Treatment of Persistent Conjunctival Retention Cysts
For persistent conjunctival retention cysts, surgical excision remains the definitive treatment, with office-based procedures including thermal cautery, aspiration with sclerosing agent injection (trichloroacetic acid or isopropyl alcohol), or complete excision using trypan blue staining to visualize the cyst wall and prevent recurrence. 1, 2, 3
Primary Treatment Approach
Office-Based Procedures (First-Line for Most Cases)
Thermal cautery can be performed at the slit lamp under topical anesthesia and is fast, effective, and well-tolerated, particularly for post-strabismus surgery cysts. 2
Aspiration with sclerosing agent injection offers excellent results:
- Aspirate cyst contents using a fine needle (25-30 gauge) at the slit lamp under topical anesthesia 1
- Inject 20% trichloroacetic acid (TCA) into the cyst cavity, which has demonstrated complete resolution with no recurrence at 8-month follow-up 3
- Alternative: isopropyl alcohol injection using paired injection technique showed no recurrence at 9 months 1
- Irrigate the cavity after sclerosing agent application 3
Surgical Excision (For Recurrent or Large Cysts)
Complete excision with trypan blue staining is the most definitive approach for recurrent cysts:
- Inject trypan blue augmented with methylcellulose into the cyst using an insulin needle 4
- Keep the needle in place and inject methylcellulose to make cyst contents viscous, preventing collapse during excision 4
- This technique allows visualization of the entire cyst wall and enables en bloc removal 4
- Long-term follow-up (up to 2 years) shows no recurrence when complete excision is achieved 4
Post-Procedure Management
- Apply topical antibiotic prophylaxis (moxifloxacin, tobramycin, or polymyxin B/trimethoprim) 3-4 times daily for 3-5 days to prevent secondary infection 5, 6
- For infected cysts, perform mini-incision drainage with bimanual technique followed by topical antibiotics every 3 hours for one week 6
- Prescribe preservative-free artificial tears to address underlying dry eye that may contribute to cyst formation 5
Follow-Up Strategy
- Schedule follow-up in 3-7 days to assess healing and ensure no residual cyst remains 5
- Perform slit-lamp biomicroscopy to evaluate for corneal epithelial defects or persistent inflammation 5
- Monitor for recurrence, which is more common with simple aspiration alone compared to excision or sclerosing agent injection 1, 2
When to Refer to Ophthalmology
Immediate ophthalmology referral is indicated for:
- Corneal involvement with epithelial defects or scarring 5
- Recurrent cysts despite appropriate treatment 5
- Associated conjunctival scarring or cicatricial changes 5
- Visual disturbance or moderate to severe pain 5
- Lack of response to initial treatment 5
Important Caveats
Simple aspiration alone has high recurrence rates and should be avoided as monotherapy. 1 The addition of sclerosing agents (TCA or isopropyl alcohol) or thermal cautery significantly reduces recurrence. 1, 2, 3
Post-strabismus surgery cysts may be more challenging to completely excise due to scarring and tissue adherence, with one study noting unsuccessful removal in this specific population. 4 Thermal cautery or sclerosing injection may be preferable in these cases. 1, 2