Iris cysts are hollow cavities in the eye filled with secretion. They come in various sizes, numbers, shapes, pigments and can be free-floating, attached to the pupillary margin or within the posterior chamber. [1] Most frequently iris cysts don't cause any issues, but they can cause problems like: "fly biting" behavior, corneal endothelial pigment, lens capsular pigmentation, altered iris movement, decreased aqueous outflow with subsequent glaucoma or block the vision when grown too big. [1] They can be acquired or innate. Possible causes are inflammation, drug-induced, uveitis, a trauma, tumor-induced, parasitic or implantation. [2] Most frequently iris cysts are benign and need no treatment. Sometimes iris cysts are causing problems and need to be deflated. Iris cysts can be treated with trans corneal diode laser treatment, fine-needle aspiration or surgical excision. [1] For the treatment of iris cysts is a conservative approach favored. [2]
Mackenzie diagnosed the first iris cyst in 1830, which was a posttraumatic iris cyst in the anterior chamber. [2] Because of the wide variety of iris cysts, a categorization was needed. This categorization was proposed by Shields in 1981 and was based on 2 main groups: primary and secondary cyst. Primary cysts origin is neuroepithelial, and rarely causes any issue. Primary cysts can be subcategorized based on their location in the eye. However, secondary cysts can cause problems like decreased vision, secondary glaucoma, uveitis or corneal edema and origin from implantation, metastasis, miotics or parasites. Secondary cysts are further categorized based on their origin. [2]
The iris is a thin circular structure in the eye which consists of two layers, on top is the stroma and underneath the pigmented epithelial cells. It separates the eye in the anterior and posterior chamber, is responsible for the eye's color, and its function is to regulate the size of the pupil. By controlling the size of the pupil it regulates the amount of light reaching the retina. Depending on the amount of light, the iris opens with high intensity light and closes with low intensity light. [3] The iris is able to control the size of the pupil due to radial and circular muscles which attach to the stroma. The circular muscle, sphincter muscle, contracts in a circular motion, making the pupil smaller, but by contracting the radial muscles, dilator muscles, the pupil enlarges. [4]
The classification of primary cysts is according to the categorization of Shields. The origin of primary cysts is neuroepithelial. Primary cysts are rarely causing any problems, fluid-filled and have smooth surfaces. They are subcategorized according to their location in the eye. Pupillary cysts, also central cysts, are located from the pupillary margin to the iris root, midzonal cysts are located from the iris root to the ciliary body, and peripheral cysts are located at the iridociliary sulcus. Free-floating cysts can occur in the anterior and vitreous chamber and are usually dislodged epithelium cysts. [2]
Cysts of the iris stroma are anteriorly located and as they develop, they usually cause deformation of the iris and need treatment. Especially the congenital secondary cysts require often treatment. They are usually unilateral and solitary. Acquired secondary cysts, on the other hand, require very rarely treatment and often occur at a later age.
Secondary cysts are usually unilateral and solitary and have a smooth surface. Secondary cysts may obstruct the eye's vision, cause intraocular pressure or iris displacement. The categorization of secondary cysts is categorized according Shields categorization. [2] Secondary cysts are classified into 6 subcategories.
Iris cyst must be differentiated from other kinds of possible "bodies" in the eye. After the body has been established as an iris cyst, it must be categorized as primary or secondary. It is necessary to differentiate secondary cysts even further. Clinical examination can achieve this differentiation with the use of multimodal imaging techniques like UBM, ultrasound B-scan (USB), anterior segment optical coherence tomography (as-OCT) and magnetic resonance imaging. [2]
Primary cysts come in various sizes and number but are usually fluid-filled, with regular borders and a smooth surface. The iris could be slightly displaced anteriorly because of a primary cyst, but normally no problems occur with primary cysts. Secondary cysts cause most of the times problems, and thus also need treatment. Secondary cysts usually have a rough surface, irregular borders, solitary and unilateral. Possible problems could be displacement of the iris, iritis and raised intraocular pressure. [2]
A clinician should also be able to tell the difference between a cyst and a tumor. The main differences are that cysts usually cause displacement or the iris whereas a tumor arises and grows into the iris stroma. In the presence of an intrinsic or sentinel vessel than you probably have to deal with a tumor. The last main difference can be shown with transillumination, since transillumination always creates a shadow with a tumor but almost never with a cyst. [9]
