Giant Orbital Cysts After Strabismus Surgery - University of Colorado ...

more, immunostaining analysis was remarkable for the
cytokeratin-7 marker, suggesting an epithelial-derived tumor.
Systemic evaluation was negative for a primary
malignancy. The patient’s right eye became prephthisical
and painful. Because the potential for rehabilitation was
considered extremely poor, the right eye was enucleated.
Histopathology of the globe revealed an ocular surface
squamous neoplasm that appeared to invade the eye
through the cataract incision site and remain contiguous
with epithelial cells on the corneal endothelium and the
iris epithelial tumor (Figure 3). A prominent inflammatory
infiltrate was observed in the region of the iris mass
(Figure 3). These findings were consistent with metaplastic
epithelial downgrowth of a limbal squamous cell carcinoma
with secondary intraocular inflammation. This phenomenon
should be included in the differential diagnosis
of chronic inflammation after intraocular surgery.
REFERENCES
1. Vargas LG, Vroman DT, Soloman KD, et al. Epithelial
downgrowth after clear cornea phacoemulsification: report of
two cases and review of the literature. Ophthalmology 2002;
109:2331–2335.
2. Giaconi JA, Coleman AL, Aldave AJ. Epithelial downgrowth
following surgery for congenital glaucoma. Am J Ophthalmol
2004;138:1075–1077.
3. Kim SK, Ibarra MS, Syed NA, Sulewski ME, Orlin SE.
Development of epithelial downgrowth several decades after
intraocular surgery. Cornea 2005;24:108–109.
Giant Orbital Cysts After Strabismus
Surgery
Theodore H. Curtis, MD, Ann U. Stout, MD,
Arlene V. Drack, MD,
and Vikram D. Durairaj, MD
PURPOSE: To describe a rarely reported complication of
strabismus surgery.
DESIGN: Observational case series.
METHODS: A review of four eyes in three patients with
orbital cysts following strabismus surgery.
RESULTS: Each patient had either a symptomatic strabismus
or visible mass that brought them to medical attention
many years, often decades after surgery (mean 34
years). All had some degree of incomitancy. During
surgery, all cysts were found to be associated with the
involved rectus muscle.
Accepted for publication Apr 25, 2006.
From the Rocky Mountain Lions Eye Institute, University of Colorado,
Aurora, Colorado (T.H.C., A.V.D., V.D.D.); and the Casey Eye Institute,
Oregon Health and Sciences University, Portland, Oregon (A.U.S.).
Inquiries to Vikram D. Durairaj, MD, 1675 N Ursula St, Box 6510,
Aurora, CO 80045; e-mail: vikram.durairaj@uchsc.edu
FIGURE 1. An intraoperative photo of a giant orbital cyst,
which developed after strabismus surgery. The inferior portion
of the medial rectus is shown under the muscle hook and the
collapsed cyst is drawn superiorly on the suture.
CONCLUSIONS: Orbital cysts are a rarely recognized complication
of strabismus surgery. However, it should be
considered in the differential of orbital cysts after strabismus
surgery because of the risk of muscle damage
during surgical excision. (Am J Ophthalmol 2006;
142:697–699. © 2006 by Elsevier Inc. All rights reserved.)
ORBITAL CYSTS ARE UNCOMMON LONG-TERM COMPLIcations
of strabismus surgery. Herein, we report on
three patients with giant orbital cysts after strabismus
surgery, including one with bilateral cysts. A retrospective
review of three patients with four orbital cysts after
strabismus surgery was initiated after obtaining approval
from the institutional review board.
● CASE 1: A 52-year-old male presented with an enlarging
left orbital mass for two years. His history was remarkable
for esotropia with bilateral strabismus surgery at age 10,
forty-two years before presentation, without subsequent
eye surgeries or injuries. The motility examination showed
an adduction deficit of the left eye with a left exotropia
at distance. Slit-lamp examination showed a blue-hued,
mildly vascular cystic mass superonasally. An orbital CT
scan revealed a well-defined anterior-medial mass associated
with the left medial rectus. The globe and bony orbit
were otherwise normal. During surgery, the superior portion
of the medial rectus was found attached to the
posterior aspect of the cyst; the inferior portion of the
medial rectus was attached to sclera posterior to it’s
original insertion (Figure 1). Histopathology revealed a
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FIGURE 2. External view of a giant orbital cyst, which developed
decades after strabismus surgery in Case 3. The cyst is
located over the insertion of the right lateral rectus.
sudoriferous cyst with an attached stump of striated
muscle.
