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Year : 2023  |  Volume : 3  |  Issue : 2  |  Page : 271-273

Unusual application of topical brimonidine for the management of epithelial cysts

Department of Ophthalmology, Wolfson Medical Center, Holon, Israel and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel

Date of Submission08-Oct-2022
Date of Acceptance02-Jan-2023
Date of Web Publication28-Apr-2023

Correspondence Address:
Ran Moshkovsky
Department of Ophthalmology, Wolfson Medical Center, Ha-Lokhamim St. 62, Holon, 5822012
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJO.IJO_2628_22

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The mainstay management of progressive epithelial cysts spans from fine-needle aspiration of the cyst content to radical en bloc excision. Such a surgical approach may result in cyst rupture, recurrence, or collateral tissue damage. Based on previous experience, we aimed at evaluating the off-label use of topical brimonidine as a conservative measure for treating epithelial cysts of the iris and conjunctiva before commencing a surgical excision. We describe two different cases of epithelial cysts in which topical brimonidine was issued with successful outcome, making the more traditional surgical intervention redundant.

Keywords: Cornea, cyst, epithelial downgrowth, epithelial ingrowth, iris cyst, iris lesion

How to cite this article:
Moshkovsky R, Avizemer H, Kleinmann G. Unusual application of topical brimonidine for the management of epithelial cysts. Indian J Ophthalmol Case Rep 2023;3:271-3

How to cite this URL:
Moshkovsky R, Avizemer H, Kleinmann G. Unusual application of topical brimonidine for the management of epithelial cysts. Indian J Ophthalmol Case Rep [serial online] 2023 [cited 2023 Jun 1];3:271-3. Available from: https://www.ijoreports.in/text.asp?2023/3/2/271/374960

Brimonidine, a selective α2-adrenergic agonist, has a dual mechanism of intraocular pressure (IOP) lowering: it both reduces aqueous humor production and stimulates uveoscleral outflow.[1] Due to its influence on the pupil size, it has also been suggested for alleviating photic phenomena post-laser vision correction surgery and multifocal intraocular lens (IOL) implantation.[2],[3] We describe two different cases in which local application of brimonidine resulted in the resolution of epithelial cysts.

  Case Reports Top

Case 1

A 73-year-old woman was referred to our clinic due to a progressive expansion of an iris cystic lesion with suspected epithelial downgrowth in her right eye. Past ocular history was remarkable for uneventful tunnel extracapsular cataract extraction (ECCE) surgery in the same eye 7 years earlier. One and a half years later, the patient presented with an aqueous humor leakage from an opening of a scleral fistula in the operated eye, as imaged by anterior segment optical coherence tomography (AS-OCT).

A revision of the surgical wound was performed with the creation of a scleral flap to facilitate fistula closure. Pathological specimen showed dense fibrotic tissue with no evidence of epithelial cells; however, the first sign of a membrane at the superior portion of the iris and cornea was noted, accompanied by pupillary traction. The patient continued ambulatory follow-up for 3 years and was eventually referred due to progressive expansion of an iris cystic lesion.

On present referral, visual acuity in the same eye was 20/25. A superior iridocorneal synechiae with the suspected membrane was noted along with a cystic lesion that spread through 12 o'clock to 1 o'clock hours, inclining toward the visual axis. Ultrasound biomicroscopy (UBM) revealed iridocorneal adhesions and a localized area of significant corneal thinning [Figure 1]a.
Figure 1: Right eye of Case 1. Slit-lamp photograph and a corresponding UBM showing iris cystic lesion and a membrane upon referral (a) and at 9 months after commencing treatment with topical brimonidine (b). UBM = ultrasound biomicroscopy

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Relying on a previous similar case in our community, twice-daily administration of topical brimonidine was initiated, which gave good results. By 9 months, the cyst had completely absorbed, while the superior membrane or, possibly, iridoschisis remained [Figure 1]b. The patient maintained excellent visual acuity throughout the follow-up period of 24 months with no signs of cyst recurrence.