Ultrasound B-scan (USB) uses wavelengths of 10-20 MHz to form an image of the eye. USB can be used to identify the extension of the iris cyst in either the anterior or posterior chamber. It can also be used to identify midzonal cysts behind the iris and to determine whether there is ciliary body involvement. The preferred method to determine ciliary body involvement, however, is not USB but ultrasound biomicroscopy. [2]
Ultrasound biomicroscopy, (UBM) has a higher resolution than USB and it also uses soundwaves with a higher frequency from 50 to 100 MHz. UBM is used for the identification of thin ultrastructure's and for internal echogenicity of cysts. Due to the high resolution small cysts can easily be distinguished, multilocated cysts are easy to find and it is easier to determine whether the cyst is bilateral. The only disadvantage of UBM is its limited penetration. Despite this disadvantage, UBM is still the golden standard for the diagnosis of iris cysts. [9] [2]
AS-OCT has the highest resolution of all diagnosis methods but it has a major disadvantage. AS-OCT creates a heavy shadowing caused by the iris pigment epithelium regarding iris lesions. AS-OCT is used to show the anterior border of an iris lesion. The internal structure of the cyst and what is behind the cyst, however, is not that clear due to heavy shadowing. That is why UBM is preferred over AS-OCT, the borders will be less visible but with UBM the whole structure of the cyst and the surrounding tissues is shown. [9] [2]
Fine-needle aspiration, FNA, is only used if every other method has failed to establish what kind of cyst it is and if it is presumably a solid tumor. FNA is used as a last diagnosis method because it is the most invasive method since the eye has to be penetrated with a needle. FNA has been very successful with differentiating tumors with cystic spaces, like melanomas, adenomas or metastatic tumors. FNA can also be used as a treatment. [2]
MRI is not used as a diagnosis method by itself. It is more used as a method to gain some extra information about the cyst. Magnetic resonance imaging can establish very well whether the cyst is in contact or attached to the sclera or whether the cyst is a primary tumor.
The preferred treatment option is observation, since most iris cysts do not hurt or cause any pressure. A veterinarian however prefers to check the cyst from time to time to make sure that the cyst does not grow and does not cause any problems or pain. If the cyst is growing, causing pain or some issues over time, then the cyst will need another treatment. [10]
Fine-needle aspiration (FNA) is, as discussed earlier, also a diagnosis method but can also be used as a treatment. With FNA a very fine needle is inserted in the eye in the cyst. The purpose of the needle is to penetrate the membrane of the cyst, so that the cyst will deflate. This method has proven to be successful but there is a possibility that the cyst will not disappear fully but only shrink. If the cyst has shrunk enough that it is not causing any pain or trouble anymore, then a second treatment might not be necessary. But if the cyst is still causing an issue after the treatment, the treatment must be repeated, or another method has to be used. [2]
Intracystic injection of absolute alcohol has proven to be a very effective method. The alcohol gets injected in the cyst through a needle which is penetrating the eye from outside into the cyst. The injection of the alcohol regresses the cyst or will at least stabilize it. It can take a few weeks before the cyst has disappeared fully. A common side effect of this method is an inflammation in the anterior chamber, but this can easily be treated with topical steroids (cream or gel with anti-inflammatory properties). [11] [12]
Antimitotic agents are used mainly when a cyst is resistant to all other treatments apart from surgery, since surgery is the last resort. Antimitotic agents are injected into the cyst and left inside for 5 minutes; after 5 minutes the agents are rinsed out. Antimitotic agents have the side effect of creating a small inflammation which can easily be treated with topical steroids. Antimitotic agents stop the mitose of the cells of the cyst by interfering with a particular phase of the cell cycle, which stops the cyst from growing and will eventually kill the cells and thus the cyst. [2]
Laser therapy is a treatment which has to be repeated several times. The treatment gets repeated every week until the cyst is gone. Despite not having the highest success rate it is nowadays the most preferred treatment against iris cyst because it is the least invasive method since the eye doesn't need to be punctured or cut. Two kinds of laser beams can be used for laser therapy: thermal (diode or argon laser) and Nd:YAG laser. Sometimes both methods are combined for a better result since thermal laser can harden the cyst and stop the intracystic fluid production and Nd:YAG can perforate the cyst membrane and drain the cyst. [13] [ unreliable source? ] [2]
Surgery is considered to be the last resort because surgery has the highest chance at complications. The surgical approach depends on where the cyst is located, how big the cyst is and the number of cysts.
