䡠 Epithelial Iris Cyst Treatment with Ethanol Irrigation Table 1. Patient Demographics and Surgical Outcome No. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65
Age
Sex
43 51 55 9 64 60 42 5 25 60 57 47 60 58 46 52 70 69 70 65 5 57 9 32 61 69 54 44 50 65 65 58 51 42 57 54 46 55 52 42 68 68 69 70 66 65 62 22 24 33 32 57 71 69 61 36 59 60 64 59 60 4 7 19 20
M M M M M M F M M F F M M M F F M F M M M F M M M F M M F F M F F F F M M M M M F F F M M M M M F M M F M M F M M M F M F M F F M
Causes
Pupil Involvement
Trauma ICCE ⫹ VL ICCE ⫹ VL Trauma ICCE ⫹ VL ICCE ⫹ VL Trauma Trauma Trauma ICCE ⫹ VL ICCE ⫹ VL Trauma ICCE ⫹ VL ICCE ⫹ VL Trauma ICCE ⫹ VL ICCE ICCE ICCE ⫹ VL ICCE Trauma ICCE ⫹ VL Trauma Trauma ICCE ICCE ⫹ VL ICCE ⫹ VL Trauma Trauma ICCE ⫹ VL ICCE ICCE Trauma Trauma ICCE ⫹ VL ICCE ⫹ VL Trauma ICCE ⫹ VL ICCE ⫹ VL Trauma ICCE ⫹ VL ICCE ICCE ⫹ VL ICCE ⫹ VL ICCE ⫹ VL ICCE ⫹ VL ICCE Trauma Trauma Trauma Trauma ICCE ⫹ VL ICCE ⫹ VL ICCE ⫹ VL ICCE ⫹ VL Trauma ICCE ⫹ VL ICCE ⫹ VL ICCE ICCE ⫹ VL Tx Unknown Trauma Trauma ECCE ⫹ PCIOL
⫺ ⫹ ⫹ ⫺ ⫺ ⫺ ⫹ ⫺ ⫺ ⫺ ⫹ ⫹ ⫺ ⫹ ⫺ ⫺ ⫺ ⫺ ⫺ ⫺ ⫺ ⫹ ⫺ ⫹ ⫺ ⫺ ⫺ ⫺ ⫹ ⫺ ⫺ ⫺ ⫺ ⫹ ⫺ ⫺ ⫺ ⫹ ⫺ ⫹ ⫺ ⫺ ⫺ ⫹ ⫺ ⫺ ⫺ ⫺ ⫹ ⫹ ⫺ ⫺ ⫹ ⫺ ⫺ ⫹ ⫺ ⫹ ⫺ ⫺ ⫺ ⫺ ⫺ ⫹ ⫺
Vision before Irrigation
Vision after Irrigation
7/10 HM LP ⫺ 2 m CF 6 m CF HM ⫺ 9/10 2/10 LP HM 3/10 10 cm CF 10/10 4 m CF 2 m CF 4/10 6/10 Omitted ⫺ 10 cm ⫺ 10 cm 1/10 8/10 Omitted 10/10 HM 2 m CF 6 m CF 3/10 8/10 10 cm CF 3/10 1 m CF 9/10 LP 6/10 HM 2/10 7/10 8/10 LP 6/10 3/10 8/10 10/10 HM HM Omitted 4 m CF LP 5/10 4/10 LP 3/10 10 cm CF 7/10 6/10 4/10 ⫺ ⫺ LP 10/10
7/10 HM LP ⫺ 2 m CF 6 m CF 7/10 ⫺ 9/10 2/10 8/10 8/10 3/10 10 cm CF 10/10 4 m CF 2 m CF 4/10 6/10 Omitted ⫺ 10 cm ⫺ 9/10 1/10 8/10 Omitted 10/10 4/10 ⫺ ⫺ 3/10 8/10 10 cm CF 3/10 1 m CF 9/10 LP 6/10 HM 2/10 7/10 8/10 1/10 6/10 3/10 8/10 10/10 4/10 3/10 Omitted 4 m CF 3/10 5/10 4/10 2/10 3/10 4/10 7/10 6/10 4/10 ⫺ ⫺ 3/10 10/10
Postirrigation Finding Dense pupillary membrane Vitreous opacity
Dense papillary membrane
Vitreous opacity
Cataract
Dense papillary membrane Cataract
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Ophthalmology Volume 110, Number 8, August 2003 Table 1. (Continued) No.
