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Original Investigation |

Iris Stromal Cyst Management With Absolute Alcohol–Induced Sclerosis in 16 Patients

Carol L. Shields, MD1; Sruthi Arepalli, BA1; Erin B. Lally, MD1; Sara E. Lally, MD1; Jerry A. Shields, MD1
[+] Author Affiliations
1Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania
JAMA Ophthalmol. 2014;132(6):703-708. doi:10.1001/jamaophthalmol.2014.160.
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Importance  The management of symptomatic iris stromal cyst is challenging using methods of aspiration with or without adjunctive cryotherapy, intracameral cautery, or photocoagulation. Failed cases often require surgical resection, with risks for epithelial downgrowth, glaucoma, blindness, and loss of the eye.

Objective  To study the safety and efficacy of the management of iris stromal cysts with aspiration and alcohol irrigation to induce cyst sclerosis.

Design, Setting, and Participants  Interventional case series at a tertiary referral center among 16 patients.

Exposures  Microscopically monitored transcorneal aspiration of cysts was performed with a 30-gauge needle on a 3-way T-extension into a 3-mL syringe, followed by immediate infusion of absolute alcohol from a separate 1-mL syringe through the other arm of the T-extension. Subsequent alcohol aspiration and repetition of the cycle was performed until the collapsed cyst wall appeared gray.

Main Outcomes and Measures  Cyst involution, visual acuity, and treatment complications.

Results  The iris stromal cysts were primary congenital (n = 6), primary acquired (n = 4), or secondary (n = 6). The cysts had a median basal diameter of 12 mm and a thickness of 4 mm, occupying 50% or more of the anterior or posterior chamber in each case. Treatment was administered following failure of simple aspiration (n = 16) and additional methods (n = 8). During a median follow-up period of 5 years, treatment was successful in 14 of 15 patients (1 patient was lost to follow-up). Cyst sclerosis with stabilization (n = 1) or involution (n = 13) was achieved following 1 (n = 10), 2 (n = 2), or 3 (n = 2) procedures. The single failure occurred in a 3-year-old child with cyst recurrence and severe photophobia requiring resection. Visual acuity remained stable or had improved in 14 patients and was reduced in 1 patient because of cataract. Complications included transient corneal edema (n = 4) and transient anterior chamber inflammation (n = 1), which resolved following topical corticosteroid therapy. No evidence was seen of treatment-related glaucoma, epithelial downgrowth, tissue necrosis, cataract, posterior segment toxic effects, or need for enucleation.

Conclusions and Relevance  Microscopically monitored aspiration and absolute alcohol–induced sclerosis of iris stromal cysts is safe and effective, with cyst involution obtained in 93% (14 of 15) of patients.

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Figure 1.
Technique of Absolute Alcohol–Induced Sclerosis of an Iris Stromal Cyst

A, Absolute (100%) dehydrated alcohol (JCB Laboratories) is used for sclerosis and is drawn into a 1-mL syringe. B, Three-arm T-extension for 2 female attachments (syringes) and 1 male attachment to a 30-gauge needle. The female attachments are to a 3-mL aspiration syringe and to a connector tubing attached to an alcohol-filled 1-mL syringe. The alcohol is primed through to the distal margin of the connector tubing to minimize injection of air. C, After viscoelastic fill of the anterior chamber, the cyst is entered through its attachment to the endothelium. D, Aspiration to syringe 1 collapses the cyst. E, Infusion of alcohol through the primed connector tube causes the cyst wall to appear slightly gray. Occasionally, a bubble of air enters the cyst at this point. The alcohol remains in the cyst for 1 to 2 minutes and then is withdrawn. This cycle is repeated for 2 or 3 washes. F, Alcohol is removed from the cyst, and it appears collapsed against the endothelium, with viscoelastic material removed through paracentesis (anterior chamber deep) and wound hydration (to the right). The visual axis is unobstructed.

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Figure 2.
Before (Left) and After (Right) Absolute Alcohol–Induced Sclerosis of Iris Stromal Cysts in 4 Cases

A and B, A 1-year-old girl with a primary congenital iris stromal cyst that failed simple aspiration (A) and manifested immediate cyst involution following therapy (B), which persisted at the 9-year follow-up visit, with visual acuity of 20/20. C and D, A 57-year-old woman with a slowly enlarging primary congenital iris stromal cyst (C), in whom a single treatment of aspiration with absolute alcohol manifested permanent sclerosis of the cyst at the 3-year follow-up visit (D); visual acuity was 20/400 because of progressive cataract. E and F, A 52-year-old man with an iris stromal cyst secondary to trauma and failure to control the cyst after 2 aspirations with laser elsewhere (E); 1 year after treatment with absolute alcohol, the collapsed cyst was stable, and visual acuity had increased to 20/20 (F). G and H, A 71-year-old woman with a primary acquired iris stromal cyst (G); after 3 aspirations with absolute alcohol, the cyst was sclerotic at the 3-year follow-up visit, and visual acuity was 20/40 (H).

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