There are many options when treating an iris cyst. Mentioned above are the most used treatments but in the past there have been other methods but they haven't been successful enough to be still used today. A clinician has to consider a lot of things when choosing a treatment. The golden rule when treating iris cysts however is to choose the least invasive method. That means that cysts which are not causing any problems will not be treated but observed. The least invasive treatment is laser therapy and is, therefore, also the preferred method to treat an iris cyst. Depending on the kind of cyst, the clinician will choose either antimitotic agents or AS-OCT, if laser has failed or if laser is not possible. It is unlike that FNA will be used due to its low potential for removing the cyst. Surgery is the most invasive method and the one with the highest chance of complications. That is why surgery is the last resort. [2]
Glaucoma is a group of eye diseases that lead to damage of the optic nerve, which transmits visual information from the eye to the brain. Glaucoma may cause vision loss if left untreated. It has been called the "silent thief of sight" because the loss of vision usually occurs slowly over a long period of time. A major risk factor for glaucoma is increased pressure within the eye, known as intraocular pressure (IOP). It is associated with old age, a family history of glaucoma, and certain medical conditions or medications. The word glaucoma comes from the Ancient Greek word γλαυκóς, meaning 'gleaming, blue-green, gray'.
In humans and most mammals and birds, the iris is a thin, annular structure in the eye, responsible for controlling the diameter and size of the pupil, and thus the amount of light reaching the retina. Eye color is defined by the iris. In optical terms, the pupil is the eye's aperture, while the iris is the diaphragm.
Eye surgery, also known as ophthalmic surgery or ocular surgery, is surgery performed on the eye or its adnexa. Eye surgery is part of ophthalmology and is performed by an ophthalmologist or eye surgeon. The eye is a fragile organ, and requires due care before, during, and after a surgical procedure to minimize or prevent further damage. An eye surgeon is responsible for selecting the appropriate surgical procedure for the patient, and for taking the necessary safety precautions. Mentions of eye surgery can be found in several ancient texts dating back as early as 1800 BC, with cataract treatment starting in the fifth century BC. It continues to be a widely practiced class of surgery, with various techniques having been developed for treating eye problems.
Pilocarpine is a medication used to reduce pressure inside the eye and treat dry mouth. As an eye drop it is used to manage angle closure glaucoma until surgery can be performed, ocular hypertension, primary open angle glaucoma, and to constrict the pupil after dilation. However, due to its side effects it is no longer typically used for long-term management. Onset of effects with the drops is typically within an hour and lasts for up to a day. By mouth it is used for dry mouth as a result of Sjögren syndrome or radiation therapy.
Uveitis is inflammation of the uvea, the pigmented layer of the eye between the inner retina and the outer fibrous layer composed of the sclera and cornea. The uvea consists of the middle layer of pigmented vascular structures of the eye and includes the iris, ciliary body, and choroid. Uveitis is described anatomically, by the part of the eye affected, as anterior, intermediate or posterior, or panuveitic if all parts are involved. Anterior uveitis (iridocyclitis) is the most common, with the incidence of uveitis overall affecting approximately 1:4500, most commonly those between the ages of 20-60. Symptoms include eye pain, eye redness, floaters and blurred vision, and ophthalmic examination may show dilated ciliary blood vessels and the presence of cells in the anterior chamber. Uveitis may arise spontaneously, have a genetic component, or be associated with an autoimmune disease or infection. While the eye is a relatively protected environment, its immune mechanisms may be overcome resulting in inflammation and tissue destruction associated with T-cell activation.
Ectopia lentis is a displacement or malposition of the eye's crystalline lens from its normal location. A partial dislocation of a lens is termed lens subluxation or subluxated lens; a complete dislocation of a lens is termed lens luxation or luxated lens.
An Eye neoplasm is a tumor of the eye. A rare type of tumor, eye neoplasms can affect all parts of the eye, and can either be benign or malignant (cancerous), in which case it is known as eye cancer. Eye cancers can be primary or metastatic cancer. The two most common cancers that spread to the eye from another organ are breast cancer and lung cancer. Other less common sites of origin include the prostate, kidney, thyroid, skin, colon and blood or bone marrow.
Optic neuropathy is damage to the optic nerve from any cause. The optic nerve is a bundle of millions of fibers in the retina that sends visual signals to the brain. [1].
Ciliary body melanoma is a type of cancer arising from the coloured part (uvea) of the eye.
Corneal ulcer, also called keratitis, is an inflammatory or, more seriously, infective condition of the cornea involving disruption of its epithelial layer with involvement of the corneal stroma. It is a common condition in humans particularly in the tropics and in farming. In developing countries, children afflicted by vitamin A deficiency are at high risk for corneal ulcer and may become blind in both eyes persisting throughout life. In ophthalmology, a corneal ulcer usually refers to having an infection, while the term corneal abrasion refers more to a scratch injury.
