Sodium-Hyaluronate Cystic-like Lesion in the Anterior Chamber Following Cataract Surgery: A Case Report

Thisisacasereportdescribingtheuncommonfindingofacystic-likelesionanditsmanagementintheanteriorchamberofamale patientaftercataractsurgery.


INTRODUCTION
There is limited literature regarding free-floating anterior chamber cysts and cystic-like lesions with most of them being pigmented iris cysts (1)(2)(3)(4)(5)(6).In this case report we describe a sodium hyaluronate free-floating cyst-like lesion in the anterior chamber following uncomplicated phacoemulsification.

CASE REPORT
An 83-year-old man underwent uncomplicated phacoemulsification for stage 2 LOCS-III cataract, and received a foldable monofocal intraocular lens (IOL) in his left eye.Following surgery, he was prescribed fixed combination of tobramycin & dexamethasone (FCTD) q.i.d. and 0.1% sodium hyaluronate q.i.d.For non-medical reasons, the patient missed his first postoperative follow-up examination (1 week postop) and scheduled for the 2nd postoperative visit at 4 weeks.However, 20 days postoperatively, he urgently visited our outpatient service due to transient blurring of vision, and ocular redness.He reported that blurred vision was aggravated during certain activities, such as leaning down or lying in bed.On the other hand, he reported no visual disturbances when standing.
Uncorrected Distance Visual Acuity (UDVA) was log-MAR 0.1 and intraocular pressure was 18 mmHg.Slit-lamp biomicroscopy revealed a round, clear, non-pigmented, free-floating cystic-like structure in the anterior chamber.With the patient standing, the cystic structure was almost hidden at the top (12th hour) of the anterior chamber; on the other hand, during certain head postures, it occasionally obstructed the visual axis.No inflammatory cells could be detected in the anterior chamber.Despite that fact, grade 1 conjunctival redness could be detected.Anterior segment optical coherence tomography (AS-OCT) visualized the free-floating structure; however, it presented as a uniform, solid structure and not a cyst (Figures 1, 2).
Immediate surgical extraction was decided, and the cystic-like lesion was successfully removed.When extracted from the anterior chamber it was dissolved in a clear gelatinous substance (Figures 3, 4).Histopathological examination returned no organic cells, but sodium hyaluronate.Three months following extraction surgery, UDVA remains at logMAR 0.1 with symptom-free quality of vision.

DISCUSSION
A variety of cystic-like lesions have been reported in the anterior chamber.Differential diagnosis includes an iris cyst, a non-keratinized squamous epithelium cyst and cysticercosis.In our case, lack of the pigmentation of the inner wall (1) made the diagnosis of an iris cyst less probable (6), as well as its appearance on OCT imaging, presenting as an equally hyperreflective lesion, internally and externally, with typical OCT findings of hyperreflective walls and hypo-reflective internal structure being the most common (7)(8).On the other hand, cysticercosis cysts show characteristic contracting and expanding movements with the presence of a live scolex as a dense white spot (9).Histopathological examination confirmed sodium-hyaluronate, which, to our knowledge, is the first incident to be reported and should be taken into consideration as a rare complication in an otherwise uncomplicated phacoemulsification.

CONCLUSIONS
Such lesions have not been reported in the literature.The appearance of cysts after cataract surgery is relatively rare and usually consist of epithelial cells.In our case, the prognosis was good and the patient made a full recovery.

FINANCIAL DISCLOSURE
No financial support was received for this case report.None of the authors has any proprietary interests or conflicts of interest related to this submission.It is not simultaneously being considered for publication at any other journal.