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Clinical evaluation of a novel surgical technique (large cross incision) for conjunctival cysts

Published:August 24, 2017DOI:https://doi.org/10.1016/j.jcjo.2017.06.013
      An acquired conjunctival cyst may occur spontaneously or after ocular surgery or trauma.
      • Shields J.A.
      • Shields C.L.
      Tumors of the conjunctiva and cornea.
      Chief complaints are foreign-body sensation or cosmetic issues. Although simple needle aspiration might be an easy choice for the treatment of conjunctival cysts, such an approach may be associated with frequent recurrence of the cysts. Typically, a simple resection can resolve the problem; however, incomplete resection may also result in recurrence of the lesion. Moreover, identification of the cyst margin can be difficult because of poor visualization of the cyst capsule. Fragility of the cyst capsule also makes the complete removal of the cyst difficult. Several other surgical methods have been proposed for the removal of conjunctival cysts; these include intracyst injection of isopropyl alcohol,
      • Kothari M.
      A novel method for management of conjunctival inclusion cysts following strabismus surgery using isopropyl alcohol with paired injection technique.
      thermal cautery,
      • Hawkins A.S.
      • Hamming N.A.
      Thermal cautery as a treatment for conjunctival inclusion cyst after strabismus surgery.
      argon laser photoablation,
      • Han S.B.
      • Yang H.K.
      • Hyon J.Y.
      Removal of conjunctival cyst using argon laser photoablation.
      and high-frequency radiowave electrosurgery.
      • Park J.
      • Lee S.
      • Suh E.
      Removal of conjunctival cyst with high-frequency radio-wave electrosurgery.
      Alternatively, staining of the conjunctival cyst capsule using dyes such as indocyanine green and trypan blue and/or colored hyaluronate helps to visualize the cyst margin, enabling safe and complete resection of the cyst.
      • Kobayashi A.
      • Saeki A.
      • Nishimura A.
      • et al.
      Visualization of conjunctival cyst by indocyanine green.
      • Kobayashi A.
      • Sugiyama K.
      Visualization of conjunctival cyst using Healon V and trypan blue.
      • Kobayashi A.
      • Sugiyama K.
      Successful removal of a large conjunctival cyst using colored 2.3% sodium hyaluronate.
      • Chan R.Y.
      • Pong J.C.
      • Yuen H.K.
      • Lai J.S.
      Use of sodium hyaluronate and indocyanine green for conjunctival cyst excision.
      • Eom Y.
      • Ahn S.E.
      • Kang S.Y.
      • Kim H.M.
      • Song J.S.
      Sutureless small-incision conjunctival cystectomy.
      However, the cyst resection must be performed in an operating theatre.
      Herein, we report a novel and simple surgical technique for conjunctival cysts (large conjunctival cross incision) that can be performed at an outpatient clinic under slit-lamp biomicroscopy. We also report the preliminary clinical outcomes.

      Methods

      Patients

      Three patients (3 females; mean age, 50 years) with conjunctival cysts were included in this study (Table 1). Two patients experienced recurrence of the cysts after simple needle aspiration.
      Table 1Clinical data from 3 patients with conjunctival cysts
      CaseSex/Age (years)EyeChief ComplaintSlit-Lamp FindingsPrevious Ocular SurgerySurgeryPostoperative MedicationFollow-up Period (months)Clinical Outcomes After Surgery
      1F/37RIrritationConjunctival cyst at the inferonasal conjunctivaSeveral needle aspirations of the cystLarge cross incision of the conjunctivaTopical 0.5% Levofloxacin and 0.1% fluorometholone16Disappearance of the cyst and no recurrence
      2F/50LConjunctival injectionLarge conjunctival cyst at the inferonasal conjunctivaNoneLarge cross incision of the conjunctivaTopical 0.5% Levofloxacin and 0.1% fluorometholone16Disappearance of the cyst and no recurrence
      3F/63RConjunctival injectionConjunctival cyst at the inferior fornixSeveral needle aspirations of the cystLarge cross incision of the conjunctivaTopical 0.5% Levofloxacin and 0.1% fluorometholone12Disappearance of the cyst and no recurrence

      Large Cross Incision Technique

      Topical anaesthesia was administered using 2 drops of 0.4% oxybuprocaine hydrochloride ophthalmic solution. A lid retractor was then applied, and the conjunctival cyst walls were pricked using an ophthalmic microknife under a slit-lamp biomicroscope. The conjunctiva around the pricked hole was held with nontoothed forceps to insert a blade of Westcott scissors through the hole. The cyst walls were incised with a large cross using the Westcott scissors so that the cyst was completely opened. No sutures were used. Topical 0.5% levofloxacin and 0.1% fluorometholone were administered and tapered over 1 month.

      Results

      Case 1

      A 37-year-old female, otherwise healthy, reported irritation in her right eye and was referred to our hospital. She had undergone simple needle aspiration and experienced recurrence of the cyst several times before referral. A slit-lamp examination revealed a relatively small conjunctival cyst located at the inferonasal conjunctiva. She denied any history of surgery or trauma to her right eye. No abnormalities were observed in her left eye. After informed consent was obtained, the cross incision procedure was performed. No recurrence was observed 16 months after surgery.