Ronald H. Silverman is an American ophthalmologist. He is currently Professor of Ophthalmic Science at Columbia University Medical Center. He is currently the director of the CUMC Basic Science Course in Ophthalmology, which takes place every January at the Harkness Eye Institute. He departed Weill Cornell Medical College in 2010, where he was Professor of Ophthalmology as well as a Dyson Scholar and the Research Director of the Bioacoustic Research Facility, Margaret M. Dyson Vision Research Institute at Weill Cornell.
Corneal tattooing is the practice of tattooing the cornea of the human eye. Reasons for this practice include improvement of cosmetic appearance and the improvement of sight. Many different methods and procedures exist today, and there are varying opinions concerning the safety or success of this practice.
A staphyloma is an abnormal protrusion of the uveal tissue through a weak point in the eyeball. The protrusion is generally black in colour, due to the inner layers of the eye. It occurs due to weakening of outer layer of eye by an inflammatory or degenerative condition. It may be of five types, depending on the location on the eyeball.
Canine glaucoma refers to a group of diseases in dogs that affect the optic nerve and involve a loss of retinal ganglion cells in a characteristic pattern. An intraocular pressure greater than 22 mmHg (2.9 kPa) is a significant risk factor for the development of glaucoma. Untreated glaucoma in dogs leads to permanent damage of the optic nerve and resultant visual field loss, which can progress to blindness.
Diktyoma, or ciliary body medulloepithelioma, or teratoneuroma, is a rare tumor arising from primitive medullary epithelium in the ciliary body of the eye. Almost all diktyomas arise in the ciliary body, although, rarely, they may arise from the optic nerve head or retina.
A breast biopsy is usually done after a suspicious lesion is discovered on either mammography or ultrasound to get tissue for pathological diagnosis. Several methods for a breast biopsy now exist. The most appropriate method of biopsy for a patient depends upon a variety of factors, including the size, location, appearance and characteristics of the abnormality. The different types of breast biopsies include fine-needle aspiration (FNA), vacuum-assisted biopsy, core needle biopsy, and surgical excision biopsy. Breast biopsies can be done utilizing ultrasound, MRI or a stereotactic biopsy imaging guidance. Vacuum assisted biopsies are typically done using stereotactic techniques when the suspicious lesion can only be seen on mammography. On average, 5–10 biopsies of a suspicious breast lesion will lead to the diagnosis of one case of breast cancer. Needle biopsies have largely replaced open surgical biopsies in the initial assessment of imaging as well as palpable abnormalities in the breast.
Plateau iris is a medical condition of the eye resulting from anterior displacement of the peripheral iris by the ciliary body, causing angle closure glaucoma. First line treatment for all causes of narrow angle glaucoma is laser iridotomy. If narrow angle glaucoma persists after iridotomy, it is called plateau iris syndrome and subsequently managed either medically (miotics) or surgically. This condition is sometimes discovered after an iridotomy causes a rapid increase in eye pressure. Due to its rarity, few ophthalmologists have experience with treating those affected by plateau iris syndrome.
Corneal opacification is a term used when the human cornea loses its transparency. The term corneal opacity is used particularly for the loss of transparency of cornea due to scarring. Transparency of the cornea is dependent on the uniform diameter and the regular spacing and arrangement of the collagen fibrils within the stroma. Alterations in the spacing of collagen fibrils in a variety of conditions including corneal edema, scars, and macular corneal dystrophy is clinically manifested as corneal opacity. The term corneal blindness is commonly used to describe blindness due to corneal opacity.
Secondary glaucoma is a collection of progressive optic nerve disorders associated with a rise in intraocular pressure (IOP) which results in the loss of vision. In clinical settings, it is defined as the occurrence of IOP above 21 mmHg requiring the prescription of IOP-managing drugs. It can be broadly divided into two subtypes: secondary open-angle glaucoma and secondary angle-closure glaucoma, depending on the closure of the angle between the cornea and the iris. Principal causes of secondary glaucoma include optic nerve trauma or damage, eye disease, surgery, neovascularization, tumours and use of steroid and sulfa drugs. Risk factors for secondary glaucoma include uveitis, cataract surgery and also intraocular tumours. Common treatments are designed according to the type and the underlying causative condition, in addition to the consequent rise in IOP. These include drug therapy, the use of miotics, surgery or laser therapy.
Uveitis–glaucoma–hyphaema (UGH) syndrome, also known as Ellingson syndrome, is a complication of cataract surgery, caused by intraocular lens subluxation or dislocation. The chafing of mispositioned intraocular lens over iris, ciliary body or iridocorneal angle cause elevated intraocular pressure (IOP) anterior uveitis and hyphema. It is most commonly caused by anterior chamber IOLs and sulcus IOLs but, the condition can be seen with any type of IOL, including posterior chamber lenses and cosmetic iris implants.