Iris Cysts: Clinical Features, Imaging Findings, and Treatment Results

The Secondary Childhood Glaucomas

The secondary childhood glaucomas are a heterogenous group, often associated with other ocular or systemic abnormalities. These childhood glaucomas are distinct from primary childhood glaucomas, both in terms of their clinical features and their response to conventional treatment. Surgical management can be challenging in children with secondary glaucoma. On average, this group undergo more surgical procedures and revisions than those with primary congenital glaucoma. We provide a synopsis of secondary childhood glaucomas in terms of classification, clinical features, and management strategies, with emphasis on recent developments.

Cysts and tumours of the iris: Diagnostic tools and key management considerations-A review

The iris is a unique structure, with exquisite variations in colour and form. Pathological changes, specifically including iris cysts and tumours are relatively uncommon, difficult to diagnose, and yet potentially blinding or life-threatening. Based on a comprehensive literature review, with highly illustrated key case examples, this report aims to guide the clinician in filtering the differential diagnoses of iris cysts and tumours. Evaluation is in the context of key diagnostic clinical tools and management considerations. Diagnostic imaging techniques include serial anterior segment photography, ultrasound, anterior segment optical coherence tomography, and iris fluorescein angiography, however, the roles of computerised topography and magnetic resonance imaging are also considered in this review. Management includes categorisation in terms of solid iris tumours (melanocytic vs. non-melanocytic), or iris cysts (primary vs. secondary) that may be usefully differentiated by clinical assessment, avoiding more invasive interventions. Cystic lesions are generally benign, although implantation cysts in particular cause significant complications and surgical challenges. Most solid tumours are melanocytic and also typically benign. However, in larger lesions, rapid growth, symptoms and complications more likely indicate malignancy, requiring further investigation.

Fluctuating hypermetropia due to intraocular lens displacement caused by iris pigment epithelial cyst

Purpose

To report a case of hyperopic shift following lens replacement surgery due to an enlarging iris pigment epithelial (IPE) cyst.

Observations

A gentleman presented with reduced visual acuity (Snellen unaided 20/25) 12 months followed lens replacement surgery. Examination revealed a retro-pupillary iris lesion that appeared to be displacing the posterior chamber intraocular lens (IOL) and was causing a hyperopic shift (refraction +2.00). Anterior segment optical coherence tomography imaging confirmed this to be an IPE cyst with a posteriorly displaced IOL body. After observation over 30 months, the IPE cyst spontaneously reduced in size and the IOL returned to a more physiological position. Unaided visual acuity improved to Snellen 20/16 and refraction improved to +0.50.

Conclusions and Importance

To our knowledge, an IPE cyst that shows growth following intraocular surgery has not previously been reported. This growth resulted in a hyperopic shift due to posterior displacement of the IOL. This case demonstrates spontaneous regression of the cyst, and suggests that over time these cysts can change in size.

Imaging of Anterior Segment Tumours: A Comparison of Ultrasound Biomicroscopy Versus Anterior Segment Optical Coherence Tomography

Anterior segment tumours of the eye are relatively rare but can pose significant morbidity and mortality. We conducted a literature review to compare the performance of ultrasound biomicroscopy to anterior segment optical coherence tomography in the imaging of these tumours. A total of seven studies were included accounting for a cumulative 1,114 eyes. Ultrasound biomicroscopy has traditionally formed, and remains, the mainstay of tumour imaging due to its ability to penetrate pigmented lesions and delineate the posterior border of tumours, and the current evidence supports this.

Current clinical applications of anterior segment optical coherence tomography angiography: a review

Optical coherence tomography (OCT) is a revolutionary in vivo imaging technology that presents real-time information on ocular structures. Angiography based on OCT, known as optical coherence tomography angiography (OCTA), is a noninvasive and time-saving technique originally utilized for visualizing retinal vasculature. As devices and built-in systems have evolved, high-resolution images with depth-resolved analysis have assisted ophthalmologists in accurately localizing pathology and monitoring disease progression. With the aforementioned advantages, application of OCTA has extended from the posterior to anterior segment. This nascent adaptation showed good delineation of the vasculature in the cornea, conjunctiva, sclera, and iris. Thus, neovascularization of the avascular cornea and hyperemia or ischemic changes involving the conjunctiva, sclera, and iris has become prospective applications for AS-OCTA. Although traditional dye-based angiography is regarded as the gold standard in demonstrating vasculature in the anterior segment, AS-OCTA is expected to be a comparable but more patient-friendly alternative. In its initial stage, AS-OCTA has exhibited great potential in pathology diagnosis, therapeutic evaluation, presurgical planning, and prognosis assessments in anterior segment disorders. In this review of AS-OCTA, we aim to summarize scanning protocols, relevant parameters, and clinical applications as well as limitations and future directions. We are sanguine about its wide application in the future with the development of technology and refinement in built-in systems.