● CASE 2: A 31-year-old male presented with unsightly
eye misalignment. He had strabismus surgery at age 20,
eleven years before presentation. On examination, he had
a large-angle exotropia, greater in right gaze. Slit-lamp
examination showed bilateral conjunctival scars. No adduction
deficit was appreciated. During surgery, a 10-mm
bluish mass was noted attached to the left medial rectus
and connected to the insertion by fibrous tissue. The cyst
and the underlying muscle were resected. Histopathology
revealed an epithelial inclusion cyst partially surrounded
by striated muscle.
● CASE 3: A 53-year-old woman presented with a fivemonth
history of a right orbital mass. She had strabismus
surgery as an infant, almost fifty years previously. Her
motility examination showed an alternating exotropia,
worse in left gaze. Slit-lamp examination revealed a large,
bluish cystic lesion over the insertion of the right lateral
rectus (Figure 2). The left eye was unremarkable. Preoperative
magnetic resonance imaging showed a 13 11-mm
cystic lesion involving the right lateral rectus; a similar 9
7-mm lesion was seen within the left medial rectus
(Figure 3). During surgery, the cyst was found to have
intimate adhesions to the lateral rectus muscle. Histopathology
showed a cyst lined by stratified and simple
columnar epithelium.
Giant orbital cysts after strabismus surgery are a rarely
described complication. Patients can present either with
the complaint of a mass or with the clinical picture of a
slipped or lost muscle. 1–4 The cystic mass maybe undetectable,
even on careful slit-lamp examination. One of our
cases had no signs or symptoms to suggest a cyst other than
FIGURE 3. T-1 weighted MRI image without contrast (axial
cut) of Case 3, showing a giant orbital cyst intimately involved
with both the right lateral rectus and left medial rectus at their
insertions. The patient had bilateral strabismus surgery as an
infant.
incomitant, recurrent strabismus. The two who presented
with a mass were found to have an incomitant strabismus.
Incomitant strabismus as a late finding after strabismus
surgery may suggest the presence of an orbital cyst. Finally,
our last patient had evidence of bilateral orbital cysts. To
our knowledge, this is the first reported bilateral case in the
literature.
The prevailing hypothesis on the etiology of these
cysts is that conjunctival cells are captured by the suture
material and deposited while securing the muscle or
while making the scleral pass. 1 This is supported by
the pathology of our cases, where muscle fibers were
involved with the cystic mass. The slow growth of
these lesions can be inferred by the lag time between
surgery and presentation. Previously, cysts were noted
as long as 35 years after strabismus operations. 1,5 Our
mean time between strabismus surgery and presentation
was 34 years, with two presenting four decades after
surgery.
Although these cysts are benign, they can encroach on
other orbital structures. Special care is required during
surgery because of the involvement of the affected rectus
muscle. Extensive dissection may be necessary. Orbital
cysts should be considered in the differential of orbital
masses in all patients who have a history of strabismus
surgery, no matter how remote.
698 AMERICAN JOURNAL OF OPHTHALMOLOGY
OCTOBER 2006

REFERENCES
1. Kushner BJ. Subconjuctival cysts as a complication of strabismus
surgery. Arch Ophthalmol 1992;110:1243–1245.
2. Cibis CW, Waelterman JM. Muscle inclusion cyst as a
complication of strabismus surgery. Am J Ophthalmol 1985;
100:740–741.
3. Basar E, Pazarli H, Ozdemir H, Kaner G. Subconjunctival cyst
extending into the orbit. Int Ophthalmol 1998;22:341–343.
4. Metz HS, Searl S, Rosenberg P, Sterns G. Giant orbital cyst
after strabismus surgery. J AAPOS 1999;3:185–187.
5. Shields JA, Shields CL. Orbital cysts of childhood-classification,
clinical features, and management. Surv Ophthalmol
2004;49:281–299.
Real Depth Vs Randot Stereotests
David A. Leske, BS, Eileen E. Birch, PhD,
and Jonathan M. Holmes, BM, BCh
PURPOSE: To compare the performance of real depth and
Randot stereotests in strabismic and nonstrabismic patients.
DESIGN: Observational case series.
METHODS: Stereoacuity was tested in 182 patients with a
variety of strabismic conditions, using the Frisby-Davis 2
(FD2) distance stereotest, the near Frisby (nF) (both real
depth tests), the Preschool Randot (nR), and Distance
Randot (dR) tests (both based on Polaroid vectographs).
