CLINICAL SCIENCES Anterior Segment Implantation Cysts Ultrasound Biomicroscopy With Histopathologic Correlation Flavio A. Marigo, MD; Paul T. Finger, MD; Steven A. McCormick, MD; Raymond Iezzi, MD; Kohji Esaki, MD; Hiroshi Ishikawa, MD; John Seedor, MD; Jeffrey M. Liebmann, MD; Robert Ritch, MD Objective: To correlate the clinical, histopathologic, and reflective cyst walls encapsulating a relatively hy- ultrasound biomicroscopic characteristics of anterior seg- poechoic core. In 3 cases, the cyst contents consisted of ment implantation cysts. variably reflective material. The other 4 were com- pletely sonolucent. Histopathologic correlation showed Methods: We performed a retrospective review of 7 cases that the cyst walls were lined with stratified squamous of secondary anterior segment implantation cysts. We re- epithelium. The moderately reflective cyst contents were viewed the clinical history, visual acuity, clinical find- found to be degenerated conjunctival cells with inflam- ings, and ultrasound biomicroscopic characteristics in all matory foci and cholesterol crystals. The sonolucent re- cases. Histopathologic correlation was possible in 4 cases. gions correlated with inflammatory cells and fluid. Results: Six eyes had been subjected to major trauma Conclusions: This study demonstrates that implanta- prior to cyst formation. Trauma was noted as blunt in 3 tion cysts are unilateral, large, and thick walled. They eyes and surgical in 3 eyes. The diagnosis was con- may be sonolucent or exhibit variable internal reflec- firmed in 1 eye when conjunctival cells were aspirated tivity. These findings as well as the extent of anterior on fine needle biopsy. Ultrasound biomicroscopy re- segment involvement (particularly posterior exten- vealed large (mean ± SD greatest diameter, 4.7 ± 0.9 mm) sion) could be evaluated by ultrasound biomicroscopy cystic tumors. In 1 patient, a cyst-related indentation of prior to surgery. the anterior lens surface was seen. Ultrasonographic evalu- ations of internal reflectivity revealed thick, moderately Arch Ophthalmol. 1998;116:1569-1575 YSTIC LESIONS occurring ultrasound images—both normal and within the anterior seg- abnormal. As of yet, very few such cor- ment may be classified as relations have been performed.8,10,11 The primary or secondary.1 purpose of this article is to provide fur- Primary cysts are of neu- ther correlations. Croepithelial origin, while secondary cysts occur as the result of implantation, meta- REPORT OF CASES From the Departments of static or parasitic lesions, or after long- Ophthalmology and 1 term use of miotics. Implantation cysts re- CASE 1 Pathology–Laboratory sult from implantation of epithelial cells Medicine, The New York Eye on the iris after penetrating or surgical and Ear Infirmary An 88-year-old man was referred for evalu- (Drs Marigo, Finger, trauma, which may lead to a solid (pearl) ation of a mass in his right eye (Figure 1). McCormick, Iezzi, Esaki, mass, a fluid-filled (serous) cyst, or epi- He had previously undergone extracap- 1-6 Ishikawa, Seedor, Liebmann, thelial ingrowth. Such lesions can, in sular cataract extraction with posterior and Ritch), and the New York turn, cause corneal edema, uveitis, glau- chamber implantation in that eye. University School of Medicine coma, and decreased visual acuity. 1-3,5-7 Uncorrected visual acuity was 20/25 and North Shore Long Island Ultrasound biomicroscopy (UBM) OD, intraocular pressure (IOP) was 20 mm Jewish Health System has become indispensable for evaluating Hg OD. Ophthalmic examination re- (Dr Finger), New York; and the anterior segment tumors and cysts, in- vealed a shallow anterior chamber and an- New York Medical College, cluding those undetectable by slitlamp terior iris convexity from the 1- to 4-o’clock Valhalla (Drs McCormick, biomicroscopy or conventional water- positions. Transillumination suggested a Liebmann, and Ritch). The 8-10 authors have no proprietary bath ultrasonography. However, cystic lesion. On gonioscopy, the mass ob- interest in any of the accurate interpretation of ultrasound scured visualization of the anterior cham- instruments or technologies images relies on established correlations ber angle, which was otherwise open. The described. among anatomy, histologic study, and posterior segment was nor- ARCH OPHTHALMOL / VOL 116, DEC 1998 1569 ©1998 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/28/2021 Table 1. Clinical Features of Male Patients PATIENTS AND METHODS With Implantation Cysts* Patient No./ IOP, Ultrasound biomicroscopy was performed using a Race/Age, y Eye Origin VA mm Hg Location Position commercial unit (model 840, Humphrey-Zeiss, San 1/W/88 OD ECCE/PCIOL 20/25 20 PC 1-4 Leandro, Calif). This system operates at 50 MHz, pro- 2/H/42 OS Trauma 20/50 16 AC 10-3 viding a maximum resolution of 50 µm and a tissue 3/W/69 OS ECCE/PCIOL 