From the Department of Ophthalmology, Institute of Clinical Medicine, University of Tsukuba (TH, YK, FO, TO), Ibaraki, Japan.
The authors have no financial or proprietary interest in the materials presented herein.
Address correspondence to Takahiro Hiraoka, MD, Department of Ophthalmology, Institute of Clinical Medicine, University of Tsukuba, 1-1-1, Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan.
Orbital cystic lesions are fairly common and account for 6% of all orbital lesions.1 In particular, it has been reported that simple cysts account for 17% of orbital cystic lesions.1 Although a small asymptomatic cyst may not require treatment, most large cysts should be removed surgically. In such case, the lesion needs to be removed completely, without disruption of its epithelial lining. This can usually be achieved by meticulous dissection using an anterior approach. However, it is occasionally difficult to remove an orbital cyst in an intact manner because of its thin and fragile capsule. In the event of cyst rupture during surgery, it becomes highly difficult to distinguish the cyst wall from the adjacent soft tissues and this may result in incomplete or excessive resection, especially when the cysts extend into the deep orbit. Incomplete resection may cause recurrence of the lesion, whereas excessive resection could lead to various ophthalmic dysfunctions such as ophthalmoplegia, blepharoptosis, and visual impairment. To our knowledge, there have been no reports of the use of ophthalmic viscosurgical device (OVD) and indocyanine green (ICG) in orbital cyst removal. Herein, we report a case of an intraoperatively ruptured orbital cyst that was successfully removed using OVD and ICG.
A healthy 64-year-old man presented with a non-tender mass in the upper inner quadrant of the anterior left orbit (Fig. 1A). The mass was first noted about 2 years ago, which has been growing gradually thereafter. He had no history of surgery or trauma in the left eye. On palpation, the mass was soft and not adhered to the overlying skin. Although there was no apparent proptosis, the left eye demonstrated slight inferotemporal displacement. Magnetic resonance imaging revealed a 14 × 16 × 14–mm homogeneous cystic lesion in the anterior superonasal orbit with a distinct margin. No obvious deformity of the left eyeball was observed, in spite of the mass being largely attached to it (Fig. 1B). The visual acuity, intraocular pressure, and ocular motility recorded before surgery were normal. Based on the above findings, a simple orbital cyst was suspected, and its surgical removal was planned.
Figure 1. External Photograph and Magnetic Resonance Imaging (MRI). (A) An External Photograph Demonstrates the Mass in the Upper Inner Quadrant of the Anterior Left Orbit. (B) MRI (T2-Weighted Image) Revealed a Homogeneous Cystic Lesion in the Anterior Superonasal Orbit with a Distinct Margin. No Obvious Deformity of the Left Eyeball Was Observed, in Spite of the Mass Being Largely Attached to it.
A transconjunctival incision was made near the upper fornix to access the mass (Fig. 2A). After the Tenon capsule was dissected, the mass became visible and was identified as a cyst by macroscopic examination (Fig. 2B). It was then dissected from the adjacent orbital tissues (Fig. 2C). During dissection, however, the cyst ruptured unexpectedly at its lower end. A milky serous fluid drained out and the cyst collapsed (Fig. 2D). After the drainage, the cyst capsule could not be distinguished from the adjacent tissues, especially at the lower end.
Figure 2. Intraoperative Photographs (Surgeon’s View). (A) A Transconjunctival Incision was made near the Upper Fornix to Access the Mass. (B) After the Tenon Capsule was Dissected, the Cyst Became Visible. (C) The Cyst was then Dissected from the Adjacent Orbital Tissues. (D) However, the Cyst Ruptured Unexpectedly During Dissection. A Milky Serous Fluid Drained Out (arrow) and the Cyst Collapsed. (E) A Mixture of 0.5 ml of 2.3% Sodium Hyaluronate and 0.5 ml of 1% Indocyanine Green was Injected into the Cyst Using a 27-Gauge Needle. (F) The Cyst Became Easily Visible and Clearly Defined, and Thereafter it Could be Removed Without Difficulty.
A mixture of 0.5 mL of 2.3% sodium hyaluronate (Healon® V, Pfizer Inc., New York, NY) and 0.5 ml of 1% ICG (Diagnogreen, Daiichi pharmaceutical Co., Tokyo, Japan) was injected into the orbital cyst, using a 27-gauge needle (Fig. 2E). Consequently, the cyst became easily visible and clearly defined, and we could resume the dissection. This procedure enabled successful removal of the cyst without difficulty (Fig. 2F). Finally, the conjunctival wound was sutured using interrupted 8–0 silk suture. Histopathological examination revealed that the cyst wall was lined by nonkeratinized stratified squamous epithelial tissue containing rare goblet cells. No recurrence of the orbital cyst was found during the 6-month follow-up after surgery.
