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 Table of Contents  
Year : 2021  |  Volume : 33  |  Issue : 1  |  Page : 78-80

Conjunctival inclusion cyst presenting as proptosis: A rare scenario

Department of Oculoplasty, Little Flower Hospital, Ernakulam, Kerala, India

Date of Submission07-May-2020
Date of Acceptance27-May-2020
Date of Web Publication19-Apr-2021

Correspondence Address:
Dr. Indu B Narayanan
Department of Oculoplasty, Little Flower Hospital, Angamaly, Ernakulam, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/kjo.kjo_51_20

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Conjunctival inclusion cysts are an uncommon complication following various surgeries. They usually present as cystic masses confined to the anterior segment. We report a case of large inclusion cyst with orbital extension, which presented as proptosis and diplopia.

Keywords: Conjunctival inclusion cyst, scleral buckling, strabismus

How to cite this article:
Narayanan IB, Ann J K, Mathew DA, Sreedhar A. Conjunctival inclusion cyst presenting as proptosis: A rare scenario. Kerala J Ophthalmol 2021;33:78-80

How to cite this URL:
Narayanan IB, Ann J K, Mathew DA, Sreedhar A. Conjunctival inclusion cyst presenting as proptosis: A rare scenario. Kerala J Ophthalmol [serial online] 2021 [cited 2021 Jun 13];33:78-80. Available from: http://www.kjophthal.com/text.asp?2021/33/1/78/314098

  Introduction Top

Conjunctival inclusion cysts are benign lesions which are lined by stratified squamous nonkeratinizing epithelium, filled with serous fluid and shed cells.[1] They can be either congenital or acquired. Acquired inclusion cysts occur due to implantation of conjunctival epithelium following trauma or surgery or may occur in inflammatory conditions.[2] It has been reported following various surgeries – strabismus surgery,[3] scleral buckling,[4] pars plana vitrectomy,[5] small incision cataract surgery,[6],[7] glaucoma valve surgery,[8] and subtenon anesthesia injection.[9]

  Case Report Top

A 54-year-old male presented with protrusion of the right eye, which was painless and gradually progressed over the past 4 years. He also had complaints of double vision. He had undergone scleral buckling surgery in the same eye 10 years back.

On examination, his best-corrected visual acuity was 6/9 (right) and 6/6 (left). The right eye showed gross eccentric proptosis of 30 mm with inferior dystopia [Figure 1]. A cystic swelling (8 mm × 6 mm) was noted beneath the superolateral conjunctiva, which was extending into the superior orbit. All extraocular movements were restricted [Figure 2]; elevation was maximally affected. Fundus examination in the right eye showed the attached retina with buckle effect. Left eye anterior segment examination was within normal limits, and the retina showed prophylactic laser marks.
Figure 1: Gross proptosis with inferior dystopia(right eye)

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Figure 2: Severe restriction of abduction and elevation

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Computed tomography of the orbit disclosed a cystic, nonenhancing, well-defined mass in the superior orbit with posterior extension, in relation to the buckle [[Figure 3] – axial cut with an arrow pointing the buckle], displacing the eyeball inferolaterally [[Figure 4] – coronal section]. There was no bony erosion.
Figure 3: Axial sections of CT orbit (arrowhead shows buckle)

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Figure 4: CT Orbit-Coronal sections

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Orbitotomy was done. A well-defined cystic mass was identified. Clear fluid was drained, and wall biopsy was sent for histopathology examination. It was reported as conjunctival inclusion cyst [Figure 5].
Figure 5: Histopathology - stratified squamous epithelium lined cyst wall

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One-month follow-up revealed orthophoric alignment of the eyes [Figure 6], with no extraocular movement restriction [Figure 7]. He had been followed up for 6 months, and there is no recurrence.
Figure 6: Postoperatively,proptosis and dystopia corrected

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Figure 7: Postop-abduction and elevation resumed completely

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  Discussion Top

Conjunctival inclusion cyst can be primary or secondary. Primary may be congenital which occurs due to excessive conjunctival invagination during the embryonic period. Acquired primary cysts occur due to chronic inflammation, wherein the loose epithelium gets implanted into the deeper tissue even with trivial trauma.[10] Secondary cysts develop following trauma or surgery. Conjunctival inclusion cysts occur as an uncommon complication of common surgeries. It is most commonly seen following strabismus surgery and can present even decades after the procedure. Kalantzis et al.[11] in a retrospective study described orbital implantation cysts, in which maximum cases were following strabismus surgery, orbital fracture repairs, evisceration/enucleation, and retinal detachment surgery in order.

