target

To describe the surgical administration of epithelial cystic downgrowth by en bloc excision and use of syngeneic auricular cartilage in two children.

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Study style

Retrospective interventional case series.

technique

The charts of 2 patients treated for epithelial cystic downgrowth with en bloc excision and also auricular cartilage transplant were reviewed. Details of ocular history, preoperative and also postoperative visual acuity, intraocular pressure, ocular examination findings, surgical procedure and also subsequent management were noted.

results

Two kids aged 4 and also 6 years, through epithelial cysts that underwent en bloc excision to be identified. The cysts had arisen following penetrating eye injury. Surgery involved en bloc resection of the cyst and associated tissue, and replacement of the excised corneoscleral tissue through syngeneic auricular cartilage. One patient additionally required synechiolysis, discission the a second cataract and anterior vitrectomy. In both cases, the epithelial tissue was properly removed and the auricular cartilage transplant to be well-apposed. Visual acuity remained at the preoperative level in the an initial patient because of amblyopia; in the second patient visual acuity enhanced to 6/7.5 with mild astigmatic correction.

Conclusion

En bloc excision gives the many definitive surgical procedure of cystic epithelial downgrowth. Auricular cartilage may be offered for sclerokeratoplasty as soon as donor cornea or sclera is unavailable.


Intraocular epithelial cysts are caused by intrusion of epithelium right into the anterior chamber with an inadequately apposed corneal or scleral defect. Castle may also develop as soon as epithelial cells are introduced right into the anterior chamber at the time of penetrating injury. In the anterior chamber, the epithelium grow sheet-like throughout ocular structures, or develops a cyst. Epithelial cysts deserve to remain dormant for countless years. Small, stable, and also asymptomatic cysts may thus be observed. Therapy is indicated if the cyst is farming to avoid or law iridocyclitis, secondary glaucoma, or ns of vision. Numerous surgical ideologies to the monitoring of epithelial cysts have been reported, including cryotherapy,1 photocoagulation,2 and excision.3

En bloc excision of paracentral cystic epithelial downgrowth right into the anterior chamber gives the many definitive and curative surgical procedure of this condition.4, 5, 6 This requires the usage of donor cornea, which might not be available in countless parts the the world. Us report ~ above the successful different of implanting custom-made syngeneic auricular cartilage because that sclerokeratoplasty to regulate intraocular epithelial cysts.


Case 1

A 5-year-old boy sustained a penetrating cornea–iris–lens injury v a knife in his left eye, and underwent wound repair and also lens extraction at a neighborhood hospital. This was followed 3 months later on by a an additional posterior chamber intraocular lens implantation. Postoperatively he developed an ‘iris cyst’, intraocular lens dislocation, and a secondary cataract, and also was described us.

At presentation, the child had photophobia, left exotropia (20 p.d. Krimsky), and a best-corrected intuitive acuity that OD 6/6 and OS 6/120. Intraocular pressure was OU: 18 mmHg. The ocular check of the ideal eye was unremarkable. The left eye had actually a corneal scar extending from the limbus in ~ 9–11 O"clock. A partial anterior chamber edge closure native 9–11 O"clock as result of the epithelial cystic downgrowth originating indigenous the corneal penetration was observed. The iris to be impressed by the mass, causing pupillary distortion. Posterior synechiae, intraocular lens displacement into the anterior chamber, and also a an additional cataract were additionally present (Figure 1a). Fundus details could not it is in visualized; B-scan ultrasonography revealed an unremarkable posterior segment.


Figure 1

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At surgery, the corneal lesion was demarcated through a 7.3 mm trephine. Penetrating trephination of the cornea and also lamellar cut of the sclera was brought out. Cut of the iris cyst en bloc, synechiolysis, discission the the secondary cataract, and anterior vitrectomy were performed.

The auricular cartilage graft to be prepared applying two haemostats to the margin the the best ear to evert the ear and also facilitate technique to the posterior surface. After marking the incision along the mid-portion of the pinna, a no. 15 Bard-Parker blade was supplied to incise the skin and underlying subcutaneous tissue. The overlying organization was separated indigenous the auricular cartilage with blunt dissection using Wescott scissors. The compelled size the graft to be measured, a tiny incision to be made through the cartilage with the no. 15 blade, and lamellar dissection the the cartilage to be completed making use of Wescott scissors. The wound was then closed v interrupted 4-0 nylon sutures.

After tailoring the graft to a dimension of 7.2 mm diameter × 0.4 mm thickness, a 10-0 ethilon GS 12 to run suture was used for permanent of the graft come the cornea, and 7-0 vicryl interrupted sutures for fixation come the sclera. The cartilage was covered with conjunctiva ~ above the scleral side. Anterior chamber depth was kept with viscoelastic.