Age
Sex
Causes
66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82
14 17 7 60 45 22 21 14 18 38 37 21 28 48 50 56 41
F F M M M F M F M F M M M M M M M
83 84 85
57 40 50
M M F
86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102
66 68 48 67 21 26 67 50 62 41 18 34 21 32 40 49 35
M M M M M M M F M F M F M M M F F
Trauma Trauma Trauma ECCE Trauma Tx Trauma Trauma Trauma Trauma Trauma Trauma Trauma ECCE Trauma Trauma ECCE ⫹ PCIOL Trauma Trauma ECCE ⫹ PCIOL ECCE ICCE Trauma ECCE Trauma Trauma ECCE Trauma ICCE Trauma Trauma Trauma Trauma Trauma Trauma Trauma Trauma
Pupil Involvement
Vision before Irrigation
Vision after Irrigation
⫺ ⫺ ⫺ ⫺ ⫹ ⫺ ⫺ ⫺ ⫺ ⫺ ⫹ ⫺ ⫹ ⫺ ⫹ ⫺ ⫺
7/10 6/10 ⫺ 9/10 HM 6/10 9/10 4/10 2/10 HM LP LP LP 6/10 HM 2/10 8/10
8/10 6/10 ⫺ 9/10 HM 6/10 9/10 4/10 2/10 HM 4/10 LP 3/10 6/10 HM 2/10 8/10
⫺ ⫹ ⫺
10/10 HM 10/10
10/10 1/10 10/10
⫺ ⫺ ⫹ ⫺ ⫺ ⫺ ⫺ ⫹ ⫺ ⫺ ⫺ ⫹ ⫺ ⫺ ⫹ ⫺ ⫺
7/10 3/10 HM 10/10 8/10 9/10 2/10 LP 1 m CF 4 m CF 10/10 HM 5/10 2 m CF HM 6/10 8/10
7/10 3/10 6/10 10/10 8/10 7/10 2/10 1/10 1 m CF 4 m CF 10/10 2/10 5/10 2 m CF 5/10 6/10 8/10
Postirrigation Finding
Cataract
Cataract
F ⫽ female; M ⫽ male; ICCE ⫽ intracapsular cataract extraction; ECCE ⫽ extracapsular cataract extraction; VL ⫽ vitreous loss; Tx ⫽ trabeculectomy; HM ⫽ hand motion; LP ⫽ light perception; CF ⫽ counting fingers; PCIOL ⫽ posterior chamber intraocular lens; Omitted ⫽ because of connection EIC to anterior chamber.
Results Pretreatment Findings Clinical examination of the cysts indicated that the bases of all the cysts were connected either to the incisions made during previous operations or to sites of laceration in penetrating trauma. Cysts formed between 3 months and 9 years after injury. The etiology was considered to be related to penetrating trauma in 50 cases (49.1%); intracapsular cataract extraction with vitreous loss (ICCE ⫹ VL) in 30 cases (29.9%); intracapsular cataract extraction (ICCE) in 11 cases (10.8%); extracapsular cataract extraction (ECCE) in 5 cases (4.9%); ECCE with posterior chamber intraocular lens (PCIOL) in 3 cases (2.9%); trabeculectomy in 2 cases (1.9%); and unknown in 1 case (0.48%). The cysts had covered the pupils in 28 patients and filled the anterior chamber in 5 patients. The cysts were connected to the anterior chambers in three patients, two of which had epithelial down growths detected by argon laser. These three patients were excluded from the study. The cyst wall contained keratic precipitates in three cases, and was vascularized in two cases.