Majority of the cysts are small, are anterior in location, and are often asymptomatic. But rarely, they can be large with orbital extension producing proptosis, extraocular movement restriction, and compromised cosmesis. One such case following scleral buckling was reported, wherein the patient presented 17 years after the surgery.[8] Garg et al. reported conjunctival inclusion cyst which developed 1 year after scleral buckling, but it was confined to the anterior bulbar conjunctiva.[12] Our patient presented to us after 10 years of surgery, but had complaints 6 years after the procedure. Similar clinical presentation had been reported as a complication of hydrogel explants which expanded their own, clinically misdiagnosed as conjunctival cyst.[13] Treatment includes simple surgical excision, or with modifications such as injecting trypan blue and methylcellulose,[14] intralesional injection of trichloroacetic acid,[10] aspiration, and sclerotherapy.[15]

Our case report enlightens the occurrence of inclusion cyst as an uncommon complication of many ocular surgeries and that it can have varied presentations.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Mudhar HS. Update on conjunctival pathology. Indian J Ophthalmol 2017;65:797-807.  Back to cited text no. 1
[PUBMED]  [Full text]  
Grossniklaus HE, Green WR, Luckenbach M, Chan CC. Conjunctival lesions in adults. Cornea 1987;6:78-116.  Back to cited text no. 2
Hawkins AS, Hamming NA. Thermal cautery as a treatment for conjunctival inclusion cyst after strabismus surgery. J Am Assoc Pediatr Ophthalmol Strabismus 2001;5:48-9.  Back to cited text no. 3
Newton JC, Pruett RC, Merhige KE, Maris PJ. Giant cysts of the conjunctiva following scleral buckling. Ophthalmic Surg Lasers Imaging Retin 1987;18:295-8.  Back to cited text no. 4
Bourcier T, Monin C, Baudrimont M, Larricart P, Borderie V, Laroche L. Conjunctival inclusion cyst following pars plana vitrectomy. Arch Ophthalmol 2003;121:1067.  Back to cited text no. 5
Deshmukh S, Bhattacharjee K, Hawaibam S. Conjunctival inclusion cyst, an uncommon complication of a common surgery: A case report and review of literature. Adv Ophthalmol Vis Syst 2018;8:298-9.  Back to cited text no. 6
Narayanappa S, Dayananda S, Dakshayini M, Gangasagara SB, Prabhakaran VC. Conjunctival inclusion cysts following small incision cataract surgery. Indian J Ophthalmol 2010;58:423-5.  Back to cited text no. 7
[PUBMED]  [Full text]  
Johnson DW, Bartley GB, Garrity JA, Robertson DM. Massive epithelium-lined inclusion cysts after scleral buckling. Am J Ophthalmol 1992;113:439-42.  Back to cited text no. 8
Vishwanath MR, Jain A. Conjunctival inclusion cyst following sub-Tenon's local anaesthetic injection. Br J Anaesth 2005;95:825-6.  Back to cited text no. 9
Owji N, Bolkheir A. Treatment of giant fornix cysts with intralesional trichloroacetic acid injection. Med Life Open Access (Ophthalmol) 2018;1:1-4.  Back to cited text no. 10
Kalantzis GK, Verity DH, Rose GE. Periocular implantation cysts: A late complication of ophthalmic surgery. Eye 2014;28:1004-7.  Back to cited text no. 11
Garg SP, Verma L, Khosla PK. Conjunctival cyst after retinal detachment surgery. Indian J Ophthalmol 1988;36:182.  Back to cited text no. 12
[PUBMED]  [Full text]  
Leibovitch I, Crompton J, Selva D. New onset diplopia: 14 years after retinal detachment surgery with a hydrogel scleral buckle. Br J Ophthalmol 2005;89:640.  Back to cited text no. 13
Rajab GZ, Demer JL. Long-term results of surgical excision of conjunctival retention cyst using trypan blue with methylcellulose. Am J Ophthalmol Case Rep 2019;14:28-31.  Back to cited text no. 14
Dave T, Taneja S, Tiple S, Basu S, Naik MN. Conjunctival retention cysts: Outcomes of aspiration and sclerotherapy with sodium tetradecyl sulfate. Ophthalmic Plast Reconstr Surg 2019;35:165-9.  Back to cited text no. 15


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]


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