Postoperatively, prednisolone acetate fall q2 h and gentamicin 0.3% autumn q.i.d. To be commenced. Sutures were removed after 8 weeks. Refraction showed a gentle hypermetropic astigmatism (+2.0/is−2.0/90°). Spectacle correction and also patching the the ideal eye for 6 h every day to be advised.

Histopathological testimonial of the excised tissue shown the diagnosis of one epithelial cyst. At 5 months postoperatively the best-corrected visual acuity remained at OS+2.0/−2.0/90°=6/120. The graft was well-apposed and also vascularized in the periphery, leaving the visual axis clean (Figure 1b). The anterior chamber to be deep and quiet, pupil central, intraocular lens in situ, and also the intraocular push at 20 mmHg. Fundus examination revealed a typical disc, macula, and also periphery. The patient was advised to proceed using the refractive mediate (polycarbonate lenses) and also maintenance occlusion that the left eye for 1 h every day.

Case 2

A 6-year-old boy continual a penetrating corneal injury v a bird beak in his best eye, and was recommend wound repair. The parents refuse surgery. After ~ 6 month he presented with photophobia and visual impairment.

Ocular check revealed a best-corrected visual acuity the OD 6/18 and OS 6/6. Intraocular push was OD 10 mmHg and also OS 16 mmHg. The left eye to be unremarkable. In the right eye, a corneal scar was checked out at the limbus at the 2 O"clock position, with an epithelial cyst create from the wound site and obstructing the visual axis (Figure 2a). Check of the anterior chamber revealed a 2+flare and also 1+cells. The lens to be clear and also normal in position. Fundoscopy revealed an unremarkable posterior segment.


Figure 2

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At surgery, after ~ peritomy, the cornea and also iris cyst were excised en bloc and a lamellar dissection the the sclera (7.5 × 4.52 mm2) to be performed.

Auricular cartilage native the appropriate ear was harvested and also fixed with interrupted sutures, as explained previously in case 1.

Histopathological examination of the tissue confirmed the clinical diagnosis of an epithelial cyst. 6 months postoperatively the best-corrected intuitive acuity to be OD+1.75/−4.5/45°=6/7.5, and the graft appeared well-apposed (Figure 2b).


The monitoring of eccentric corneoscleral lesions may necessitate a tectonic sclerokeratoplasty, which offer to maintain structural and functional verity of the globe, and also helps to stop a recurrence that the major disease.7

En bloc excision of epithelial cysts making use of a tectonic sclerokeratoplasty offers the most definitive treatment for cystic epithelial downgrowth.5, 6 Haller et al8 the evaluation surgical ideologies to the monitoring of epithelial cysts and concluded that epithelial cysts might be controlled conservatively through aspiration and endophotocoagulation, with an excellent results. They recommended this strategy specifically in children, in whom conservation of ocular structures could facilitate amblyopia management. However, various other authors have proclaimed that laser puncture, simple aspiration, or subtotal excision may transform an epithelial cyst into epithelial sheets or downgrowth, making the a more difficult management issue.9

In ours patients, we adopted a an ext aggressive method with en bloc cut of the cyst, iris, and cornea. Absence of donor material necessitated the use of auricular cartilage to replace diseased tissue. Auricular cartilage grafting has been efficiently performed for eyelid reconstruction,10 fix of orbit floor defects,11 rhinoplasty,12 laryngotracheal reconstruction,13 and temporomandibular share repair.14 The benefits of an autologous auricular cartilage graft room ease the harvesting, lack of antigenicity (a common problem through allogeneic cadaveric transplants), low nutritional requirement, and ability to maintain bulk.15 The accept of cartilage together a syngeneic graft in the corneoscleral an ar may have a biochemical basis, viz. Similarity of collagen form I in both tissues: the cornea and elastic cartilage.

Many adjustments in sclerokeratoplasty, including lamellar scleral dissection, well above the scleral spur, have actually been employed to maintain the anterior chamber angle, keep trabecular meshwork function, and avoid postoperative glaucoma.16, 17, 18 The most crucial vision-limiting variable in eccentric tectonic sclerokeratoplasty is corneal astigmatism.4 us attribute the low level the corneal astigmatism watched in our patients to a meticulous location of graft tissue and suturing technique. It is also possible that the versatility of elastic tissue in the cartilaginous graft permits it to be stretched, through a resultant minimal distortion of host tissue.

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To ours knowledge, this is the very first report ~ above the usage of auricular cartilage because that sclerokeratoplasty ~ en bloc excision of epithelial consist of cysts that the anterior chamber.