Symptomatic familial primary iris cysts at the pupillary margin in three consecutive generations: A case series

Case series purpose

Iris cysts are uncommon lesions, most of them are iris pigment epithelial (IPE) cysts which typically manifest in adults as unilateral single cysts, are typically asymptomatic and rarely require treatment. The most frequent location of IPE cysts is the iris periphery and the iridociliary sulcus, whereas pupillary cysts are rare. This observational case series aims to describe a unique occurrence of bilateral pupillary IPE cysts in three consecutive generations of a single family.

Observations

The series describes eight patients of a single family with no consanguineous marriage. All patients have IPE cysts with remarkable abnormally-shaped pupils. The patients were examined at the slit-lamp and imaged with anterior segment optical coherence tomography. Three brothers (14, 19 and 28 years old) were symptomatic and suffered from hemeralopia and reduced visual acuity. ND-YAG laser was successful in relieving the symptoms in the two younger brothers. No recurrence or refill of the cysts occurred after laser application and no intra- or ppostoperative complications were observed during a 9-month follow-up. The older family members showed spontaneously shrunken IPE cysts.

Conclusions and Importance

IPE cysts are considered idiopathic with an unclear origin. The rare familial incidence of the cysts suggests an autosomal dominant heredity pattern. Many theories were proposed to explain the origin of cysts and none is conclusive. Their principal clinical significance is their similarity to pigmented iris tumors, but they might also cause visual symptoms. Treatment modalities vary from less invasive chemical compounds and ND: YAG laser application to more invasive surgical procedures with disparate efficacy and safety. In the case of multiple cysts, examination of other family members is worthy even when asymptomatic and cardiac consultation of affected patients is warranted as IPE cysts may proclaim a coexisting cardiovascular abnormality, such as familial aortic dissection.

Advances in swept-source optical coherence tomography and optical coherence tomography angiography

Background

The fast development of swept-source optical coherence tomography (SS-OCT) and swept-source optical coherence tomography angiography (SS-OCTA) enables both anterior and posterior imaging of the eye. These techniques have evolved from a research tool to an essential clinical imaging modality.

Main text

The longer wavelength and faster speed of SS-OCT and SS-OCTA facilitate better visualization of structure and vasculature below pigmented tissue with a larger field of view of the posterior segment and 360-degree visualization of the anterior segment. In the past 10 years, algorithms dealing with OCT and OCTA data also vastly improved the image quality and enabled the automated quantification of OCT- and OCTA-derived metrics. This technology has enriched our current understanding of healthy and diseased eyes. Even though the high cost of the systems currently limited the widespread use of SS-OCT and SS-OCTA at the first beginning, the gap between research and clinic practice got obviously shortened in the past few years.

Conclusions

SS-OCT and SS-OCTA will continue to evolve rapidly, contributing to a paradigm shift toward more widespread adoption of new imaging technology in clinical practice.

Clinical applications of anterior segment swept-source optical coherence tomography: A systematic review

Optical coherence tomography (OCT) is a non-invasive method that provides the opportunity to examine tissues by taking cross-sectional images. OCT is increasingly being used to evaluate anterior segment (AS) pathologies. Swept-source (SS) OCT allows greater penetration and achieves better visualization of the internal configuration of AS tissues due to the longer wavelength employed and high scan speeds. We reviewed the utilization of AS SS-OCT in various conditions including glaucoma, ocular surface pathologies, iris tumors, refractive surgery, cataract surgery, and scleral diseases. A systematic literature search was carried out on PubMed, Scopus, and Web of Science databases between January 1, 2008, and September 1, 2022 using the following keywords: AS SS-OCT; dry eye and SS-OCT; ocular surface and SS-OCT; cornea and SS-OCT; dystrophy and SS-OCT; glaucoma and SS-OCT; ocular surface tumors and SS-OCT; conjunctival tumors and SS-OCT; refractive surgery and SS-OCT; cataract and SS-OCT; biometry and SS-OCT; sclera and SS-OCT; iris and SS-OCT; ciliary body and SS-OCT; artificial intelligence and SS-OCT. A total of 221 studies were included in this review. Review of the existing literature shows that SS-OCT offers several advantages in the diagnosis of AS diseases. Exclusive features of SS-OCT including rapid scanning, deeper tissue penetration, and better image quality help improve our understanding of various AS pathologies.

