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Epidermoid Cyst of the Iris and Ciliary Body
NOTES, CASES, INSTRUMENTS EPIDERMOID CYST O F T H E IRIS AND CILIARY BODY ALGERNON B. REESE,
M.D.
New York An infant girl, 2y2 years old, had, from birth, a spot on the right iris in the six o'clock meridian. The parents felt that re cently the spot had increased in size, and this observation was confirmed by photographs they submitted. The lesion was composed of a pearly-white avascular portion partly re placing the iris and extending into the an terior chamber. The peripheral portion, which was pinkish and vascular, lay in apposition to the cornea and extended into the ciliary body (fig. 1). It was thought that this could be either a relatively benign localized encapsulated type of dictyoma or an ectopic lacrimal gland with cyst formation. An excision was advised because of the possibility of a dictyoma and because the le sion had shown progression. A corneoscleral iridocyclectomy was per formed employing a 6 mm trephine. The ex cised button, which consisted of the tumefac tion, together with the adjacent cornea, sclera, iris and ciliary body (fig. 2) was re-
Fig. 1 (Reese). An epidermoid cyst of the iris and the ciliary body, (a) pearly white portion of the cyst projecting into the anterior chamber; (b) vascularized portion of the cyst against the cornea; (c) a portion of the iris covering the anterior surface of the cyst From the Institute of Ophthalmology, ColumbiaPresbyterian Medical Center.
Fig. 2 (Reese), (a) Cyst lined with keratinized epithelium and keratin flakes; (b) pupillary por tion of iris; (c) ciliary body; (d) iris stroma interposed between cyst wall and cornea.
placed by a corneal graft covered with a conjunctival flap. Before the excision was made, 1 cc of vitreous was removed at the 12 o'clock meridian with an 18-gauge needle through the plane part of the ciliary body, 5 mm from the limbus, for the purpose of re ducing the vitreous volume. Convalescence was uneventful, and four months after surgery an examination of the eye under general anesthesia showed a white eye with clear media, normal f undus, and in traocular tension of 12 mm Hg. Two years have now passed since the op eration, and the eye appears normal except for the iris and the ciliary body coloboma (fig. 3 ) . The microscopic examination of the ex cised specimen shows an epidermoid cyst containing flakes of keratin (fig. 2 ) . Dr. Lorenz Zimmerman tells me that the Armed Forces Institute of Pathology has three cases of dermoid cysts of the iris and
450
VOL. 65, NO. 3
451
NOTES, CASES, INSTRUMENTS
A N E W W I R E IRIS RETRACTOR FOR U S E IN CATARACT SURGERY F. C.
RODGER,
F.R.C.S.
(GLASGOW)
Swindon, England
Fig. 3 (Reese). Appearance two months following surgery
the ciliary body. One of these cases showed, in addition to a large cyst occupying the an terior chamber, a lobule of normal-appearing lacrimal gland tissue. We have not been able to find any reports in the literature on dermoid cysts of the iris or ciliary body. The case reported here was referred by Dr. Gilbert C. Norton of Endicott, New York, who considered in his differential di agnosis the possibility of the lesion being a dermoid cyst. A dermoid cyst of the iris and the ciliary body arises from a congenital rest of primi tive ectoderm at the closure site of a fetal cleft, and that is what occurred in this case. This lesion, therefore, can be viewed as a choristoma composed of multipotential tis sue. This tissue may manifest itself as a pure tumefaction (cyst, lacrimal gland, or any other derivative of the primitive ecto derm), or as any combination of the deriva tives of this congenital rest. 635 West 165th Street (10032)
The preferred technique for extraction of cataracts is usually personal to the surgeon. While the fundamental procedure is essen tially similar in all techniques, each surgeon sooner or later settles on a method which suits his individual characteristics. Some times the choice is partly determined by tra dition, at other times by practical factors: for example, there are many hospitals in Afro-Asia where facilities for keeping Graefe knives in good shape do not exist, or where resources do not run to a cryosurgical apparatus. Basically, cataract extraction techniques fall into two groups: in one, the Graefe knife makes a full 170-180° section ending with a small central conjunctival flap, and in the other a keratome entrance wound in midsection is enlarged by scissors after first re flecting a more substantial conjunctival flap. The first method is clearly better because it disturbs the tissues less: it should heal with less reaction and with a lower astigmatic error. There is in fact no procedure so at tractive to watch or satisfying to accomplish as the sweep of the small silver Graefe knife through 180°, especially when the surgeon sits as motionless yet as graceful as a mata dor at the patient's head, using his right hand for the right eye, his left hand for the left eye. Whichever method is used, however, there is no doubt that extraction of the lens through a round, intact pupil is the crux of the whole operation; only too often a tight small pupil damages the capsule, preventing a clean intracapsular extraction. A retractor for the iris has been designed to increase the size of the pupillary aperture without ob structing the surgeon's view of the extracFrom the Department of Ophthalmology, Princess Margaret Hospital.
