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The Official Scientific Journal of Delhi Ophthalmological Society
An Unusual Case Of Ruptured Post-Traumatic Iris Implantation Cyst With Co-Existent Anterior Chamber Cilia
1Chandana Chakraborti, 2Nabanita Barua, 1Sheuli Kumar, 3Anjan Kumar Das, 1Rosy Kahakashan Christi
1Department of Ophthalmology, Calcutta National Medical College and Hospital, Kolkata, West Bengal, India
2Department of Ophthalmology, Nil Ratan Sircar Medical College and Hospital, Kolkata, West Bengal, India
3Department of Pathology, Calcutta National Medical College and Hospital, Kolkata, West Bengal, India

Corresponding Author:
Chandana Chakraborti MS, DO
Associate Professor
Department of Ophthalmology, 
Calcutta National Medical College and Hospital
Kolkata, West Bengal, India
Email Id: cchakoptha@yahoo.com
Received: 28-JUN-2017 Accepted: 31-OCT-2017 Published Online: 03-MAR-2018
DOI: http://dx.doi.org/10.7869/djo.334
Abstract
A 13-year old boy reported with dimness of vision and whitish material inside the right eye since two weeks. There was history of injury with metallic wire in the same eye one and half years ago for which he received symptomatic treatment. He remained asymptomatic apart from mild redness in that eye occasionally. Visual acuity was 6/12 and 6/6 in the right and left eye respectively. A linear corneal scar was noted at the supero-temporal quadrant. Anterior chamber showed presence of whitish fluffy material, part of which was attached to the peripheral iris at 10-11 o’clock. A hair like foreign body was found at the bottom of the anterior chamber. The entire material was removed surgically along with the foreign body. The whitish material revealed small multiple hair like structures under the microscope. Histopathological examination showed eosinophilic acellular material with squam, suggestive of implantation dermoid. The foreign body was subsequently proven to be human hair after forensic evaluation. It was diagnosed as a case of ruptured iris implantation cyst with anterior chamber cilia.
Keywords : post traumatic iris cyst, anterior chamber cilia

Introduction
Anterior chamber iris implantation cysts are rare cases seen after penetrating keratoplasty, cataract surgery or perforation of cornea.1-4 If wound margins stays unapposed following penetrating trauma, corneal, conjunctival, lid or adnexal epithelium may migrate inside the anterior chamber covering the corneal endothelium, iris surface and anterior chamber angle. This epithelium after implantation into the iris, gets favourable milieu for cellular proliferation and forms an epithelial inclusion cyst.5,6 Coexistence of intraocular eyelash and anterior chamber cyst following penetrating trauma or surgery is very rare. Spontaneous rupture of such a cyst has not yet been reported in literature. We have not found any such case after extensive PUBMED research.

Case Report 
A 13- year- old male child presented in the eye out patient department with complaints of dimness of vision along with appearance of whitish material in his right eye (RE) for 2 weeks. On enquiry, there was a history of injury with a metallic wire in the same eye one and half years ago which was treated conservatively by a local physician. He remained asymptomatic apart from mild redness in the right eye from time to time. On examination, the best corrected visual acuity in RE was 6/12 and in LE, it was 6/6. Slit lamp biomicroscopy of the RE showed mild ciliary congestion. A linear corneal scar 2 mm in length was noted at 11 o’ clock position, close to the limbus. The anterior chamber (AC) showed presence of whitish fluffy material and a hair like foreign body lying at the bottom (Figure 1). Further examination revealed the mass to be attached to the cornea and at iris periphery at 10 to 11 o clock. The whitish material was present covering almost 2/3rd of the pupillary area without any AC reaction. The pupil was round, regular and briskly reacting to light. After dilation of pupil, there was no lenticular opacity (Figure 2). Fundus examination showed clear media with no abnormality. The intraocular pressure by applanation tonometry was 10 mm Hg. Examination of the other eye was within normal limits. The hair like foreign body was removed intact through a clear corneal incision at 9 ’o clock position with a Mc Phersons forceps under general anaesthesia (Figure 3). The whitish material was aspirated by an anterior chamber cannula through the side port. There was a gap found in iris tissue at 11 o’ clock. The AC was formed with air and subconjuctival injection of gentamicin and dexamethasone was given. Three curly small hair like structures were found entangled with the white mass under the operative microscope (Figure 4). Histopathological (HP) examination of the white material showed mostly acellular eosinophilic granular substance, few refractile bodies and squam (exfoliated squamous epithelium) (Figure 5a & 5b). Features were suggestive of implantation dermoid. Gram stain and culture sensitivity of the material showed no growth. Silver and PAS stain were negative for fungal body. The removed foreign body was confirmed to be human hair by forensic laboratory (Figure 6). The patient was put on topical broad spectrum antibiotic (Cap Amoxyclav 375 mg three times a day for 5 days) and steroid (T. Prednisolone 1mg/kg body wt/d). His post operative vision on day 1 was 6/12 with mild anterior chamber reaction. On day 3, his BCVA was 6/6 and the AC was quiet. No complication or recurrence occurred till 6 months of follow up.