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In three cases, the cystic fluid (yellowish precipitate) was subsequently sent to the laboratory for further evaluation. The laboratory results indicated a negative culture and the cytology report showed only rare lymphocytes (Fig 3). Fifteen cases had undergone yttrium aluminum garnet laser therapy before the ETOH irrigation, and 21 cases had high IOP (IOP⬎20 mmHg, 26.9⫾2), which was controlled by antiglaucoma drugs.
Posttreatment Findings The cysts shrank in 78 cases by 1 day after the ETOH irrigation, and the cysts contained turbid liquid in 20 cases that gradually disappeared in 2 weeks, after which the cysts shrank. Ethanol leaked into the anterior chamber in two cases (on irrigation any ETOH leak is clearly visible in the anterior chamber) and led to an anterior chamber reaction and pain the day after the ETOH irrigation that was subsequently treated with dexamethasone 10 ml and atropine 1% eye drops for 4 to 6 days. Anterior chamber reaction was also seen in nine cases with no ethanol leakage into the chamber, which was again treated with
Zohreh and Asghar 䡠 Epithelial Iris Cyst Treatment with Ethanol Irrigation dexamethasone 10 ml eye drops. After the ETOH irrigation, out of the 21 cases, 11 had IOP⬍20 mmHg, 8 had IOP⬎20 mmHg that was controlled by antiglaucoma drugs, and 2 needed trabeculectomy. As an indication of whether or not ETOH had leaked into the anterior chamber, endothelial cell counts were done in 25 patients. There were no changes in the number of endothelial cells, suggesting no ETOH leakage into the anterior chamber. We detected no cases of postirrigation bleeding, cataract formation or endophtalmitis during or after ETOH irrigation. The vision did not change in 64 patients whose visual axis was not involved. Vision in 19 out of 28 patients whose pupils were covered with EICs was light perception to 10 cm counting finger, which improved (1/10 –9/10, x ⫽ 4/10). The vision did not change in another nine patients. We were not able to evaluate vision in seven children who were not cooperative.
lowed by serious complications,4 ETOH irrigation has demonstrated few such complications. Most studies of various methods of treatment provide few statistics regarding patient number, side effects and success rates. Newman did report on 32 cases after surgical removal of iris cysts due to epithelial down growth and the substitution by extensive corneoscleral graft.8 In these complex and expensive surgeries, there was a high risk of glaucoma, cataract, infection, inflammation, bleeding and, most importantly, rejection of graft tissue. Ethanol irrigation is inexpensive and less invasive than previously reported techniques. To our knowledge, the present study is unique in that there have been no previous reports of ETOH irrigation for EIC. Acknowledgments. The authors thank Dr. Saeed Zarein Dolab and Dr. Ali Mirdehghan for help with the English editing.
Discussion
References
Our findings suggest that ETOH is a safe and effective agent for treatment of EIC. Of course, we had only a short follow-up before many of the patients returned to their local physician. Later recurrences may develop, but the referring physicians might have commented on this. The short-term safety appears to be good. At the 1-month examinations, visions were stable (or improved in some patients who had the pupil blocked by the cyst) and no obvious signs of toxicity were appreciated. Long-term safety, of course, remains to be demonstrated. A literature search (PubMed, January 8, 2003, search terms “ocular” and “ethanol” and “toxicity”) failed to reveal manuscripts citing evidence of intraocular ethanol use or damage from it. The effect is assumed to be a result of destruction of the lining epithelium. The cyst walls probably stick together preventing reformation. Compared with other techniques, such as diathermy5 excision,3,4 laser therapy,6,7 evacuation or injection of chemicals other than ETOH, frequently fol-
1. Frager WC, Scheie HG. Cataract surgery. In: Tasman W, Jaeger EA, eds. Duane’s Clinical Ophthalmology, revised, Vol. 3. Philadelphia: Lippincott, 1978;11–2. 2. Yanoff M, Fine BS, Gass JD. Ocular Pathology. 4th ed. Philadelphia: Mosby, 1996;119,308,594. 3. Wingate, Robertbray. An Atlas of Ophthalmic Surgery, 3rd ed. Philadelphia: Lippincott, Williams & Wilkins,1986:456. 4. Roper Hall MJ. Stallard’s Eye Surgery, 7th ed. London. John Wright, 1989:268. 5. Tsai JC, Arrindell EL, O’Day DM. Needle aspiration and endodiathermy treatment of epithelial inclusion cyst of the iris. Am J Ophthalmol 2001;131:263–5. 6. Scholz RT, Kelley JS. Argon laser photocoagulation treatment of iris cyst following penetrating keratoplasty. Arch Ophthalmol 1982;100:926 –7. 7. Sihota R, Tiwari HK, Azad RV, et al. Photocoagulation of large iris cysts. Ann Ophthalmol 1988;20:470 –2. 8. Naumann GO, Rummelt V. Block excision of cystic and diffuse epithelial ingrowth of the anterior chamber. Report on 32 consecutive patients. Arch Ophthalmol 1992;110:223–7.