20/20 16 I 9 penetration depth of approximately 4 to 5 mm. The 4/W/13 OS Congenital 20/20 15 PC 6:30 scanner produces a 5 3 5-mm field with 256 image 5/W/52 OD Trauma HM 16 AC 4-8 lines at a scan rate of 8 frames per second. The probe 6/H/73 OD ECCE/PCIOL LP 30 AC 11-2 is suspended from an articulated arm to reduce mo- 7/H/58 OD Trauma CF 16 PC 1-4:30 tion artifacts, and lateral distortion is minimized by a linear scan format. Scanning was performed with *VA indicates visual acuity; IOP, intraocular pressure; position, of the cyst the patient in the supine position, using a 20-mm eye according to the meridian (clock hours); w, white; ECCE/PCIOL, cup filled with saline solution. The probe was moved extracapsular cataract extraction/posterior chamber lens implantation; PC, posterior chamber; H, Hispanic; HM, hand motion; AC, anterior chamber; perpendicular to the structure to be scanned to pro- I, iris; LP, light perception; and CF, counting fingers. duce radial and transverse sections. Following sur- gical excision, the cysts were immediately fixed in 10% formalin for 24 hours. After routine processing, par- hyperemia (1+ to 2+) and a full-thickness central linear affin sections were prepared and stained with hema- scar extending from limbus to limbus in the horizontal toxylin-eosin. Photomicrographs were prepared in meridian, from approximately the 9:30- to 2:30-o’clock comparable planes of view and magnification to cor- positions. The cyst extended from approximately the 1- relate with the previously obtained UBM images. to 4-o’clock position. It was apparently located in the iris We report on the UBM evaluations of 7 pa- stroma, which was compressed and thinned by the le- tients with anterior segment cysts. Histopathologic reports were available for 4 eyes. sion. A superficial vessel ran superiorly to the periphery The clinical, UBM, and histopathologic fea- of the cyst. The anterior chamber was shallow superi- tures of the cases studied are summarized in Table 1 orly with a mild cellular reaction, but was otherwise deep. and Table 2 and in the figures. The inferior half of the lens could be seen after dilation and appeared to be clear. In the meridians where the cyst was located, visualization of the angle structures was pre- vented by the cyst; elsewhere, gonioscopy revealed a grade 4 angle. There were no fundus abnormalities. mal. Ultrasound biomicroscopy revealed a round cyst As the cyst was covering the visual axis, we at- (radial diameter, 3.1 mm; height, 2.7 mm) attached to tempted to remove it with 5 Nd:YAG laser applications of the posterior surface of the midperipheral and pupillary 1 to 2 mJ. After the procedure, the cyst deflated and moved iris. Serial radial scans of the lesion revealed that the cyst superiorly under the edge of the pupillary margin. The an- content was sonolucent, except from the 3- to 4-o’clock terior chamber become deeper nasally and temporally, and positions, where moderately echoic material with a hy- visual acuity improved subjectively. Three weeks later, vi- perechoic core that adhered to the cyst wall was seen (Fig- sual acuity was 20/30 OS; IOP was 19 mm Hg OS. Slit- ure 1, A and B). During the following 9 months, the le- lamp biomicroscopy revealed a small remnant of the cyst sion grew and eventually was removed by sector at the superior border of the pupillary margin. iridectomy. During surgery, calcific or cholesterol-type In March 1997, the cyst returned and pushed the deposits along with mucoid material that extended into atrophic iris forward, shallowing the anterior chamber the anterior chamber were found. This material was later superiorly. Visual acuity was hand motion OS and kera- removed by irrigation. Two months after surgery, visual tometry was 43.00/49.00 with very poor mires. Ultra- acuity was 20/40 OD; IOP was 10 mm Hg OD. Patho- sound biomicroscopy revealed a cyst (radial diameter, 3.8 logic examination of the excised iris (Figure 1, C) re- mm; height, 2.7 mm) located in the iris stroma and ex- vealed that the cyst wall was composed of a stratified epi- tend ing from approximately the 10- to 3-o’clock posi- thelial lining. The cyst cavity was filled with inflammatory tion (Figure 2, A). The cyst cavity was almost com- debris. The cyst adhered to the iris. pletely sonolucent. The patient underwent anterior chamber reconstruction with penetrating keratoplasty, CASE 2 cataract extraction without intraocular lens implanta- tion, cyst excision, anterior synechialysis, and anterior A 42-year-old man was referred to us because of a cystic vitrectomy. Five months later, visual acuity was 20/100 lesion in the left eye (Figure 2). Thirteen years previ- OS. The graft was clear and a large iridectomy was lo- ously, he had had perforating trauma, which was surgi- cated between the 10-o’clock and 3-o’clock positions. cally repaired in the Dominican Republic.