Conjunctival cyst is a polyethological disease characterized by the appearance of a hollow thin–walled formation filled with transudate. Common symptoms for all forms of pathology are lacrimation, a feeling of sand or a foreign body in the eye. Diagnosis is based on physical examination, ophthalmoscopy, biomicroscopy, visiometry, tonometry and histological examination of postoperative material. Specific treatment is excision of pathological formation within healthy tissues. Conservative therapy is ineffective.
A conjunctival cyst is a congenital or acquired cavity formation with an intra- or subepithelial location. About 22% of all benign neoplasms of the conjunctiva is a dermoid cyst. In 0.25% of cases, an operation to eliminate strabismus (strabismus) leads to the development of this pathology. In 50%, the cause of a postoperative cyst is surgical intervention on the lateral, in 41.6% – on the middle and 8.1% – on the lower rectus muscle. According to the statistics obtained in practical ophthalmology, postoperative cysts are more often formed at a young age. Men are more likely to develop the disease (62%). 5.7% of patients after removal of the eyeball face the problem of the appearance of subepithelial cystic formations.
Causes of conjunctival cyst
Congenital conjunctival cysts are genetically determined diseases of the visual organ. Dermoid is a teratoma that occurs in isolation or in combination with other manifestations of Goldenhar syndrome (anomalies of the structure of the auricles, mandible, tongue, palate and teeth), Madelung deformity or gill arch syndrome. The cause of the development of a dermoid cyst is a violation of the differentiation of the germ sheets that give rise to the structures of the eyeball.
In most cases, conjunctival cysts are the result of post-inflammatory fibrosis, which occurs in patients with conjunctivitis of bacterial, viral or fungal origin, scleritis, canaliculitis, rarely blepharitis in the anamnesis. There is an etiological relationship between this pathology and acquired dilation of the excretory ducts of the accessory lacrimal glands. Intraepithelial cysts are often formed after injury to the eyes, prolonged friction of the eyelashes during inversion or inversion of the eyelids. Subepithelial cysts can become a consequence of surgical intervention. The causes of the development of retention cystic formations are obstruction of the excretory ducts of the sebaceous glands of Krause and Wolfring, violation of lymph outflow.
Acquired forms may develop after surgical treatment of strabismus or removal of the eyeball by evisceration with resection of the posterior pole and preservation of the cornea. The trigger of early complications after surgical treatment of strabismus is often poor-quality suturing of the conjunctiva, leading to a violation of the location of the tenon capsule. In the late postoperative period, the cause of the formation of cysts is the penetration of cells from the tenon capsule in the area of the scleral tunnel incision.
Cystic formations after evisceration develop in the area of the musculoskeletal stump (MSS). The etiological factor is the increased proliferation of cells of the conjunctiva of the limbal zone. If the congruence of the touching surfaces of the prosthesis and the MSS is violated, the pressure in the cavity of the eye socket changes dramatically. Different degrees of pressure on the adjacent tissues and their prolonged injury lead to the formation of a cyst of the type of corn.
There are the following forms of conjunctival cyst: dermoid, implantation (traumatic, postoperative), retention and post-inflammatory. Cystic formations can be single or multiple, single or multi-chamber. Single occur both in the upper and lower parts of the eyeball, multiple – mainly in the proximal arch of the conjunctiva. The characteristic location of the subepithelial cysts is the semilunar fold. Intraepithelial formations are a cluster of goblet-shaped cells located in the upper part of the bulbar conjunctiva.
Common to all forms of the disease are symptoms such as lacrimation, a feeling of sand or a foreign body in the eye. Small cysts are usually painless and do not affect visual acuity. An increase in the volume of pathological formation leads to compression syndrome, the appearance of dull bursting pain and a decrease in visual functions. During the closing of the eyes or when blinking, there is a constant traumatization of the cyst with eyelashes, which causes micro-injuries, hyperemia and irritation of the conjunctiva. It is possible to attach a clinical picture of secondary conjunctivitis.