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Epithelial invasion of the iris stroma is a rare but potentially blinding complication of penetrating anterior segment trauma or surgery. The origin of the cysts is not always known but they may be the result of trauma or surgical implantation of epithelium, iris incarceration, or poor wound closure during cataract surgery. Histologically, the cysts are lined by a multilayered epithelium resembling cornea or conjunctival epithelium, which may even contain goblet cells. The cysts generally contain clear fluid. They may become large and cause visual problems by covering the pupil, and in some cases they may occlude the angle and cause secondary angle-closure glaucoma.1,2 Many techniques have been devised to treat EICs, such as surgical excision of the cyst and surrounding iris tissues,3,4
aspiration of the cyst, photocoagulation, and injection of chemicals into the cyst such as iodine 1%, pure carbonic acid, and trichloroacetic acid 10%.4 Surgical excision, aspiration,5 laser therapy, and photocoagulation6, 7 are invasive techniques with potentially serious complications such as bleeding, endophthalmitis, cataract, and cyst rupture with conversion to the sheet form of epithelial ingrowth. The success rate and the side effects of methods using chemical compounds are not well documented. Recurrence of EICs has followed many previous surgical therapies, presumably due to incomplete excision. The rationale for ethanol (ETOH) use is that this chemical inflames the cyst wall and destroys the lining epithelium. The large number of cases reviewed in this manuscript also provides an opportunity to consider probable etiology, structure, contents, and types of EICs.
Originally received: October 15, 2001. Accepted: January 18, 2003. Manuscript no. 210509 1 Department of Ophthalmology, Emam Hossein Hospital, Shahid Beheshti University School of Medicine, Tehran, Iran. 2 Department of Ophthalmology, Yale University School of Medicine, New Haven, Connecticut. Presented at the American Academy of Ophthalmology Annual Meeting, New Orleans, Louisiana, November 2001. Reprint requests to Zohreh Behrouzi, MD, 9th FL, DRS BLDG, Royan Alley, Keshavarz BLVD, Tehran 14159, Iran.
Material and Methods
© 2003 by the American Academy of Ophthalmology Published by Elsevier Inc.
Patients During the last 18 years (1982–2000), 102 consecutive patients (102 eyes) with EIC, 35 female and 67 male, aged between 4 and 71 years were referred to our center (Emam Hossein Hospital). All referred patients with this diagnosis were included in the study, excluding only those whose EICs were connected to the anterior chamber. Institutional review board approval was obtained from ISSN 0161-6420/03/$–see front matter doi:10.1016/S0161-6420(03)00543-8
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Ophthalmology Volume 110, Number 8, August 2003
Figure 2. Double iris cyst.