RESULTS: Patients appreciated finer disparities with the
nF test than the nR test at near and with the FD2 test
than the dR test at distance.
CONCLUSIONS: The type of stereotest influences measurable
thresholds, and the results from different tests are
not interchangeable. The choice of test should depend on
the question being asked; nF and FD2 would be appropriate
for determining presence or absence of stereopsis
and best measurable stereopsis. The more rigorous Randot
tests would be appropriate for determining subtle
changes. (Am J Ophthalmol 2006;142:699–701. ©
2006 by Elsevier Inc. All rights reserved.)
TWO COMMONLY USED CATEGORIES OF STEREOTESTS
are “real depth” tests, such as the near Frisby (nF) 1 and
the distance Frisby-Davis 2 (FD2), 2,3 and Polaroid vecto-
Accepted for publication Apr 28, 2006.
From the Department of Ophthalmology, Mayo Clinic College of
Medicine, Rochester, Minnesota (D.A.L., J.M.H.); Retina Foundation of
the Southwest, Dallas, Texas (E.E.B.); and Department of Ophthalmology,
University of Texas Southwestern Medical Center, Dallas, Texas
(E.E.B.).
Supported by National Institutes of Health Grants EY015799 and
EY011751 (J.M.H.) and EY005236 (E.E.B.), Research to Prevent Blindness,
New York, New York (J.M.H. as Olga Keith Weiss Scholar and an
unrestricted grant to the Department of Ophthalmology, Mayo Clinic
College of Medicine).
Inquiries to Jonathan M. Holmes, BM, BCh, Ophthalmology E7, Mayo
Clinic College of Medicine, Rochester, MN 55905; e-mail: holmes.
jonathan@mayo.edu
graph “randot” tests, such as the near Preschool Randot
(nR) 4 and the new Distance Randot (dR). 5 To determine
whether there are systematic differences between these
categories of tests, we evaluated their performance in a
large cohort of patients.
One hundred and eighty-two patients in a strabismus
practice, ages 4 to 84 years, with visual acuity of 20/40 or
better in each eye, up to 70 prism diopters (pd) of
esotropia, 55 pd exotropia, or 30 pd of hypertropia completed
the nF, FD2, nR, and dR stereotests as part of
routine evaluation. Criterion of 20/40 in each eye was used
to avoid bias against Randot tests because of dot resolution.
All four tests were administered using previously
described presentation protocols. 3–6 The study was approved
by respective Institutional Review Boards and
conducted in a Health Insurance Portability and Accountability
Act (HIPAA)–compliant manner. To eliminate
potential bias of comparing tests with different ranges of
stereopsis, results were rescored as “fine” (20 to 60 seconds
of arc [sec arc]), “moderate” (75 to 200 sec arc), or
“coarse/nil” (400 sec arc to nil) stereo (Table 1). We
compared these rescored stereopsis levels between tests and
determined the frequency of one test indicating a finer or
measurable threshold compared with the alternative test.
At near, patients appreciated finer disparities with the
nF than the nR test (median “moderate” vs “coarse/nil,” P
.0001). At distance, patients appreciated finer disparities
on the FD2 than the dR test (median “moderate” vs
“coarse/nil,” P .0001). Only 4% of patients had better
stereoacuity with nR than nF, and no patient had better
stereoacuity with dR than FD2. When one test indicated
nil stereopsis, the patient was much more likely to have
measurable stereopsis with a real depth test (nF or FD2)
than a Randot test (Table 2).
One possible explanation for different median thresholds
is that one or more tests were more prone to false
positives. We therefore analyzed patients with 20 pd of
constant deviation. Only one of 21 (5%) patients with
20 pd at near had measurable stereopsis with the nF and
one of 25 (4%) with 20 pd at distance had measurable
stereopsis the FD2 (none with the Randot tests), and that
individual patient had Duane’s syndrome with marked
incomitance. It is possible that, despite attempting to
measure the stereoacuity in primary position, this patient
adopted a subtle face turn during stereoacuity testing,
reducing his angle of deviation. Previous studies have
suggested that our standardized presentation protocols 3,7
reduce the impact of monocular cues to a negligible level.
There are at least three possible explanations why the
real depth tests might demonstrate measurable stereopsis
when the Randot tests demonstrate no stereopsis: (1)
patients had intermittent tropias that were better controlled
when viewing real world targets, (2) there was
greater dissociation under conditions of Randot testing
(when the deviation by alternate cover test (ACT)
simultaneous prism cover test [SPCT]), and (3) the tests
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