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JAMA Ophthalmology Clinical Challenge
October 28, 2021

Waking Up With Cloudy Vision

Author Affiliations
  • 1Bascom Palmer Eye Institute, University of Miami School of Medicine, Miami, Florida
  • 2Focus Eye Center, Los Angeles, California
  • 3Brody School of Medicine, East Carolina University, Greenville, North Carolina
JAMA Ophthalmol. 2021;139(12):1321-1322. doi:10.1001/jamaophthalmol.2021.1461

A 63-year-old woman was referred by optometry after waking up with cloudy vision in the left eye and an ache around the left brow. Visual acuity was 20/20 OD and light perception OS. Intraocular pressure (IOP) was 15 mm Hg OD and 54 mm Hg OS. Anterior segment examination of the left eye was remarkable for a large cystic iris stromal lesion from the 2- to 7-o’clock position with iris-cornea touch. The anterior chamber was shallow in the area of the enlarged cystic lesion with a large amount of pigmented cells. The pupil was irregular with blood at the pupillary margin. Her intraocular lens was not visible because of occlusion by a cystic lesion behind the iris (Figure 1). Her ocular history was notable for indiscriminate trauma to her left eye, primary open-angle glaucoma in both eyes treated with dorzolamide hydrochloride and brimonidine tartrate, and pseudophakia in both eyes. Four years prior, an inferior cystic iris stromal lesion was discovered in the left eye that measured approximately 5 × 2 mm in basal dimensions at the slitlamp. Fine-needle aspiration was negative for malignancy, and the lesion was managed by close follow-up.

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1 Comment for this article
The Therapeutic Challenge of Secondary Iris Cysts
Lan Nguyen, MD | Naval Medical Center San Diego
We read with interest the recent JAMA Ophthalmology Clinical Challenge, entitled “Waking up With Cloudy Vision”1. The authors recommend a YAG laser to perforate the cystic wall. The article seems to recommend treatment options for iris cysts based on the presence of secondary complications of the cyst, regardless of the underlying etiology. We agree that YAG laser is an excellent first option in symptomatic primary iris pigment epithelial cysts. However, we disagree with YAG laser cyst perforation as a treatment for secondary iris cysts formed after trauma or surgery.

Secondary iris cysts may be caused
by corneal or conjunctival epithelial implantation2. The risk of treating epithelial inclusion cysts with a YAG laser is that perforation may liberate epithelial cells, causing sheets of epithelial downgrowth which can obstruct the visual axis, cause uveitis and glaucoma3.

In the present case, surgical excision and endoscopic cyclophotocoagulation resulted in resolution of the cyst with no recurrence at 10 months following the procedure1. We agree that any primary treatment of these cysts should be focused on eradication of the epithelial cells and that adding the endoscopic ablation to the surgical removal was an excellent option. Intracystic ethanol irrigation is a relatively non-invasive approach, which treats secondary iris cysts by destroying the epithelium lining of the cyst2.

Secondary iris cysts pose a therapeutic challenge as the surgical approach should be selected with the goal of reducing the recurrence rate. Secondary iris cysts often recur and may require several treatments prior to achieving eradication of the epithelial tissue. In some cases, recurrence of epithelial cells have been found decades after the first treatment4.

1. Khine KT, Clark WM, Harbour JW. Waking Up With Cloudy Vision. JAMA Ophthalmol. 2021 Dec 1;139(12):1321-1322. doi: 10.1001/jamaophthalmol.2021.1461. PMID: 34709370.

2. Behrouzi Z, Khodadoust A. Epithelial iris cyst treatment with intracystic ethanol irrigation. Ophthalmology. 2003;110(8):1601-1605. doi:10.1016/s0161-6420(03)00543-8

3. Georgalas I, Petrou P, Papaconstantinou D, Brouzas D, Koutsandrea C, Kanakis M. Iris cysts: A comprehensive review on diagnosis and treatment. Survey of Ophthalmology. 2018;63(3):347-364. doi:10.1016/j.survophthal.2017.08.009

4. Gupta V, Rao A, Sinha A, Kumar N, Sihota R. Post-traumatic inclusion cysts of the iris: a longterm prospective case series. Acta Ophthalmologica Scandinavica. 2007;85(8):893-896. doi:10.1111/j.1600-0420.2007.00975.x