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Figure 1 (A) Pigmentedposterior Vitreous Cyst, Ultrasound

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Figure 1 (A) Pigmentedposterior Vitreous Cyst, Ultrasound 1026 Letters which the cyst was mobile within a small cav- 5 Francois J. Pre-papillary cyst developed from ity in the posterior vitreous overlying the optic remnants of the hyaloid artery. BrJ7 Ophthalmol 1950;34:365-8. nerve and macula, highlighted the controversy 6 Hilsdorf C. Uber einen Fall einer einseitigen over their pathogenesis.7 Orellana and col- Glaskorpercyste. Ophthalmologica 1965;149:12- leagues reported on the microscopic appear- 20. 7 Feman SS, Straatsma BR. Cyst of the posterior ance of a free floating vitreous cyst with its vitreous. Arch Ophthalmol 1974;91:328-9. wall made up of a layer of heavily pigmented 8 Awan KJ. Multiple free floating vitreous cysts cuboidal cells, intermingled with non- with congenital nystagmus and esotropia. J Pae- pigmented cells, forming papillae. Electron diatr Ophthalmol 1975;12:49-53. 9 Raymond LA. Neodymium:YAG laser treatment microscopy showed the lining cells to contain for haemorrhages under the internal limiting mature and immature melanosomes, polar- membrane and posterior hyaloid face in the ised basement membrane, and apical micro- macula. Ophthalmology 1995;102:406-11. 10 Tsai WF, Chen YC, Su CY. Treatnent of villi.' These findings support the hypothesis vitreous floaters with neodymium YAG laser. Br that the cysts originate from the pigmented J Ophthalmol 1993;77:485-8. ciliary epithelium and that trauma may play a role in their development. Awan, however, reported a history of trauma in only 2.7% of cases.8 Sudden unilateral visual loss and brain The likelihood is that vitreous cysts origi- infarction after autologous fat injection nate from different intraocular structures, the into nasolabial groove vascularised, attached cysts from hyaloid vascular remnants and pigmented, free float- EDIrOR,-Central retinal artery occlusion ing cysts from the ciliary body epithelium. (CRAO) following cosmetic surgery seems to Although the majority are asymptomatic, be a very rare and devastating disease troublesome symptoms can arise when they inducing sudden visual loss. Even if vigorous float across the visual axis or come within its and massive treatment is advocated initially, vicinity. In the case reported, the onset of the prognosis of visual recovery is very disap- symptoms may have been associated with pointing. Figure 1 (A) Pigmentedposterior vitreous cyst, increased mobility of the cyst due to liquefac- freefloating in the posterior segment. (B) B scan In this paper, we report one case of CRAO ultrasound demonstrating the posterior vitreous tion of the surrounding vitreous gel or partial combined with brain infarction resulting from cyst measuring 5.4 mm in diameter. The posterior vitreous detachment. an autologous fat injection for cosmetic prob- posterior hyaloidface was intact. The severity of symptoms occasionally war- lems. rants treatment. Surgical excision through the We confirmed CRAO by fluorescein angio- pars plana has been reported,' but there is graphy and brain infarction by magnetic reso- vascular system.34 The presence of blood ves- potential for serious complications from this nance imaging (MRI) and four vessel angiog- sels in some cases, and their proximity to approach. Argon laser photocystotomy offers raphy. Cloquet's canal, gave support to this hypoth- an alternative to surgical treatment,2 but its To our knowledge, there have been no esis. However, some cysts are neither vascular- effectiveness depends on the presence of ised nor are attached or located reports of CRAO combined with brain infarc- they to, near, extensive pigment in the cyst wall and there is tion in autologous fat injection procedures. Cloquet's canal. In a review of the literature, a risk of inadvertent retinal photocoagulation. Francois five vascularised This case gives a warning to cosmetic plas- reported cysts out Neodymium-YAG laser has previously been tic surgeons and ophthalmologists of the of nine.5 Hilsdorf, in a further review of 34 used for the treatment of persistent subinter- importance of careful manipulation and im- cases ofvitreous cysts, found 11 to be anterior nal limiting membrane and posterior hyaloid mediate awareness and treatment ofiatrogeni- cysts, and of the posteriorly situated cysts face haemorrhages, vitreous floaters, vitreous cally induced ocular complications. seven were found in association with retinitis adhesions, and for the lysis of vitreous pigmentosa and two with optic atrophy.6 bands.910 In the case described, Nd-YAG laser Feman and Straatsma in a report of a case in was effective in disrupting the wall of a poste- CASE REPORT rior vitreous cyst. Although the cyst did not A 42-year-old woman came to the emergency disappear completely, disruption of the cyst room in an irritated state. Two hours earlier, wall caused a reduction in its size. In addition, the cyst wall, being denser than the surround- ing liquefied vitreous, gravitated out of the visual axis with relief of symptoms. In conclusion, vitreous cysts, though rare, can give rise to intractable