Figure 1. Steps taken to irrigate ethanol in epithelial iris cysts.
the local ethics committee and certified by the Vice-Chancellor for Research Affairs of the university. Before the treatment, a complete eye examination was done in all patients and their vision checked a using a Snellen chart. Their intraocular pressure (IOP) was recorded with applanation tonometry (Haag Streit, Koeniz, Switzerland). The status of the cornea, endothelium, lens, anterior chamber reaction, and anterior vitreous was examined with a silt lamp. The angle was evaluated using a Goldmann or Zeiss gonioscope. Echography was performed on those patients in whom a connection between the EIC and the posterior segment was suspected. Inflammation and elevated IOP were controlled before irrigation. Three of the patients were excluded from the study because their EICs were connected to the anterior chamber. Decrease in anterior chamber depth during aspirations of EIC fluid indicated anterior chamber connection. The patients’ medical records were reviewed regarding their history of previous trauma or surgeries. Institutional review board approval was obtained.
(Fig 1D). The ETOH was left inside the cyst for approximately 1 minute or until the cyst wall turned white, a sign of destruction of the lining epithelium. The ETOH was drained and the needle removed (Fig 1E). Because the risk of ETOH leakage into the anterior chamber was presumed higher for those patients who had previously undergone laser therapy, the duration of the ETOH irrigation in these cases was shortened because of concern that the wall of the cyst could be easily ruptured. Typically, the volume of alcohol for each irrigation was in the range of 0.05 cc to 0.18 cc and was felt to be the same volume as that of the cyst fluid that had been drained. After irrigation, patients were treated with that of atropine 1% four times per day for 4 to 5 days to dilate the pupil and help the deflated cyst walls stick together. Dexamethasone 5 ml eye drops (Sina Daro Drug Co., Tehran, Iran) were also prescribed to control the possible reaction of the anterior chamber and were maintained until the inflammation subsided. Patients were examined on the day of the irrigation, the next day, at 2 weeks and after 1 month. The patients were then referred to their own centers for further follow-up. The cyst normally collapsed and scarred after 2 to 4 weeks. The statistical tests used in this study were mean scores and percentages. The follow-up period was 4 months to 15 years (mean ⫾ SD ⫽ 3.85⫾4.1). In fact, most patients did not return to their original centers because treatment had been successful.
Ethanol Irrigation Procedure The procedure was done under local or general anesthesia depending on patient cooperation. Depending on the location of the EIC, the eye was stabilized with a superior rectus or inferior rectus traction suture (4 – 0 silk). A 27-gauge needle was inserted into the base of the cyst from approximately 2 mm posterior to the limbus, using a microscope with high magnification (Fig 1A, B) and the cyst fluid was gently aspirated. In cases of double or triple cysts (Fig 2), before draining the fluid the cysts were joined to each other by the tip of the needle. The process of drainage was terminated if the depth of the anterior chamber decreased. This decrease was an indication of the connection of the anterior chamber with the EIC, which meant a high risk of ETOH (96.2%) leakage into the chamber. After drainage of the fluid and the consequent shrinkage of the cyst, without changing the position of the needle the syringe was replaced with one containing an equal amount of ETOH (medical grade absolute ethyl alcohol) to the drained cyst fluid (Fig 1C). Ethanol was steadily irrigated into the cyst until it reinflated
1602
Figure 3. Precipitate level in epithelial iris cyst.
