1 Department of Ophthalmology, Kent and Canterbury Hospital, Ethelbert Road, Canterbury, Kent CT1 3NG, UK. 2 Department of Ophthalmology, Royal Oldham Hospital, Oldham, UK
* Corresponding author. E-mail: m.vishwanath{at}virgin.net
Accepted for publication July 8, 2005.
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Abstract |
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Keywords: anaesthesia, local, sub-Tenon's ; complications, conjunctival inclusion cyst
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Introduction |
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Case report |
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Discussion |
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Inclusion cysts of the conjunctiva can be congenital or acquired. Acquired inclusion cysts form as a result of implantation of conjunctival epithelium underneath the stroma following injury or surgery.7 They can be unilocular or multilocular. Conjunctival inclusion cyst formation has been reported following strabismus surgery,8 vitreoretinal surgery9 and scleral tunnel phacoemulsification,10 which are all surgical procedures where the conjunctiva is disturbed.
The initial description of this technique1 involved making a snip in the conjunctiva, raising a small bleb to identify the tenon's fascia and then making a further snip to enter the sub-Tenon's space. However, this procedure is not strictly followed. The common practice is to grasp both conjunctiva and tenon's fascia 5 mm away from the limbus in the inferonasal quadrant of the globe. A small incision is then made in this tented tissue with blunt tipped Westcott scissors. The closed scissors are then slid through to create a tunnel or to ensure that the sub-Tenon's space has been opened. The blunt cannula is then passed through this along the curvature of the globe to reach posterior to the equator. Then the anaesthetic is injected slowly. It should be remembered that the conjunctiva is loosely adherent to the underlying tissues on moving away from the limbus. A large fold of conjunctiva is likely to be grasped because of this laxity and the surgeon's or anaesthetist's intent to grasp the tenon's fascia as well in the same grip. In such a case, unless care is taken to make a small nick, a large cut in the conjunctiva will result. Novice surgeons or anaesthetists tend to make larger cuts. Small snips result in a small oval hole in the conjunctiva. Large snips result in an arcuate hole with a redundant conjunctival flap on one edge (the caruncle side) which can potentially roll inwards (Fig. 2). The introduction of the closed scissors or the cannula can fold this flap of conjunctiva inwards, leading to implantation of conjunctival epithelium and eventual cyst formation.
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In conclusion, this case highlights the need for close attention to the surgical technique of even the simple step of making a conjunctival incision to avoid this complication.
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References |
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