M.D.
New York An infant girl, 2y2 years old, had, from birth, a spot on the right iris in the six o'clock meridian. The parents felt that re cently the spot had increased in size, and this observation was confirmed by photographs they submitted. The lesion was composed of a pearly-white avascular portion partly re placing the iris and extending into the an terior chamber. The peripheral portion, which was pinkish and vascular, lay in apposition to the cornea and extended into the ciliary body (fig. 1). It was thought that this could be either a relatively benign localized encapsulated type of dictyoma or an ectopic lacrimal gland with cyst formation. An excision was advised because of the possibility of a dictyoma and because the le sion had shown progression. A corneoscleral iridocyclectomy was per formed employing a 6 mm trephine. The ex cised button, which consisted of the tumefac tion, together with the adjacent cornea, sclera, iris and ciliary body (fig. 2) was re-
Fig. 1 (Reese). An epidermoid cyst of the iris and the ciliary body, (a) pearly white portion of the cyst projecting into the anterior chamber; (b) vascularized portion of the cyst against the cornea; (c) a portion of the iris covering the anterior surface of the cyst From the Institute of Ophthalmology, ColumbiaPresbyterian Medical Center.
Fig. 2 (Reese), (a) Cyst lined with keratinized epithelium and keratin flakes; (b) pupillary por tion of iris; (c) ciliary body; (d) iris stroma interposed between cyst wall and cornea.
placed by a corneal graft covered with a conjunctival flap. Before the excision was made, 1 cc of vitreous was removed at the 12 o'clock meridian with an 18-gauge needle through the plane part of the ciliary body, 5 mm from the limbus, for the purpose of re ducing the vitreous volume. Convalescence was uneventful, and four months after surgery an examination of the eye under general anesthesia showed a white eye with clear media, normal f undus, and in traocular tension of 12 mm Hg. Two years have now passed since the op eration, and the eye appears normal except for the iris and the ciliary body coloboma (fig. 3 ) . The microscopic examination of the ex cised specimen shows an epidermoid cyst containing flakes of keratin (fig. 2 ) . Dr. Lorenz Zimmerman tells me that the Armed Forces Institute of Pathology has three cases of dermoid cysts of the iris and
450
VOL. 65, NO. 3
451
NOTES, CASES, INSTRUMENTS
A N E W W I R E IRIS RETRACTOR FOR U S E IN CATARACT SURGERY F. C.
RODGER,
F.R.C.S.
(GLASGOW)
Swindon, England
Fig. 3 (Reese). Appearance two months following surgery
the ciliary body. One of these cases showed, in addition to a large cyst occupying the an terior chamber, a lobule of normal-appearing lacrimal gland tissue. We have not been able to find any reports in the literature on dermoid cysts of the iris or ciliary body. The case reported here was referred by Dr. Gilbert C. Norton of Endicott, New York, who considered in his differential di agnosis the possibility of the lesion being a dermoid cyst. A dermoid cyst of the iris and the ciliary body arises from a congenital rest of primi tive ectoderm at the closure site of a fetal cleft, and that is what occurred in this case. This lesion, therefore, can be viewed as a choristoma composed of multipotential tis sue. This tissue may manifest itself as a pure tumefaction (cyst, lacrimal gland, or any other derivative of the primitive ecto derm), or as any combination of the deriva tives of this congenital rest. 635 West 165th Street (10032)
The preferred technique for extraction of cataracts is usually personal to the surgeon. While the fundamental procedure is essen tially similar in all techniques, each surgeon sooner or later settles on a method which suits his individual characteristics. Some times the choice is partly determined by tra dition, at other times by practical factors: for example, there are many hospitals in Afro-Asia where facilities for keeping Graefe knives in good shape do not exist, or where resources do not run to a cryosurgical apparatus. Basically, cataract extraction techniques fall into two groups: in one, the Graefe knife makes a full 170-180° section ending with a small central conjunctival flap, and in the other a keratome entrance wound in midsection is enlarged by scissors after first re flecting a more substantial conjunctival flap. The first method is clearly better because it disturbs the tissues less: it should heal with less reaction and with a lower astigmatic error. There is in fact no procedure so at tractive to watch or satisfying to accomplish as the sweep of the small silver Graefe knife through 180°, especially when the surgeon sits as motionless yet as graceful as a mata dor at the patient's head, using his right hand for the right eye, his left hand for the left eye. Whichever method is used, however, there is no doubt that extraction of the lens through a round, intact pupil is the crux of the whole operation; only too often a tight small pupil damages the capsule, preventing a clean intracapsular extraction. A retractor for the iris has been designed to increase the size of the pupillary aperture without ob structing the surgeon's view of the extracFrom the Department of Ophthalmology, Princess Margaret Hospital.