Zohreh and Asghar 䡠 Epithelial Iris Cyst Treatment with Ethanol Irrigation Table 1. Patient Demographics and Surgical Outcome No. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65
Age
Sex
43 51 55 9 64 60 42 5 25 60 57 47 60 58 46 52 70 69 70 65 5 57 9 32 61 69 54 44 50 65 65 58 51 42 57 54 46 55 52 42 68 68 69 70 66 65 62 22 24 33 32 57 71 69 61 36 59 60 64 59 60 4 7 19 20
M M M M M M F M M F F M M M F F M F M M M F M M M F M M F F M F F F F M M M M M F F F M M M M M F M M F M M F M M M F M F M F F M
Causes
Pupil Involvement
Trauma ICCE ⫹ VL ICCE ⫹ VL Trauma ICCE ⫹ VL ICCE ⫹ VL Trauma Trauma Trauma ICCE ⫹ VL ICCE ⫹ VL Trauma ICCE ⫹ VL ICCE ⫹ VL Trauma ICCE ⫹ VL ICCE ICCE ICCE ⫹ VL ICCE Trauma ICCE ⫹ VL Trauma Trauma ICCE ICCE ⫹ VL ICCE ⫹ VL Trauma Trauma ICCE ⫹ VL ICCE ICCE Trauma Trauma ICCE ⫹ VL ICCE ⫹ VL Trauma ICCE ⫹ VL ICCE ⫹ VL Trauma ICCE ⫹ VL ICCE ICCE ⫹ VL ICCE ⫹ VL ICCE ⫹ VL ICCE ⫹ VL ICCE Trauma Trauma Trauma Trauma ICCE ⫹ VL ICCE ⫹ VL ICCE ⫹ VL ICCE ⫹ VL Trauma ICCE ⫹ VL ICCE ⫹ VL ICCE ICCE ⫹ VL Tx Unknown Trauma Trauma ECCE ⫹ PCIOL
⫺ ⫹ ⫹ ⫺ ⫺ ⫺ ⫹ ⫺ ⫺ ⫺ ⫹ ⫹ ⫺ ⫹ ⫺ ⫺ ⫺ ⫺ ⫺ ⫺ ⫺ ⫹ ⫺ ⫹ ⫺ ⫺ ⫺ ⫺ ⫹ ⫺ ⫺ ⫺ ⫺ ⫹ ⫺ ⫺ ⫺ ⫹ ⫺ ⫹ ⫺ ⫺ ⫺ ⫹ ⫺ ⫺ ⫺ ⫺ ⫹ ⫹ ⫺ ⫺ ⫹ ⫺ ⫺ ⫹ ⫺ ⫹ ⫺ ⫺ ⫺ ⫺ ⫺ ⫹ ⫺
Vision before Irrigation
Vision after Irrigation
7/10 HM LP ⫺ 2 m CF 6 m CF HM ⫺ 9/10 2/10 LP HM 3/10 10 cm CF 10/10 4 m CF 2 m CF 4/10 6/10 Omitted ⫺ 10 cm ⫺ 10 cm 1/10 8/10 Omitted 10/10 HM 2 m CF 6 m CF 3/10 8/10 10 cm CF 3/10 1 m CF 9/10 LP 6/10 HM 2/10 7/10 8/10 LP 6/10 3/10 8/10 10/10 HM HM Omitted 4 m CF LP 5/10 4/10 LP 3/10 10 cm CF 7/10 6/10 4/10 ⫺ ⫺ LP 10/10
7/10 HM LP ⫺ 2 m CF 6 m CF 7/10 ⫺ 9/10 2/10 8/10 8/10 3/10 10 cm CF 10/10 4 m CF 2 m CF 4/10 6/10 Omitted ⫺ 10 cm ⫺ 9/10 1/10 8/10 Omitted 10/10 4/10 ⫺ ⫺ 3/10 8/10 10 cm CF 3/10 1 m CF 9/10 LP 6/10 HM 2/10 7/10 8/10 1/10 6/10 3/10 8/10 10/10 4/10 3/10 Omitted 4 m CF 3/10 5/10 4/10 2/10 3/10 4/10 7/10 6/10 4/10 ⫺ ⫺ 3/10 10/10
Postirrigation Finding Dense pupillary membrane Vitreous opacity
Dense papillary membrane
Vitreous opacity
Cataract
Dense papillary membrane Cataract
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Ophthalmology Volume 110, Number 8, August 2003 Table 1. (Continued) No.