      Case 2

      A 50-year-old female experiencing redness in her left eye visited our hospital. She had regular visits because of Sjögren’s syndrome and dry eye. A slit-lamp examination revealed a relatively large conjunctival cyst located at the inferonasal conjunctiva in her left eye (Fig. 1A). She denied any history of surgery or trauma to her left eye. Dry eye was observed in her left eye. After informed consent was obtained, the cross incision procedure was performed. No recurrence was observed 16 months after surgery (Fig. 1B).
      Fig. 1
      Fig. 1(A) Conjunctival inclusion cyst from case 2. Black lines indicate the location of the cross incision. (B) After treatment, the cyst disappeared and no recurrence was observed.

      Case 3

      A 63-year-old female, otherwise healthy, experienced conjunctival injection in her right eye and was referred to our hospital. She underwent simple needle aspiration and experienced recurrence of the cyst twice before referral. A slit-lamp examination revealed a relatively small conjunctival cyst located at the inferior fornix (Fig. 2A). She denied any history of surgery or trauma to her right eye. No abnormalities were observed in her left eye. After informed consent was obtained, the cross incision procedure was performed. No recurrence was observed 12 months after surgery (Fig. 2B).
      Fig. 2
      Fig. 2(A) Conjunctival inclusion cyst located at the inferior fornix from case 3. Black lines indicate the location of the cross incision. (B) After treatment, the cyst disappeared and no recurrence was observed.

      Discussion

      Herein, we describe a novel surgical procedure named the “large cross incision technique” and report its clinical outcomes for conjunctival cysts in 3 patients. After treatment with this relatively simple and less-invasive technique, the conjunctival cysts rapidly disappeared in all cases without recurrence. We are unaware of previous reports of any such procedure and could find no reference to it in a computerized search using PubMed (as of April 13, 2017).
      Previously, it was thought that total removal of the cyst wall was of paramount importance to avoid reaccumulation of cyst fluid. To achieve this goal, several strategies have been used: one is to destroy the cells of the inner surface of the cysts with an argon laser,
      • Han S.B.
      • Yang H.K.
      • Hyon J.Y.
      Removal of conjunctival cyst using argon laser photoablation.
      radiowaves,
      • Park J.
      • Lee S.
      • Suh E.
      Removal of conjunctival cyst with high-frequency radio-wave electrosurgery.
      or isopropyl alcohol injection.
      • Kothari M.
      A novel method for management of conjunctival inclusion cysts following strabismus surgery using isopropyl alcohol with paired injection technique.
      Alternatively, to assist in the visualization of the cyst wall, biological staining (e.g., indocyanine green and trypan blue) with/without viscoelastic materials has been advocated.
      • Kobayashi A.
      • Saeki A.
      • Nishimura A.
      • et al.
      Visualization of conjunctival cyst by indocyanine green.
      • Kobayashi A.
      • Sugiyama K.
      Visualization of conjunctival cyst using Healon V and trypan blue.
      • Kobayashi A.
      • Sugiyama K.
      Successful removal of a large conjunctival cyst using colored 2.3% sodium hyaluronate.
      • Chan R.Y.
      • Pong J.C.
      • Yuen H.K.
      • Lai J.S.
      Use of sodium hyaluronate and indocyanine green for conjunctival cyst excision.
      These techniques are especially useful when the cysts are small and relatively isolated and mobile under the conjunctiva, although these procedures must be performed in an operating theatre and usually require sutures. Most recently, complete cyst removal via small conjunctival incisions has been reported to be more optimal.
      • Eom Y.
      • Ahn S.E.
      • Kang S.Y.
      • Kim H.M.
      • Song J.S.
      Sutureless small-incision conjunctival cystectomy.
      • Ikeda N.
      • Ikeda T.
      • Ishikawa H.
      In toto extraction of spontaneous conjunctival cysts without incision under slit-lamp microscopic view.
      The large cross incision technique reported herein relies on a completely different concept. To prevent regeneration of the cyst wall, the conjunctiva is scored with a large crosswise incision, and the wound is kept open without any sutures. Incision shape and size are reported be quite important for the wound healing process.
      • Kerstein M.D.
      The scientific basis of healing.
      Theoretically, large cross incision leaves the cyst wall wide open for a longer period compared to straight or dot-shaped incision by delaying wound healing. We hypothesize that the cells of the inner surface of the cyst wall merge with the healthy conjunctival surface during the healing process, resulting in no regeneration of the cyst wall and making it difficult for secreted fluid to reaccumulate.
      The technique takes only minutes, and the entire process can be performed in an outpatient clinic under a slit-lamp biomicroscope. This technique is especially suited for cysts that are quite large, are adhered to the surrounding tissue without mobility, and/or are located deep within the fornix, as cysts in these situations are difficult to excise completely using previously reported surgical techniques.
      In conclusion, this novel surgical technique using a large cross incision may be useful not only for conventional cysts but also for recurring cases and/or cases with large conjunctival lesions without mobility, in which total resection is difficult. Moreover, this technique is quite simple and can be performed in an outpatient clinic with slit-lamp biomicroscopy. Further evaluation of this technique in a large number of patients is required to fully understand the utility of this surgical option.

      Disclosure

      This study was supported by a Grant-in-Aid for Scientific Research © KAKENHI, Japan (No. 16K11261). The sponsor or funding organization had no role in the design or conduct of this research. The authors have no proprietary or commercial interest in any materials discussed in this article

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