Inclusion conjunctival cyst after infected buckle removal

Isha Agarwal; Janani Sreenivasan; Yamini Attiku; Ekta Rishi; Pukhraj Rishi

doi:10.4103/ijo.IJO_2034_20

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CASE REPORT

Year : 2021 | Volume : 1 | Issue : 2 | Page : 231-233

Inclusion conjunctival cyst after infected buckle removal

Isha Agarwal, Janani Sreenivasan, Yamini Attiku, Ekta Rishi, Pukhraj Rishi
Shri Bhagwan Mahavir Vitreoretinal Services, Sankara Nethralaya, Chennai, Tamil Nadu, India

Date of Submission	29-Jun-2020
Date of Acceptance	08-Dec-2020
Date of Web Publication	01-Apr-2021

Correspondence Address:
Dr. Pukhraj Rishi
Shri Bhagwan Mahavir Vitreoretinal Services, Sankara Nethralaya, 18 College Road, Chennai - 600 006, Tamil Nadu
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_2034_20

Abstract

This case report describes the unique presentation of post buckle infection, inclusion conjunctival cyst. A 17-year-old male presented with pain, redness and a mass lesion in the left eye status post an infected scleral buckle removal. Surgical exploration revealed retained sutures and the capsule presumed to be formed around the buckle. After removal of both, patient was asymptomatic with stable BCVA and fundus findings. Surgical management includes not just the removal of the buckle material, but also the buckle sutures and the capsule formed around the episcleral buckle implant to completely remove the foci of infection and inflammation.

Keywords: Eye, imaging, inclusion conjunctival cyst, infection, inflammation, retina, retinal detachment, scleral buckle, ultrasound

How to cite this article:
Agarwal I, Sreenivasan J, Attiku Y, Rishi E, Rishi P. Inclusion conjunctival cyst after infected buckle removal. Indian J Ophthalmol Case Rep 2021;1:231-3

How to cite this URL:
Agarwal I, Sreenivasan J, Attiku Y, Rishi E, Rishi P. Inclusion conjunctival cyst after infected buckle removal. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2021 Apr 20];1:231-3. Available from: https://www.ijoreports.in/text.asp?2021/1/2/231/312351

Scleral buckling is an established surgical technique to repair rhegmatogenous retinal detachment (RRD). The implant materials and sutures being foreign material can serve as nidus for infection. Extrusions and infections after scleral buckling surgery have an incidence of 1.3%–24.4%.^[1],[2] Removal of the implant as a result of infection has been reported to be most commonly seen with the use of a silicone sponge (9%) or hydrogel implant (1.3%), and least commonly encountered with a silicon rubber band (0.6%).^[3] Hereby, we report a peculiar case of persistent episcleral inflammation and inflammatory fluid collection within the surgical site episcleral capsule presenting as conjunctival inclusion cyst even after removal of the infected episcleral implant [Figure 1].

Figure 1: At presentation, Slitlamp photographs showing episcleral inflammation, exuberant conjunctival mass in the superior (a), temporal (b) and inferior (c) quadrants. Left eye Pseudo-colour wide-angle (Optos) fundus photograph (d) shows attached retina, clear media, healthy disc, macula, normal vessels and no signs of inflammation. Fundus photo showing inferior quadrant with residual buckle effect, post-cryotherapy chorioretinal scar, areas of white-without-pressure (e). Fundus photo showing nasal quadrant with post-cryotherapy chorioretinal scar, areas of white-without-pressure (f)

