1) An 8-year-old boy presented with a progressive corneal edema and brown pupil in his left eye following a history of trauma from a pen tip 8 months prior which required surgery. 2) Examination found a central corneal edema, brown pupil, iris cyst, and elevated intraocular pressure of 60mm Hg. B-scan was unremarkable. A diagnosis of anteriorly subluxated lens with malignant glaucoma or iris pigment epithelial/ciliary body tumor was considered. 3) The intraocular pressure was reduced with medications but remained elevated. The iris cyst was then aspirated using a minimally invasive approach with chemical ablation using absolute alcohol, resulting in cyst retraction and improved vision.

1. Mystery of the Brown pupil
Dr. Madhu Karna
Consultant Pediatric Ophthalmologist

2. Presentation
• 8 year old boy with progressive DOV LE
• h/o Hit with a nib of a pen for which he was
operated LE 8 months ago
O/E Left eye
• Vn - perception of light
• CCC + Central corneal edema + brown pupil
• adherent leucoma INQ + iridodialysis at 6 o’clock
• IOP - 60mm Hg
Right Eye - 6/6, normal eye

3. Brown Pupil with Flat AC
with INQ corneal scar

4. B scan vitreous clear, retina on, flat AC

5. D/D
• Anteriorly subluxated lens with posterior
pigment epithelium with Malignant Glaucoma
• Iris pigment epithelial /Ciliary body tumor
with pupillary block glaucoma (rare in
children)

6. • IOP reduced with topical, oral antiglaucoma
medication and intravenous mannitol
• Post Mannitol - AT LE 48/ 56 mm Hg
• Post second Mannitol next day – 13/19 mm
Hg

7. Traumatic corneal opacity with
vascularisation

8. An iris cyst was unveiled!

9. AC reforming superiorly, convex cyst
surface

10. Lens seen on dilation - clear

11. Central adherent iris tissue and cyst

12. Cyst with iris pigment epithelium

13. Superior AC well formed

14. Iris Cyst and Iris tissue in visual axis

15. Management
• Iris cyst excision in toto recommended – with
broad iridectomy
• 3rd Mannitol given – 11 mm Hg AT
• Managed with a novel approach of minimally
invasive cyst aspiration and chemical ablation
of cyst epithelium with absolute alcohol

16. Postoperatively
• progressive retraction of cyst
• IOP – 40 mm Hg immediate postop
• IV Mannitol given
• IOP came down to 24 mm Hg
• Vision improved to 6/24

17. Shrinking Iris cyst and well formed
superior AC with clear cornea

18. PAS nasally

19. PAS inferotemporally

20. Shrinking cyst surface inferocentrally

21. Postop day 6 – shrinking cyst, partly
adherent to lens

22. Shrinking cyst and reducing PAS,
inferior corneal edema

23. Fundus – normal disc and retina,
tortuous temporal vessels

24. At 2 weeks postop
• On Prednisolone , Homatropine, NaCl,
Betoxalol, Moxifloxacin, Dorzolamide Drops
and Acetazolamide
• Vision – 6/24 with Refn -2.25 x 100 (6/9)
• IOP – 14 mm Hg
• Fundus – Normal

25. At 8 weeks postop
• On Prednisolone, Dorzolamide, NaCl
• Vn LE 6/9
• IOP – 13 mm Hg
• Cyst shrunken, mild corneal edema inferiorly
• Endothelial count - RE 3301, LE 1676

26. 17 weeks postop
Vn 6/6 P, IOP – 13 mm Hg

27. Micro - Shot of Alcohol
Preop – PL + Postop – 6/6

29. P Rishi, E Rishi, J Biswas, K Nandi, Clinical and
histopathological features of posttraumatic iris cyst,
IJO. 2008; 56(6): 518-521
• all cysts underwent total excision with/without
iridocyclectomy. Additional surgical procedures like
lensectomy, vitrectomy, penetrating keratoplasty and
intraocular (IOL) removal
• 60% had good visual outcome
• uncontrolled glaucoma and graft failure in the rest

30. Behrouzi Z, Khodadoust A. Epithelial iris cyst treatment with
intracystic ethanol irrigation Ophthalmology. 2003
Aug;110(8):1601-5.
• 93 cysts resolved after the first irrigation, 3
after the second irrigation and 2 after the
third irrigation and 1 case did not respond
after third irrigation
• Intraocular pressure (IOP) normalized in 11
out of 21 cases who had IOP>20 mmHg before
ETOH irrigation

31. C Shields, S Arepalli, E B. Lally, S E. Lally, J Shields. Iris Stromal
Cyst Management With Absolute Alcohol–Induced Sclerosis
in 16 Patients. JAMA Ophthalmol. 2014;132(6):703-708.
• Aspiration with 30-g needle on 3-way T-extension into a 3-mL
syringe, foll. by immediate infusion of abs. alcohol from a
separate 1-mL syringe through the other arm of the T-
extension with subsequent alcohol aspiration
• 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.

32. Iris pigment epithelial
cysts
Peripheral
Mid Zonal
Pupillary

33. Free floating Pig Epith
cyst
Secondary Epith
downgrowth cyst

34. Thank you for your kind attention