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A Novel Technique to Treat a Recurrent Giant Conjunctival Cyst: A Case Report.

To the Editor: Conjunctival cysts are transparent, thin-walled, and slowly progressing cysts, commonly appearing in the superonasal/temporal area,1–3 which cause cosmetic problems, dry eye symptoms, and foreign body sensations in the affected eye.1 Usually, conjunctival cysts disappear spontaneously and often require no treatment, yet we sometimes face persistent cases that warrant interventions. Surgical excision is considered to be the most effective approach.1 Puncture of the cyst is the easiest intervention, but this makes successful excision difficult when the cyst recurs.4 Other treatment options include thermal cautery under slit lamp visualization,5 yttrium aluminum garnet lasers,6 and trichloroacetic acid injections.7 Although there are a variety of treatment options, cyst recurrence is the main postoperative concern commonly faced. In this study, we report the case of a young female patient with a recurrent giant conjunctival cyst that was successfully treated with our multiple conjunctivoscleral suture technique. A 17-year-old Japanese girl with no significant medical history noticed a growing conjunctival cyst in her left upper bulbar conjunctiva, and she underwent cyst resection and lamellar keratoplasty of the left eye at Tokyo Medical University Hospital in 1997. The cyst recurred soon after surgery, yet she had no visual problems, and no treatment had been performed since then. In 2005, when she was 25 years old, she was referred to our clinic at Keio University Hospital, complaining of foreign body sensations in her left eye and cosmetic problems due to the conjunctival cyst. Slit lamp examination showed a giant supratemporal conjunctival cyst. Her best-spectacle corrected visual acuity at a distance was 20/20 on the left side. We prescribed her four times a day 0.1% hyaluronic acid eye drops to alleviate the foreign body sensations in her left eye, but she did not want any surgical intervention then. In 2009, when she was 29 years old, she decided to undergo surgery mainly due to cosmetic problems. Slit lamp examination showed a giant supratemporal conjunctival cyst with an extremely thin sclera at the 11o’clock position. Complete resection of the cyst was considered dangerous, so we performed puncture and aspiration of the left cyst and placed three 10-0 nylon sutures at the 11-o’clock limbus position because minor leakage was observed during the procedure. Although the complete resolution of the cyst was observed on the postoperative day 1, she returned to our clinic with relapse of the conjunctival cyst a week after surgery. In 2010, 1 year after this surgery, she decided to undergo another surgery to treat the giant conjunctival cyst (Fig. 1) after we proposed a novel surgical technique. We first performed puncture and aspiration of the left cyst; then, we used 10 conjunctivoscleral 90 silk sutures over the entire area of the cyst at even intervals; finally, we placed four 10-0 nylon sutures at the 11-o’clock limbus position. On postoperative day 1, complete resolution of the cyst was observed (Fig. 2). In 2012, when she was 32 years old, no signs of recurrence of the cyst were observed (Fig. 3). At present her condition has been stable for almost 10 years after the last surgery, and she has lived her life without any ocular problems. In this case, after we failed to treat her cyst with conventional approaches, we had second thoughts about considering other invasive treatment options due to the thin sclera at the 11-o’clock position, which might have caused exacerbation if mistakenly treated. We considered how to treat the cyst without weakening the surrounding areas and conceived an idea of strengthening the conjunctivoscleral attachment with multiple sutures, and with this procedure, we succeeded in treating the cyst without recurrence. Our novel technique is an efficient and easy therapeutic modality that can provide improvement of refractory conjunctival cysts; however, whether the treatment effects are sustainable and can be adopted in other similar cases needs to be clarified in the future reports.