Discussion
Post traumatic iris implantation cyst may be of two types: pearl and serous cyst. Serous cysts are common, they are thin walled and are lined by flattened epithelium containing chronic inflammatory or cellular exudates. Pearl cysts are rare, they are round or oval, pearly white in color, may be embedded within the iris or angle.7 Our case was a ruptured pearl cyst. Gupta et al reported 11 cases of iris implantation cysts of which only one was a pearl cyst, rest were serous cysts. The time taken between trauma and appearance of the cyst may range from 6 months to 20 years.8 In a review of cystic iris lesions in children, only 4 of 57 iris cysts were of secondary origin, of which two were post-traumatic epithelial ingrowth cysts.9 Small iris cysts may remain asymptomatic and static in size. Surgery is indicated, if the cyst enlarges to avoid complications like obscuration of the visual axis , uveitis, corneal edema or glaucoma. Recurrence of cyst after surgical excision has been reported, which could be due to the retained material.9 In our case, some of the material might have been lost during AC aspiration which explains the lack of keratin and the cyst wall (a characteristic feature of dermoid) on HP examination. There are various treatment options available for iris inclusion cyst such as needle aspiration, viscodissection, endolaser photocoagulation, endodiathermy, cryotherapy, local excision, en bloc resection of the cyst or intracystic ethanol irrigation.10-12 Surgical outcome usually remains poor because of the extensive growth of epithelial cells, that may explain the poor prognosis in the young age group.8 Our case had a good surgical outcome, even after 6 months post surgery there were no complication or recurrence, probably as the cyst was removed completely.  In our case, the cilia might have entered into the AC along with corneal, conjunctival or eyelid epidermis. Reaction to retained cilia inside the eye is widely variable, ranging from quiet eye for years to acute fulminant endophthalmitis.1 In such cases, epithelial ingrowth should also be considered as a differential diagnosis as pathogenesis is similiar. In our case, there was no retrocorneal membrane, intractable glaucoma, corneal edema, positive Siedel test.13 The clinical picture was that of a ruptured implantation cyst which corroborated well with histopathology. A similiar case has been reported by Tulvatana et al, but the dermoid was intact in their case. In our case, the cyst wall was ruptured leading to more diagnostic dilemma. Pre-operatively, ultrasound biomicroscopy could have been done in this case but the patient could not afford it.

Each case of penetrating eye injury needs to be analysed and managed carefully. Primary repair of such an injury should include thorough search of possible foreign bodies by gonioscopy, ultrasound biomicroscopy and/or irrigation of the anterior chamber.

References
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  13. Tulvatana W, Chantranuwat C, Mahasuvirachai K, Amaranuntakit S. Free keratin and dermoid cyst of the iris. Arch Ophthalmol 2005; 123:402–3.

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Chandana Chakraborti, Nabanita Barua, Sheuli Kumar, Anjan Kumar Das, Rosy Kahakashan ChristiAn Unusual Case Of Ruptured Post-Traumatic Iris Implantation Cyst With Co-Existent Anterior Chamber Cilia.DJO 2018;28:41-43
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Chandana Chakraborti, Nabanita Barua, Sheuli Kumar, Anjan Kumar Das, Rosy Kahakashan ChristiAn Unusual Case Of Ruptured Post-Traumatic Iris Implantation Cyst With Co-Existent Anterior Chamber Cilia.DJO [serial online] 2018[cited 2018 Jul 19];28:41-43. Available from: http://www.djo.org.in/articles/28/3/AnUnusualCaseOfRupturedPostTraumaticIrisImplantationCystWithCoExistentAnteriorChamberCilia.html
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