Sodium-Hyaluronate Cystic-like Lesion in the Anterior Chamber Following Cataract Surgery: A Case Report

This is a case report describing the uncommon finding of a cystic-like lesion and its management in the anterior chamber of a male patient after cataract surgery.

DMEK with endophotocoagulation and cyst wall removal for corneal endothelial decompensation due to iris cyst

Purpose

Iris cysts may arise secondary to surgical or nonsurgical trauma, potentially leading to corneal decompensation via mechanical injury to the adjacent endothelium. However, no well-established protocol exists for the treatment for corneal edema arising therefrom.

Observations

A 58-year-old white male presented with an iris mass of his left eye; it occupied 1/3rd the anterior chamber volume and directly contacted the corneal endothelium. The cornea was diffusely edematous, and best corrected visual acuity (BCVA) measured 20/70 (0.3). Corneal endothelial decompensation secondary to iris cyst was diagnosed. Treatment consisted of endophotocoagulation and vitrectomy probe removal of the cyst wall, with Descemet membrane endothelial keratoplasty (DMEK) also performed as a single, combined procedure. The patient subsequently experienced a resolution of his corneal edema and disappearance of his iris cyst, without recurrence of either condition. BCVA improved to 20/25 (0.8).

Conclusions and importance

Iris cyst may be a rare cause of corneal decompensation. Viable treatment may entail a single-stage procedure involving endophotocoagulation and vitrectomy probe application to the cyst wall combined with DMEK.

Imaging of iris vasculature: current limitations and future perspective

Fluorescein and indocyanine green angiography have been the traditional ways to image the vasculature of the iris in the last few decades. Because of the invasive nature of these procedures, they are performed in rare situations, and thus, our understanding about iris vasculature is very limited. Optical coherence tomography angiography (OCTA) is a noninvasive imaging method that enables the detailed visualization of the retinal and choroidal vascular networks. More recently, it has been also used for the examination of the iris vasculature in healthy and disease eyes. However, there is a lack of uniformity in the image acquisition protocols and interpretations in both healthy and pathological conditions. Artifacts of iris OCTA include shadowing, motion, segmentations errors, mirror effects. OCTA devices have an eye-tracking system designed for the posterior segment and the applications of these systems on the anterior segment can determine motion lines, vessel duplication, and vessel discontinuity. OCTA of the iris should always be performed under ambient room lighting to create miosis and reduce iris vasculature changes during the examination. In the near future, eye-tracking systems specifically designed for the iris vessels could permit the follow-up function, and the development of new OCTA metrics could reveal interesting applications of this new imaging technique.

Implantation iris cysts developing 24 years after penetrating keratoplasty

PURPOSE

To report a case of iris implantation cysts occurring 24 years after penetrating keratoplasty and its management.

OBSERVATIONS

A 60-year-old man was referred for diagnosis and management of white iris masses of the right eye. He had undergone bilateral penetrating keratoplasty 24 years before without complication. The clinical findings were suggestive of iris implantation cysts and Ultrasound Biomicroscopy (UBM) and anterior-segment optical coherence tomography confirmed the diagnosis. The patient did not develop any ocular complications from the cysts after one-year follow-up from the diagnosis of iris implantation cysts.

CONCLUSIONS AND IMPORTANCE

Iris implantation cysts are rare benign tumors that develop after the ectopic implantation of epithelial cells within the iris stroma. They can be congenital or secondary to penetrating trauma or surgery. Their diagnosis relies on clinical examination and UBM. In case of intraocular complications, treatment may be required, otherwise observational follow-up is appropriate.

