Management of recurrent intra corneal epithelial cyst with ethanol irrigation and vacuum-assisted cyst wall excision
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- Gokhale, N.S. Int Ophthalmol (2013) 33: 429. doi:10.1007/s10792-012-9677-3
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The clinical and pathological features and management of a patient with recurrent intracorneal epithelial cyst are reported. A child presented with a large intracorneal cyst and underwent drainage with 96 % ethanol irrigation. Histopathology confirmed the epithelial nature of the cyst. The cyst recurred, however, and subsequently a repeat ethanol irrigation with removal of the cyst wall was done. The cyst wall was vacuumed to ensure complete removal of epithelial cells. There was no recurrence, with good visual and cosmetic recovery. Intracorneal epithelial cysts can be successfully managed with drainage, 96 % ethanol irrigation, and vacuum-assisted cyst wall excision.
KeywordsIntrastromal cystCorneal cystEpithelial cyst96 % EthanolDrainageSquamous epitheliumInclusion cystvacuumingCytodestruction
Summary of cases reported with management approaches
Nature of cyst
Bloomfield et al. (1980) 
Destruction of epithelial lining
Chan et al. (1989) 
Traumatic corneal cysts
PK, excision + aqueous iodine 1 % cautery
Reed et al. (1971) 
Traumatic corneal cysts
Peripheral marsupialisation, chemical cautery (cocaine)
Rao et al. (1998) 
Congenital sclerocorneal cysts
Marsupialisation of scleral portion
Trichloroacetic acid cauterization
Liakos (1978) 
Congenital sclerocorneal cyst
Drainage, wall excision and cautery
Miffilin (2001) 
Drainage and debridement
Mahmood et al. (1998) 
Congenital sclerocorneal cyst
Wilhelmus et al. (1992) 
Avni et al. (1989) 
Corneal cyst with post-PK sclera and anterior chamber extension
PK, YAG laser
Sano et al. (1999) 
Congenital (2), Post-surgical (squint) (1)
Ali Javadi et al. (2006) 
Post-surgical (squint, corneal repair)
Drainage, 96 % alcohol, wall excision
Shin et al. (2002) 
Distilled water injection
A repeat surgery was advised. This time a vertical corneal incision was made very close to the edge of the cyst at the limbus and deepened till the cyst was entered. The fluid was drained and the cyst was irrigated with 96 % ethanol for 1 min. A whitening of the cyst wall was observed after ethanol injection. Ethanol was irrigated and washed at the end of 1 min. Vacuuming and manual scraping was done with a manual irrigation aspiration reverse Simcoe cannula and an aspiration cannula attached to a phacoemulsification system to remove any residual surviving epithelial cells. The cyst wall was manually scraped with a Sinskey and a reverse Sinskey hook and removed piecemeal. The vacuuming was repeated once again and the incision was closed with a single interrupted 10-0 nylon suture.
Intracorneal epithelial cysts are rare and form due to implantation of corneal epithelial cells into the corneal stroma following developmental aberration or penetrating trauma or prior surgical interventions [1–4, 6]. Congenital or developmental aetiology is more common in the paediatric age group while the traumatic cases are commoner in older children and young adults. In many cases the trauma may be minor enough to be missed and no history or signs of past trauma may be found on examination. Even in cases without an overt history of trauma, undetected previous injury should be considered [7, 8, 13]. Post-surgical corneal cysts have been reported after strabismus surgery [8, 12, 14], cataract surgery  and corneal repair post-trauma . Corneal surgeries and keratorefractive surgeries can potentially drive viable epithelial cells into the corneal stroma and can lead to intracorneal epithelial cyst formation.
The size of the lesion may vary from 1 mm to total involvement of the cornea and is usually oval or circular in shape and contains opalescent fluid. A pseudohypopyon can sometimes be observed within the cyst caused by precipitation of epithelial debris in the lower portion [1, 6, 13]. Surgical intervention is required due to involvement of the visual axis with a drop in vision or for cosmetic purposes.
Simple cyst aspiration and drainage are associated with recurrence because the epithelial cells are not destroyed [2, 6, 9]. Drainage with chemical cytodestruction is therefore a preferred modality of treatment. Corneal epithelial cysts have been successfully treated with 96 % ethanol . Injection of alcohol into the collapsed cyst cavity in a closed chamber technique allows cytodestruction and minimizes inadvertent damage to the adjacent corneal stroma or endothelium. Whitening of the cyst wall on contact with ethanol ensures that cytodestruction has occurred throughout the cyst cavity. However if destruction of the epithelial cells is incomplete, remaining epithelial cells proliferate and the cyst recurs [2, 6, 9, 11]. Complete excision of the cyst wall after cytodestruction ensures that any remaining viable epithelial cells are also removed and no recurrence is possible.
Our patient was 9 years old and the cyst had been noted since 1 year duration. There was no history of trauma or surgery and no evidence of previous penetrating injury on examination. The epithelial nature of the cyst was confirmed by the histopathological observations. Drainage with 96 % ethanol injection was performed, but the cyst recurred, indicating that some viable epithelial cells survived within the cyst cavity and re-proliferated postoperatively. At the second surgery additional vacuuming was done to remove all possible epithelial cells that may have survived the alcohol irrigation. Scrape excision of the cyst wall was done followed by further vacuuming to ensure complete removal, and resulted in a successful outcome. The incision was also made at the extreme limbal edge of the cyst so as to obtain easier access to perform a more complete cyst wall excision. Vacuuming helps to remove any cyst wall or epithelial cell remnants after cyst wall excision and has not been previously described to the best of our knowledge.
We recommend a combined approach to treating these rare cysts. Cytodestruction must be combined with cyst wall excision and vacuuming to remove any residual epithelial cells, especially if the wall is removed piecemeal.