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Case Report

A 17-year-old male presented with redness and pain in left eye. He had a history of blunt injury to the left eye 8 years back resulting in retinal detachment that was repaired by scleral buckling, elsewhere. Exact surgical details were not available, except the use of 5 mm split-silicone-sponge episcleral implant. Five years later, he developed redness and chemosis in that eye; was diagnosed with buckle infection and underwent scleral buckle removal. However, his symptoms persisted along with an exuberant mass [Figure 1]a, [Figure 1]b, [Figure 1]c at which time he presented to us. On examination, his best-corrected visual acuity (BCVA) was 6/5 in the right eye and 6/18 in the left eye. Extraocular movements were full and free and IOP was 14 mm Hg in both the eyes; there was no RAPD. Right eye was essentially normal. Left eye had haemorrhagic chemosis with the conjunctiva bulging beyond the anterior lid margin temporally [Figure 1]a and [Figure 1]b. Gonioscopy in the left eye revealed 360 degrees' angle recession. Lens was clear. On dilated fundus evaluation with indirect ophthalmoscopy, left eye had a prominent 360 degrees retinal whitening, with chorioretinal atrophic patches in temporal periphery, disc was hyperaemic, retina was attached [Figure 1]d, [Figure 1]e, [Figure 1]f. Ultrasound biomicroscopy of the left eye revealed mass hypoechoic lesion with heterogeneous internal reflectivity from 12-8 o' clock hours involving sclera, although the posterior extent could not be ascertained [Figure 2]a and [Figure 2]b. There was no evidence of intraocular communication with the lesion [Figure 2]b. Pressure over the lesion with cotton-tipped applicator revealed its cystic nature. This raised the suspicion of collected fluid within the enclosed episcleral space inside the fibrous capsule formed around the erstwhile scleral buckle [Figure 2].

Figure 2: Ultrasound biomicroscopy (UBM) of the left eye shows a cystic mass lesion (star) involving the sclera spanning from 12 o' clock to 8 o' clock meridian with heterogenous internal reflectivity (a). Similar lesion (star) is seen encroaching up to the limbus (b; arrow pointing at iris). Posterior extent is indeterminate. External photograph at 6 weeks post-operatively shows marked reduction in the swelling and congestion of left eye (c)

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The patient underwent left eye wound exploration under general anaesthesia. Intraoperatively, after 360 degrees conjunctival peritomy and tenotomy, a white glistening cyst wall was noted, which revealed copious quantity of straw-coloured fluid within. The cyst wall was completely excised and submitted for histopathology. Retained buckle sutures were identified in three quadrants and carefully removed. Tenons and episcleral tissue were opposed to sclera in all 4 quadrants with fibrin glue to obliterate the space. Microbiological evaluation of the collected fluid did not reveal or incubate any pathogen on culture. Six weeks following surgery, the patient was asymptomatic; BCVA and fundus findings remained stable [Figure 2].

Discussion

Ours was a peculiar case of persistent episcleral inflammatory fluid collection within the surgical site episcleral capsule presenting as conjunctival inclusion cyst even after removal of the infected episcleral implant. Our patient was primarily buckled with silicone sponge explant. Postoperative infection with exposure is more common with silicone sponge explants than with solid silicone explants^[4],[5],[6] probably due to the porous nature of the sponge material that is more conducive to bacterial growth. The flora of the eyelids and conjunctiva are one major source of bacterial contamination of scleral buckles.^[7] However, in our reported case the culture from the cystic capsule wall and the contained fluid did not grow any microorganisms. The substitution of diathermy by cryotherapy and the preoperative antibiotic soaking of exoplants have helped to decrease both the severity and the incidence of buckle infections.^[7] Intraoperatively we had found a glistening capsule in the area where the episcleral buckle implant was placed. The silicone material is smooth and the implant has a rounded contour which leads to development of a tough, collagenous capsule around it.^[8] At first vascularized, the capsule becomes avascular and translucent over time. Conjunctival inclusion cysts are the result of implanting conjunctival epithelium after surgery or trauma. Considering non-infective nature of the cyst fluid the patient's findings were similar to a conjunctival inclusion cyst.

Conclusion

In conclusion, in cases of infected scleral buckles, persisting episcleral inflammation can be caused by retained buckle sutures and present as a conjunctival inclusion cyst. It can also present as conjunctival inclusion cyst of non-infective nature as seen in our case. Similar cyst has been reported containing floating silicone sponge by Kim et al.^[9] They have also been reported after strabismus surgery.^[10] Authors suggested a possible relationship with the scleral suture as the mechanism of cyst formation and that complete excision is the recommended treatment for large cysts. Hence, surgical management includes not just the removal of the buckle material, but also the buckle sutures and the capsule formed around the episcleral buckle implant, as this is a seat for continuing inflammation.

Ethics

This case report was conducted in accordance with the Declaration of Helsinki. The collection and evaluation of all protected patient health information were performed in a HIPAA- (Health Insurance Portability and Accountability Act)-compliant manner.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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