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A Translucent Cystic Iris Lesion

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A boy in his teens with no significant medical history, ocular history, or recent trauma was referred by an ophthalmologist for mild photophobia and an iris lesion. The referring clinician initially suspected traumatic iridodialysis and vitreous prolapse. On ophthalmic evaluation, visual acuity was 20/20 OS, intraocular pressure was 13 mm Hg OS, and slitlamp examination of the left eye demonstrated a clear, intrinsically vascularized, cystic lesion extending into the anterior chamber from the peripheral superonasal iris (Figure 1A). The base of the lesion was surrounded by iris atrophy and corectopia was noted. The remainder of the ocular examination was unremarkable. Examination of the right eye was also unremarkable. Ultrasonographic biomicroscopy of the anterior segment demonstrated a large, cystic lesion incorporated in the iris of the left eye with a thickness of 2.2 mm and a maximum radial extent of 6.1 mm (Figure 1B).

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Iris stromal cyst

A. Aspiration with absolute alcohol injection

Pigmented cysts arising from the iris pigment epithelium are the most common type of primary iris cyst.1 They are often of no visual consequence and typically do not require intervention.1 However, iris stromal cysts are likely to enlarge with distortion of surrounding structures and potential consequences of compromised vision, amblyopia, recurrent iridocyclitis, and glaucoma.2,3 Stromal cysts represent approximately 3% of iris tumors, and approximately 40% of iris stromal cysts are congenital.4 Congenital cysts are typically diagnosed in patients younger than 20 years.4

In this case, continued observation was not ideal given the extension into the visual axis and the significant growth over the course of 1 month. Aspiration,3 alcohol sclerosis,5,6 resection,7 and laser treatment8 have all been described; however, we believe aspiration with alcohol sclerosis is the preferred initial approach given that it is less invasive than surgical resection and potentially less inflammatory and less likely to yield recurrence than laser cystotomy.

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Article Information

Corresponding Author: C. Ellis Wisely, MD, Duke Eye Center, Department of Ophthalmology, Duke University, 2351 Erwin Rd, Durham, NC 27710 (clayton.wisely@duke.edu).

Published Online: June 20, 2019. doi:10.1001/jamaophthalmol.2019.1651

Conflict of Interest Disclosures: Dr Materin is a paid consultant and advisor for Castle Biosciences outside the submitted work. No other disclosures were reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
1.
Shields  JA, Shields  CL.  Cysts of the iris pigment epithelium: what is new and interesting?  Asia Pac J Ophthalmol (Phila). 2017;6(1):64-69. PubMedGoogle Scholar
2.
Lois  N, Shields  CL, Shields  JA, Mercado  G, De Potter  P.  Primary iris stromal cysts.  Ophthalmology. 1998;105(7):1317-1322. PubMedGoogle ScholarCrossref
3.
Georgalas  I, Petrou  P, Papaconstantinou  D, Brouzas  D, Koutsandrea  C, Kanakis  M.  Iris cysts.  Surv Ophthalmol. 2018;63(3):347-364. PubMedGoogle ScholarCrossref
4.
Shields  CL, Kancherla  S, Patel  J,  et al.  Clinical survey of 3680 iris tumors based on patient age at presentation.  Ophthalmology. 2012;119(2):407-414. PubMedGoogle ScholarCrossref
5.
Shields  CL, Arepalli  S, Lally  EB, Lally  SE, Shields  JA.  Iris stromal cyst management with absolute alcohol-induced sclerosis in 16 patients.  JAMA Ophthalmol. 2014;132(6):703-708. PubMedGoogle ScholarCrossref
6.
Behrouzi  Z, Khodadoust  A.  Epithelial iris cyst treatment with intracystic ethanol irrigation.  Ophthalmology. 2003;110(8):1601-1605. PubMedGoogle ScholarCrossref
7.
Capó  H, Palmer  E, Nicholson  DH.  Congenital cysts of the iris stroma.  Am J Ophthalmol. 1993;116(2):228-232. PubMedGoogle ScholarCrossref
8.
Gupta  A, Pandian  DG, Babu  KR, Srinivasan  R.  Primary stromal iris cysts treated successfully with ab externo laser Nd:YAG photocoagulation  [published online August 23, 2010].  J Pediatr Ophthalmol Strabismus. doi:10.3928/01913913-20100818-11PubMedGoogle Scholar
9.
Brent  GJ, Meisler  DM, Krishna  R, Baerveldt  G.  Spontaneous collapse of primary acquired iris stromal cysts.  Am J Ophthalmol. 1996;122(6):886-887. PubMedGoogle ScholarCrossref
10.
Ali  M, Zhang  W, Materin  M. Iris stromal cyst aspiration and irrigation with absolute alcohol. American Academy of Ophthalmology. https://www.aao.org/clinical-video/iris-stromal-cyst-aspiration-irrigation-with-absol. Published September 17, 2018. Accessed January 2, 2019.
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