Case 2

A 51-year-old man with possible limbal stem cell deficiency due to previous contact lens warpage turned to our clinic complaining of a “bubble” in his left eye progressing over the last few weeks. Slit-lamp examination revealed a cystic lesion located at the edge of a nasal pannus, resembling a pterygium [Figure 2]a. Before excision, an attempt was made to reduce the cyst volume using topical brimonidine administered twice daily. By the next follow-up visit at 6 weeks, the cyst had completely resolved [Figure 2]b. There were no signs of recurrence at 6 months.
Figure 2: Left eye of Case 2. Slit-lamp photographs showing a cystic lesion at the edge of a nasal pannus upon referral (a) and at 6 weeks after commencing treatment with topical brimonidine (b)

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  Discussion Top

Regarding the first case, differential diagnosis of iris cysts is divided into primary and secondary cysts. Primary cysts, which originate from iris epithelial cells, are classified by their location on the iris. Secondary cysts encompass postsurgical epithelial downgrowth cyst, pearl cyst, drug-induced cyst (i.e. secondary to miotic or prostaglandin use), medulloepithelioma or, rarely, cysts secondary to an ocular parasite.[4]

Given the past ocular history of the first case, the patient most probably developed epithelial downgrowth cyst, in which cells introduced through the wound proliferate in inner structures such as the iris or corneal endothelium. Risk factors include delayed wound healing and fistula formation.[5] Presentation of implantation cysts may range from 1 to 20 years after the inciting event.[6] Prevalence following ECCE surgeries ranges between 0.08% and 0.12%.[7]

Asymptomatic and stable cysts can be kept under observation, whereas progressive cysts can be managed surgically using different modalities spanning from fine-needle aspiration (FNA) of the cyst content to radical en bloc excision.[4] Previous work has demonstrated better results using conservative measures.[8]

Regarding the second case, conjunctival cysts can be primary or secondary inclusion cysts due to trauma, parasite, inflammatory conditions of the conjunctiva, or degeneration.[9] Given the history of previous contact lens warpage, the second patient most probably developed cystic changes in the pterygium. Histologic studies of pterygium-associated cysts demonstrated cellular downgrowth following degenerative changes in the stroma of the pterygium.[10] Treatment with complete excision may result in rupture as the cysts are thin walled and recurrence is the main postoperative concern.[9]

  Conclusion Top

We herein report the successful treatment of two different cases of epithelial cysts with local application of brimonidine, making the more traditional surgical intervention redundant. We assume that topical brimonidine may help facilitate cyst absorption by reducing aqueous fluid production, and as such, it could be considered before commencing a surgical treatment, sometimes radical. Further studies are required to support our findings and explore the mechanism of action of brimonidine in similar cases.

Off-label use of a commercial product: Brimonidine eye drops is not labeled for the management of epithelial cysts.

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


Conflicts of interest

There are no conflicts of interest.

  References Top

Kato C, Shimizu K, Kamiya K, Ishikawa H, Igarashi A. Effects of brimonidine tartrate 0.1% ophthalmic solution on the pupil, refraction, and light reflex. Sci Rep 2018;8:1-5. doi: 10.1038/s41598-018-27436-8.  Back to cited text no. 1
Lee JH, You YS, Choe CM, Lee ES. Efficacy of brimonidine tartrate 0.2% ophthalmic solution in reducing halos after laser in situ keratomileusis. J Cataract Refract Surg 2008;34:963-7.  Back to cited text no. 2
Woodward MA, Randleman JB, Stulting RD. Dissatisfaction after multifocal intraocular lens implantation. J Cataract Refract Surg 2009;35:992-7.  Back to cited text no. 3
Georgalas I, Petrou P, Papaconstantinou D, Brouzas D, Koutsandrea C, Kanakis M. Iris cysts: A comprehensive review on diagnosis and treatment. Surv Ophthalmol 2018;63:347-64.  Back to cited text no. 4
Weiner MJ, Trentacoste J, Pon DM, Albert DM. Epithelial downgrowth: A 30-year clinicopathological review. Br J Ophthalmol 1989;73:6-11.  Back to cited text no. 5
Rao A, Gupta V, Bhadange Y, Sharma R, Shields JA. Iris cysts: A review. Semin Ophthalmol 2011;26:11-22.  Back to cited text no. 6
Sugar A, Meyer RF, Hood CI. Epithelial downgrowth following penetrating keratoplasty in the aphake. Arch Ophthalmol 1977;95:464-7.  Back to cited text no. 7
Haller JA, Stark WJ, Azab A, Thomsen RW, Gottsch JD. Surgical management of anterior chamber epithelial cysts. Am J Ophthalmol 2003;135:309-13.  Back to cited text no. 8
Nath K, Gogi R. Zaidi N, Johri A. Cystic lesions of conjunctiva (a clinicopathogical study). Indian J Ophthalmol 1983;31:1-4.  Back to cited text no. 9
[PUBMED]  [Full text]  
Kapoor S, Sood GC, Aurora AL, Kapoor S. Cystic degeneration of the pterygium. Indian J Ophthalmol 1977;25:37-8.  Back to cited text no. 10
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