Surgical excision and distilled water lysis of a congenital
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A A 5-year-old female with normal development and no significant past medical history who presented for the second opinion of a left corneal opacity which was noted in the first year of life and gradually enlarged. There was no reported history of trauma. An outside cornea specialist diagnosed Salzmann's nodular degeneration and recommended superficial keratectomy. She was poorly compliant with patching treatment for amblyopia. Spectacle correction for hyperopic astigmatism of both eyes allowed for a corrected visual acuity of 20/20 (OD) and 20/60 (OS). Pre-operative photographs, Scheimpflug tomography, and anterior segment optical coherence tomography (OCT) can be seen. Scheimpflug measured 14.3 diopters of anterior corneal astigmatism.

Her family elected to pursue drainage, curettage, and distilled water rinse of the intrastromal corneal cyst. Under general anesthesia, a crescent blade was used to make an entry into the cyst at the nasal limbus with drainage of milky fluid. There was no apparent scleral involvement of the cyst. The lining of the cyst was scraped thoroughly using a Terry Descemet's scraper and sterile water was flushed repeatedly inside the cavity. Material recovered from the cyst lining was insufficient for pathology. The incision was sutured to prevent epithelial ingrowth, At the patient's one-week follow-up appointment, sutures were removed and neomycin/polymyxin/dexamethasone ointment was stopped.

Spectacle-corrected acuity at month two improved to 20/30, from 20/60 pre-operatively. Tomographic astigmatism improved from 14.3D to 4.0D. Although she maintained stromal haze in the region of the former cyst, there was no evidence for cyst recurrence at month eight. Nests of presumed intra-stromal epithelial cells were visible in the region of the former cyst. At fourteen months post-procedure, there was again no evidence for cyst recurrence and she achieved best-corrected 20/20 vision in each eye. In summary, intrastromal cysts can be congenital or sequelae of corneal trauma. They can impose a threat to the visual axis through either opacification or astigmatism induction. The authors support the use of a cytolytic agent, such as distilled water or ethanol, to reduce recurrence. Amblyopia management and long-term monitoring for recurrence are essential in caring for these patients.