Age
Sex
Causes
66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82
14 17 7 60 45 22 21 14 18 38 37 21 28 48 50 56 41
F F M M M F M F M F M M M M M M M
83 84 85
57 40 50
M M F
86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102
66 68 48 67 21 26 67 50 62 41 18 34 21 32 40 49 35
M M M M M M M F M F M F M M M F F
Trauma Trauma Trauma ECCE Trauma Tx Trauma Trauma Trauma Trauma Trauma Trauma Trauma ECCE Trauma Trauma ECCE ⫹ PCIOL Trauma Trauma ECCE ⫹ PCIOL ECCE ICCE Trauma ECCE Trauma Trauma ECCE Trauma ICCE Trauma Trauma Trauma Trauma Trauma Trauma Trauma Trauma
Pupil Involvement
Vision before Irrigation
Vision after Irrigation
⫺ ⫺ ⫺ ⫺ ⫹ ⫺ ⫺ ⫺ ⫺ ⫺ ⫹ ⫺ ⫹ ⫺ ⫹ ⫺ ⫺
7/10 6/10 ⫺ 9/10 HM 6/10 9/10 4/10 2/10 HM LP LP LP 6/10 HM 2/10 8/10
8/10 6/10 ⫺ 9/10 HM 6/10 9/10 4/10 2/10 HM 4/10 LP 3/10 6/10 HM 2/10 8/10
⫺ ⫹ ⫺
10/10 HM 10/10
10/10 1/10 10/10
⫺ ⫺ ⫹ ⫺ ⫺ ⫺ ⫺ ⫹ ⫺ ⫺ ⫺ ⫹ ⫺ ⫺ ⫹ ⫺ ⫺
7/10 3/10 HM 10/10 8/10 9/10 2/10 LP 1 m CF 4 m CF 10/10 HM 5/10 2 m CF HM 6/10 8/10
7/10 3/10 6/10 10/10 8/10 7/10 2/10 1/10 1 m CF 4 m CF 10/10 2/10 5/10 2 m CF 5/10 6/10 8/10
Postirrigation Finding
Cataract
Cataract
F ⫽ female; M ⫽ male; ICCE ⫽ intracapsular cataract extraction; ECCE ⫽ extracapsular cataract extraction; VL ⫽ vitreous loss; Tx ⫽ trabeculectomy; HM ⫽ hand motion; LP ⫽ light perception; CF ⫽ counting fingers; PCIOL ⫽ posterior chamber intraocular lens; Omitted ⫽ because of connection EIC to anterior chamber.
Results Pretreatment Findings Clinical examination of the cysts indicated that the bases of all the cysts were connected either to the incisions made during previous operations or to sites of laceration in penetrating trauma. Cysts formed between 3 months and 9 years after injury. The etiology was considered to be related to penetrating trauma in 50 cases (49.1%); intracapsular cataract extraction with vitreous loss (ICCE ⫹ VL) in 30 cases (29.9%); intracapsular cataract extraction (ICCE) in 11 cases (10.8%); extracapsular cataract extraction (ECCE) in 5 cases (4.9%); ECCE with posterior chamber intraocular lens (PCIOL) in 3 cases (2.9%); trabeculectomy in 2 cases (1.9%); and unknown in 1 case (0.48%). The cysts had covered the pupils in 28 patients and filled the anterior chamber in 5 patients. The cysts were connected to the anterior chambers in three patients, two of which had epithelial down growths detected by argon laser. These three patients were excluded from the study. The cyst wall contained keratic precipitates in three cases, and was vascularized in two cases.
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In three cases, the cystic fluid (yellowish precipitate) was subsequently sent to the laboratory for further evaluation. The laboratory results indicated a negative culture and the cytology report showed only rare lymphocytes (Fig 3). Fifteen cases had undergone yttrium aluminum garnet laser therapy before the ETOH irrigation, and 21 cases had high IOP (IOP⬎20 mmHg, 26.9⫾2), which was controlled by antiglaucoma drugs.
