A Jelly cyst - Keep your mind ticking.

Abstract

Case An 8-year-old boy presented with diminution of vision in left eye (OS) following firecracker injury 3 days back. There were no previous ocular or systemic complaints. The best corrected visual acuity (BCVA) was 20/20 in right eye (OD) and 20/120 OS. On examination, OD was within normal limits while OS upper and lower lid revealed burn marks due to fire-cracker injury [Fig. 1a]. Anterior segment evaluation revealed ciliary congestion, 4+ cells, dispersed hyphema, and dilated pupil with multiple sphincter tears. The crystalline lens was transparent and in normal position. Dispersed vitreous bleed precluded the visualization of retina. Ultrasonography revealed mild to moderate amplitude spikes in the vitreous cavity. In addition, a cystic structure with central hyperechoic area was seen [Fig. 1b]. Though the clinical features were suggestive of traumatic vitreous hemorrhage, ultrasonography image indicated the possibility of a parasitic cyst.Figure 1: Burns on the left eyelids following fire cracker injury (a). Ultrasonography showing cyst with central hyper echoic spot in the vitreous cavity (b). Ultrawide field imaging showing pigmented vitreous cyst and resolving vitreous hemorrhage (c)What is Your Next Step? Observation Conservative management with topical steroids and cycloplegic. Computed tomography (CT) scan of orbit and brain Pars-plana vitrectomy Findings The patient was managed conservatively with topical steroids and cycloplegics (B). At 1 week, BCVA in OS had improved to 20/20. Hyphema, and anterior chamber reaction was resolving. Dilated fundus examination revealed a pigmented cystic structure freely floating in the vitreous cavity along with resolving vitreous hemorrhage [Fig. 1c]. No undulating movements of the cyst were noted. The retinal periphery was normal. The patient was advised tapering of topical medication with regular follow-up. Diagnosis Pigmented congenital vitreous cyst. Correct Answer B. Discussion Congenital vitreous cysts (CVC) are usually identified on incidental examination or following trauma. Approximately 15 cases of free-floating cyst are described in literature but very few presented in childhood. Vitreous cysts can be congenital or acquired. Acquired cyst can develop after trauma. While trauma can trigger formation of a new cyst, it may also displace an already formed one.[1] CVCs are usually asymptomatic and they originate from the pigment epithelium of ciliary body. These cysts can be confused with cysticercosis and with melanoma especially if they are in posterior vitreous.[23] Ultrasound in cysticercosis shows a cystic structure with hyperechoic scolex lining internal surface. A similar appearance in our case led to suspicion of cysticercosis. As vitreous hemorrhage resolved, the pigmented appearance without any undulating movement suggested the diagnosis of CVC. This case highlights that the possibility of CVC should be kept in mind in such a clinical scenario. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.