What is the treatment for conjunctival inclusion cysts?

Treatment of Conjunctival Inclusion Cysts

For symptomatic conjunctival inclusion cysts, mechanical removal at the slit lamp using a sterile needle or fine forceps is the definitive treatment, followed by topical antibiotic prophylaxis. 1

When to Treat

• Asymptomatic cysts can be observed, as they may resolve spontaneously without intervention 2, 3
• Treatment is indicated when cysts cause:
  • Foreign body sensation or ocular irritation 4, 5
  • Corneal epithelial defects from protruding concretions 1
  • Cosmetic disfigurement 3
  • Visual disturbance or moderate to severe pain 1

Office-Based Removal Technique

The procedure should be performed at the slit lamp under topical anesthesia (proparacaine 0.5%) using a 25-30 gauge needle or jeweler's forceps to extract the cyst. 1

Step-by-Step Approach:

• Evert the eyelid to fully visualize all cysts, as they typically occur on the superior or inferior tarsal conjunctiva 1
• Make a mini-incision using a 30G needle at the cyst wall 4
• Perform bimanual drainage to evacuate cyst contents 4
• Apply topical antibiotics (moxifloxacin, tobramycin, or polymyxin B/trimethoprim) 3-4 times daily for 3-5 days post-procedure 1, 4

Alternative Office Techniques:

• Thermal cautery under slit-lamp visualization is fast, effective, and well-tolerated for post-strabismus surgery cysts 2
• Isopropyl alcohol injection using paired injection technique has shown no recurrence at 9 months follow-up 6
• Simple aspiration alone carries high recurrence risk and should be avoided as monotherapy 6

Post-Procedure Management

• Prescribe preservative-free artificial tears to address underlying dry eye disease that contributes to cyst formation 1
• Consider brief topical corticosteroid use (loteprednol 0.5%) if significant conjunctival inflammation is present, with intraocular pressure monitoring 1
• Treat chronic blepharitis with lid hygiene and topical antibiotics if present, as this contributes to recurrence 1
• Discontinue offending topical medications (particularly preserved glaucoma drops) that cause chronic conjunctival inflammation 1

Follow-Up Strategy

• Schedule follow-up in 3-7 days to assess healing and ensure no residual cysts remain 1
• Perform slit-lamp biomicroscopy to evaluate for corneal epithelial defects or persistent inflammation 1
• Monitor for recurrence up to one year, though careful intact removal minimizes this risk 3

When Surgical Excision is Required

Complete surgical excision with fluid aspiration is indicated for:

• Recurrent cysts despite office-based treatment 1, 5
• Large or complex cysts requiring intact removal to prevent recurrence 3
• Associated conjunctival scarring or cicatricial changes 1
• Corneal involvement with epithelial defects or scarring 1

Surgical Considerations:

• Careful and intact removal is critical to prevent recurrence 3
• Minor modifications in technique according to size, site, and nature of cyst help achieve intact removal 3
• Histopathology should be performed to confirm diagnosis of epithelial inclusion cyst 5, 3

Common Pitfalls to Avoid

• Do not perform blind sweeping of the fornices, as this may cause damage 7
• Avoid simple aspiration without additional treatment, as recurrence rates are high 6
• Do not overlook infected cysts, which require culture-guided antibiotic therapy in addition to drainage 4
• Ensure complete cyst wall removal during surgical excision to minimize recurrence 3

Immediate Ophthalmology Referral Indicated For:

• Corneal involvement with epithelial defects or scarring 1
• Visual disturbance or moderate to severe pain 1
• Lack of response to initial removal and treatment 1
• Recurrent concretions despite appropriate treatment 1
• Associated conjunctival scarring or cicatricial changes 1