In 2002, Kobayashi et al.2 reported the use of ICG to facilitate removal of conjunctival cyst from the ocular surface. They also demonstrated that injection of a mixture of Healon® V and trypan blue into a conjunctival cyst facilitated visualization whereas preserving its structural integrity.3,4 However, the use of a mixture of Healon® V and ICG for conjunctival cyst removal has not been reported. ICG seems to be more advantageous than trypan blue for such visualization because of its easy availability and proven safety for ophthalmic use.5–7 Currently, ICG staining is widely used in various ophthalmic procedures, e.g., visualization of lens capsule in mature cataract,5 the retinal internal limiting membrane,6 and a filtering bleb.7
In the present case, the use of OVD and ICG facilitated safe and easy excision of the orbital cyst that had accidentally ruptured. ICG staining aided identification of the capsular outline, whereas OVD maintained the cyst in a distended state and prevented it from collapsing during surgery. Kobayashi and Sugiyama3 reported that, if ICG is used singularly, the cyst wall might collapse during dye injection, and this may result in insufficient staining and make it difficult to separate the cyst from the conjunctiva. A viscous nature of OVD and ICG solution is of advantage in such a situation for several reasons. First, a ruptured cyst can be distended and maintained in a desired conformation during surgery, even if there is a relatively large rupture in the cyst capsule. Second, the location of the capsular rupture can be confirmed because the mixture slowly permeates through the rupture. However, it does not flow out easily due to its high-viscosity. Thus, it is unlikely that the OVD and ICG mixture may overflow and stain the surrounding tissues to the extent that the cyst wall cannot be distinguished from the adjacent tissues. This method might be more effective in the case of orbital cysts than in the case of conjunctival cysts, because it is more difficult to identify a ruptured cyst positioned at a deeper point.
Among the currently available OVDs, Healon® V is considered to be the most suitable for this technique due to its extremely high-viscosity (7,000,000 mPas). Kobayashi and Sugiyama4 reported that Healon® (300,000 mPas) and Viscoat® (35,000 to 60,000 mPas) (Alcon Laboratories, Fort Worth, TX) injected into the conjunctival cyst leaked shortly and the cyst collapsed.
In conclusion, we demonstrated the efficacy of the use of Healon® V and ICG for the complete and safe removal of an accidentally ruptured orbital cyst. We believe that this procedure can also be applied in the case of other orbital cystic lesions, such as epidermoid and dermoid cysts.
- Shiels JA, Shields CL. Orbital cystic lesions. Orbital simple primary cyst of conjunctival origin. In: Shields JA, Shields CL, eds. Eyelid, conjunctival, and orbital tumors. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008:476–513.
- Kobayashi A, Saeki A, Nishimura A, et al. Visualization of conjunctival cyst by indocyanine green. Am J Ophthalmol. 2002;133:827–828. doi:10.1016/S0002-9394(02)01416-2 [CrossRef]
- Kobayashi A, Sugiyama K. Visualization of conjunctival cyst using Healon V and trypan blue. Cornea. 2005;24:759–760. doi:10.1097/01.ico.0000154238.87230.05 [CrossRef]
- Kobayashi A, Sugiyama K. Successful removal of a large conjunctival cyst using colored 2.3% sodium hyaluronate. Ophthalmic Surg Lasers Imaging. 2007;38:81–83.
- Horiguchi M, Miyake K, Ohta I, Ito Y. Staining of the lens capsule for circular continuous capsulorrhexis in eyes with white cataract. Arch Ophthalmol. 1998;116:535–537.
- Da Mata AP, Burk SE, Riemann CD, et al. Indocyanine green-assisted peeling of the retinal internal limiting membrane during vitrectomy surgery for macular hole repair. Ophthalmology. 2001;108:1187–1192. doi:10.1016/S0161-6420(01)00593-0 [CrossRef]
- Ito K, Miura K, Sugimoto K, et al. Use of indocyanine green during excision of an overhanging filtering bleb. Jpn J Ophthalmol. 2007;51:57–59. doi:10.1007/s10384-006-0364-7 [CrossRef]