Posttreatment Findings The cysts shrank in 78 cases by 1 day after the ETOH irrigation, and the cysts contained turbid liquid in 20 cases that gradually disappeared in 2 weeks, after which the cysts shrank. Ethanol leaked into the anterior chamber in two cases (on irrigation any ETOH leak is clearly visible in the anterior chamber) and led to an anterior chamber reaction and pain the day after the ETOH irrigation that was subsequently treated with dexamethasone 10 ml and atropine 1% eye drops for 4 to 6 days. Anterior chamber reaction was also seen in nine cases with no ethanol leakage into the chamber, which was again treated with
Zohreh and Asghar 䡠 Epithelial Iris Cyst Treatment with Ethanol Irrigation dexamethasone 10 ml eye drops. After the ETOH irrigation, out of the 21 cases, 11 had IOP⬍20 mmHg, 8 had IOP⬎20 mmHg that was controlled by antiglaucoma drugs, and 2 needed trabeculectomy. As an indication of whether or not ETOH had leaked into the anterior chamber, endothelial cell counts were done in 25 patients. There were no changes in the number of endothelial cells, suggesting no ETOH leakage into the anterior chamber. We detected no cases of postirrigation bleeding, cataract formation or endophtalmitis during or after ETOH irrigation. The vision did not change in 64 patients whose visual axis was not involved. Vision in 19 out of 28 patients whose pupils were covered with EICs was light perception to 10 cm counting finger, which improved (1/10 –9/10, x ⫽ 4/10). The vision did not change in another nine patients. We were not able to evaluate vision in seven children who were not cooperative.
lowed by serious complications,4 ETOH irrigation has demonstrated few such complications. Most studies of various methods of treatment provide few statistics regarding patient number, side effects and success rates. Newman did report on 32 cases after surgical removal of iris cysts due to epithelial down growth and the substitution by extensive corneoscleral graft.8 In these complex and expensive surgeries, there was a high risk of glaucoma, cataract, infection, inflammation, bleeding and, most importantly, rejection of graft tissue. Ethanol irrigation is inexpensive and less invasive than previously reported techniques. To our knowledge, the present study is unique in that there have been no previous reports of ETOH irrigation for EIC. Acknowledgments. The authors thank Dr. Saeed Zarein Dolab and Dr. Ali Mirdehghan for help with the English editing.
Discussion
References
Our findings suggest that ETOH is a safe and effective agent for treatment of EIC. Of course, we had only a short follow-up before many of the patients returned to their local physician. Later recurrences may develop, but the referring physicians might have commented on this. The short-term safety appears to be good. At the 1-month examinations, visions were stable (or improved in some patients who had the pupil blocked by the cyst) and no obvious signs of toxicity were appreciated. Long-term safety, of course, remains to be demonstrated. A literature search (PubMed, January 8, 2003, search terms “ocular” and “ethanol” and “toxicity”) failed to reveal manuscripts citing evidence of intraocular ethanol use or damage from it. The effect is assumed to be a result of destruction of the lining epithelium. The cyst walls probably stick together preventing reformation. Compared with other techniques, such as diathermy5 excision,3,4 laser therapy,6,7 evacuation or injection of chemicals other than ETOH, frequently fol-
1. Frager WC, Scheie HG. Cataract surgery. In: Tasman W, Jaeger EA, eds. Duane’s Clinical Ophthalmology, revised, Vol. 3. Philadelphia: Lippincott, 1978;11–2. 2. Yanoff M, Fine BS, Gass JD. Ocular Pathology. 4th ed. Philadelphia: Mosby, 1996;119,308,594. 3. Wingate, Robertbray. An Atlas of Ophthalmic Surgery, 3rd ed. Philadelphia: Lippincott, Williams & Wilkins,1986:456. 4. Roper Hall MJ. Stallard’s Eye Surgery, 7th ed. London. John Wright, 1989:268. 5. Tsai JC, Arrindell EL, O’Day DM. Needle aspiration and endodiathermy treatment of epithelial inclusion cyst of the iris. Am J Ophthalmol 2001;131:263–5. 6. Scholz RT, Kelley JS. Argon laser photocoagulation treatment of iris cyst following penetrating keratoplasty. Arch Ophthalmol 1982;100:926 –7. 7. Sihota R, Tiwari HK, Azad RV, et al. Photocoagulation of large iris cysts. Ann Ophthalmol 1988;20:470 –2. 8. Naumann GO, Rummelt V. Block excision of cystic and diffuse epithelial ingrowth of the anterior chamber. Report on 32 consecutive patients. Arch Ophthalmol 1992;110:223–7.
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