Advances and Current Clinical Applications of Anterior Segment Optical Coherence Tomography Angiography

Optical coherence tomography angiography (OCTA) is the most relevant evolution based on optical coherence tomography (OCT). OCTA can present ocular vasculature, show detailed morphology for assessment, and quantify vessel parameters without intravenous dye agent. Research on the anterior segment OCTA (AS-OCTA) is only in its initial phase, and its advances in clinical diagnosis and treatment efficacy evaluations require a detailed comparison to traditional imaging methods. In this review of AS-OCTA, we summarize its technical features, imaging advances, current clinical applications in various eye diseases, as well as its limitations and potential future directions. AS-OCTA offers potential advantages in ophthalmic imaging, and with further development it could become a common tool in the near future.

Clinical Features of Iris Cysts in Long-Term Follow-Up

This study evaluated the characteristics and clinical course of patients with iris cysts in the long-term follow-up (24–48 months). We retrospectively analyzed the medical records of 39 patients with iris cysts (27 women and 12 men). Age, visual acuity, intraocular pressure (IOP), slit-lamp evaluation, and ultrasound biomicroscopy images were assessed. The mean age at diagnosis was 40.6 ± 17.48 years. Thirty (76.9%) cysts were peripheral, five (12.8%) were located at the pupillary margin, two (5.1%) were midzonal, and two (5.1%) were multichamber cysts extending from the periphery to the pupillary margin. A total of 23 (59%) cysts were in the lower temporal quadrant, 11 (28.2%) were in the lower nasal quadrant, and 5 (12.8%) were in the upper nasal quadrant. Cyst size was positively correlated with patient age (rs = 0.38, p = 0.003) and negatively correlated with visual acuity (rs = −0.42, p = 0.014). Cyst growth was not observed. The only complication was an increase in IOP in three (7.7%) patients with multiple cysts. The anatomical location of the cysts cannot differentiate them from solid tumors. The vast majority of cysts are asymptomatic, do not increase in size, and do not require treatment during long-term follow-up.

The Effectiveness of Ultrasound Biomicroscopic and Anterior Segment Optical Coherence Tomography in the Assessment of Anterior Segment Tumors: Long-Term Follow-Up

Background

Differential diagnosis and follow-up of small anterior segment tumors constitute a particular challenge because they determine further treatment procedures. The aim of this study was to evaluate the efficacy of the UBM (ultrasound biomicroscopy) and AS-OCT (anterior segment optical coherent tomography) in distinguishing different types of anterior segment lesions.

Methods

It was a retrospective, noncomparative study of case series of 89 patients with the suspicion of anterior segment tumor referred to the Ophthalmology Clinic, Medical University of Białystok, Poland, between 2016 and 2020. UBM was used to assess tumor morphology including height, location, and internal and external features. In cases in which UBM did not provide enough data, the AS-OCT images were analyzed. The data on demographics, best corrected visual acuity (BCVA), intraocular pressure (IOP), and rate of complications were also collected. Patients were followed up from 1 to 48 months.

Results

The mean observation period was 26.61 ± 16.13 months. Among the patients, there were 62 women and 27 men at a mean age of 55.59 ± 19.48 (range: from 20 to 89 years.) The types of tumors were cysts (41%), solid iris tumors (37.1%), ciliary body tumors (7.9%), peripheral anterior synechiae (PAS 3.4%), corneal tumors (4.5%), and others (5.6%). Patients with cysts were younger than patients with solid iris tumor (p=0.002). Women had a cyst as well as solid iris tumor more frequently than men, but less often a ciliary body tumor (p < 0.05). The horizontal size of tumor was positively correlated with patients' age (r_s = 0.38 and p=0.003) and negatively correlated with visual acuity (r_s = −0.42 and p=0.014). During the 4 years of diagnosis, only 2.2% of lesions exhibited growth (growth rate of 0.02 mm per year). Among 15 cases in which visualization with UBM was not satisfactory (mostly iris nevi), AS-OCT was helpful in diagnosis of 13 patients.

Conclusions

Both UBM and AS-OCT are effective methods in detection and diagnosis of tumors of the anterior eye segment, but in some cases, AS-OCT adds additional value to the diagnosis. Many lesions can be managed conservatively because they did not demonstrate growth during 4 years of the follow-up period.