Congenital dermoid cyst of the conjunctiva, as a rule, is detected in early childhood. Parents find a small rounded formation of pale yellow color in the child, which is more often localized in the upper lateral parts of the eye. At birth, the size of the dermoid is up to 5 mm. The lack of timely treatment leads to the fact that the cyst gradually increases in size and can cover most of the eye up to the place of projection of the lacrimal gland, which is accompanied by a sharp violation of visual functions. In rare cases, a cystic formation sprouts into the temporal zone.
Retention cyst looks like a small thin-walled bubble filled with transparent contents. It is characterized by an asymptomatic course, in rare cases spontaneous remission is possible. When cystic formations are located on the anterior surface of the MSS in the case of anophthalmos, patients complain of discomfort and a subjective feeling of displacement of the cosmetic prosthesis.
In patients with dermoid cyst of the conjunctiva, an objective examination determines a yellowish formation with a heterogeneous structure. With palpation, it is possible to detect slight mobility. The consistency is dense, the surface is smooth and shiny. The method of ophthalmoscopy determines the pallor of the lateral parts of the optic disc. Histological examination of postoperative material or cyst biopsy can detect lipid inclusions, sweat gland cells, and in rare cases, hair follicles. With a large size of the formation, the visiometry method reveals a decrease in visual acuity, with tonometry – an increase in intraocular pressure (IOP).
Patients with a cyst of post-inflammatory origin indicate conjunctivitis, scleritis, canaliculitis or blepharitis in the anamnesis. During physical examination, vascular injection and conjunctival hyperemia are visualized. Cystic formation of a regular rounded shape about 3-5 mm in diameter. Retention cyst is not accompanied by a change in the adjacent structures of the eyeball. There are no signs of inflammation during a biopsy of the contents. Visual acuity is not impaired, there is no increase. During ophthalmoscopy of the fundus, the optic nerve disc is unchanged.
An implantation cyst of traumatic origin may be accompanied by a local inflammatory reaction in the form of hyperemia and conjunctival edema. Hemorrhage foci are often found. The degree of visual acuity reduction depends on the severity of the injury. Ophthalmoscopy and biomicroscopy can be used to assess the depth of the lesion. When the cyst is punctured, there are no signs of inflammation of the contents. When a cosmetic prosthesis is dislocated due to the formation of a postoperative cyst, an expansion of the eye slit and a violation of the closing of the eyelids are observed.
Treatment of conjunctival cyst
Conservative treatment of conjunctival cysts is reduced to the local use of glucocorticosteroids, followed by the introduction into the cystic cavity of a solution of trichloroacetyl acid, which has sclerosing properties. Surgical removal of conjunctival cysts within healthy tissues is considered to be a more effective method. Surgical intervention is performed under regional anesthesia or epibulbar drip anesthesia. With a large volume of cystic formations, a radio-wave knife should be used to remove them, since this technique avoids a large burn area, provides reliable coagulation of blood vessels and makes it possible to completely remove the capsule, which prevents the development of relapses.
Before surgery, contrast (methylene blue) is injected into the cyst cavity under local anesthesia. Only dyed fabrics are subject to removal. The location of cystic formations must be coagulated and a continuous absorbable suture must be applied. In case of an extensive postoperative defect, plastic surgery using an autograft is recommended. For 2 weeks after surgery, instillation of antibacterial drops containing tobramycin should be carried out. With a small cyst size, laser excision is acceptable. This method does not lead to the development of cosmetic defects, but with a large volume of cystic formations, it is accompanied by an increase in the temperature of their contents. In case of spontaneous rupture of the capsule during surgery, a burn of the conjunctiva is possible.
Prognosis and prevention
Nonspecific prevention of conjunctival cysts consists in observing eye hygiene and preventing traumatic injuries. If pathological formations are detected on the conjunctiva of a child, it is necessary to undergo an examination by an ophthalmologist. With a burdened family history of dermoid, consultations with a specialist are shown 2 times a year. In order to prevent relapses of the disease, increased visual loads should be avoided for the first 2-3 months after surgery. No specific preventive measures have been developed. The prognosis with timely diagnosis and treatment is favorable for life and work capacity. A decrease in visual acuity and an increase in intraocular pressure is observed only with a large cyst size.