visual symptoms. Surgical treatment is hazardous and argon laser photocystotomy may not be effective. We report the successful treatment of a posterior vitreous cyst by Nd-YAG laser photo- cystotomy. The authors thank Ms M Restori for carrying out the ultrasound examination. H TABANDEH PJ ALLEN P K LEAVER Moorfields Eye Hospital, London Correspondence to: H Tabandeh, Moorfields Eye Hospital, London EC1V 2PD. Accepted for publication 28 June 1996 1 Orellana J, O'Malley RE, McPherson AR, Font RL. Pigmented free floating vitreous cysts in two young adults: electron microscopic observa- Figure 1 (A) Thefundal appearance 12 hours tions. Ophthalmology 1985;92:297-302. after autologousfat injection shows multiplefat Figure 2 (A) Posterior vitreous cyst shrank and 2 Awan KJ. Biomicroscopy and argon laser photo- emboli in the central retinal artery and vein. gravitated immediately after YAG laser cystotomy offree floating vitreous cyst. Ophthal- mology 1985;92:1710-11. Oedematous retina and cherry red spot are also photocystotomy. (B) B scan ultrasoundfollowing 3 Duke-Elder S. System of ophthalmology. Vol 2. seen. (B) Thefundus of the same patient taken YAG laserphotocystotomy, demonstrating a London: Henry Kimpton, 1964:763-4. 3 months afterfat injection shows an atrophic reduction in size to 1. 6 x 2.2 mm (borders 4 Elkington AR, Watson DM. Mobile vitreous optic nerve and thickfibrous membranes on the delineated by the measuring calipers). cysts. BrJ Ophthalmol 1974;58: 103-4. posteriorpole. Letters 1027 the left eye had a thick fibrous membrane on the posterior pole and optic atrophy (Fig 1B). COMMENrT There are several articles reporting iatrogenic CRAO caused by retrobulbar corticosteroid injection,' talc emboli in an intravenous drug abuse patient,' intranasal injection of cortico- steroid for allergic rhinitis,' injection of ligno- caine for rhinoplasty,4 and autologous fat injection into the glabellar region.5 However, it is debatable how the iatrogenically injected materials emerged in the retinal circulation. Some authors explained that the material was injected directly into a branch of the ophthal- mic artery and vascular disturbances occurred because of retrograde flow of an intra-arterial injection into the central retinal artery.`' In this case, we assumed that CRAO had developed as a result of a similar mechanism, but unlike the other cases, it was accompanied by brain infarction due to the fat embolism of the branches of the cerebral artery. It is possi- ble that the injection forces were strong enough to reach into the internal carotid artery, so a fat embolism occurred both at a branch of the ophthalmic artery and at a branch of the cerebral artery. In the treatment of CRAO, no consensus currently exists regarding therapy.6 Schmidt et al7 supported the theory that emboli resulting from lipid, cholesterol, and calcific emboli cannot be expected to respond to thrombo- lytic therapy. The patient did not take the thrombolytic agent, but received ocular mas- sage and carbon dioxide and oxygen therapy intermittently. This peculiar case should be a warning to all ophthalmologists and plastic surgeons that widely performed simple procedures can cause irreversible misery, and the risk of dam- age should be explained to the patient. If there is any evidence of a visual problem, prompt consultation with an ophthalmologist is needed. DO HYUNG LEE HAN NAM YANG JAE CHAN KIM Figure 2 Four vessel angiography ofthe central retinal artery shows decreased calibre of the KYUNG HWAN SHYN ophthalmic artery (B, arrowhead) compared with the normal side (A, arrowhead). Ocular blush in Department of Ophthalmology, Chung-Ang University the ophthalmic artery is missing on the left side (D, arrow) compared with normal ocular blush on the Hospital, Seoul, Korea right side (C, arrow). MRI scanning ofthe brain shows the low signal intensities on Tl weighted images in the left caudate head (E) and thalamus (G), compared with the high signal intensities on Correspondence to: Kyung Hwan Shyn, MD, T2 weighted images in the left caudate head (F, arrow) and thalamus (H, arrow). Department of Ophthalmology, Chung-Ang Univer- sity Hospital, 65-207 Han-gang ro 3 ga, Yong-san gu, Seoul, Korea, 140-757 she had undergone a fat transplantation of rioles (Fig IA). The patient was finally Accepted for publication 23 August 1996 abdominal fat to her nasolabial groove to cor- diagnosed with CRAO due to autologous fat rect a cosmetic problem. The procedure was emboli. performed by a local plastic surgeon. Immedi- The laboratpry examinations were found to 1 Ellis PP. Occlusion of the central retinal artery ately after injection of autologous fat (0.5 ml) be normal. Four vessel angiography revealed after retrobulbar corticosteroid injection Am J Ophthalmol 1978;85:352-8. mixed with blood and saline into her nasola- that there was decreased calibre of the left 2 Friberg TR, Gragiydas ES, Regan CDJ. Talc bial groove, she complained of headache and ophthalmic artery leading to ophthalmic emboli and macular ischemia in intravenous dyspnoea, became very irritable, and fell into artery insufficiency (Fig 2A and B) and disap- drug abuse.
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