Extensive Unilateral Limbal Cysts Associated With Episodic Intraocular Pressure Spikes: A Case Report

To present a case of a 74-year-old male with extensive conjunctival cysts in the inferior limbal area of the left eye suspected of contributing to intraocular pressure spikes. The cysts' proximity to Schlemm's canal and potential alteration of episcleral venous pressure due to engorged episcleral vessels are explored. The patient's systemic conditions, including intradermal cysts and renal oncocytoma, are also discussed.

Moorfields Eye Hospital, London.

A 74-year-old male presented with extensive conjunctival cysts in the inferior limbal area of the left eye, extending onto the inferior cornea, accompanied by episodic intraocular pressure spikes. Initially thought to have conjunctival chemosis, comprehensive ophthalmic examination revealed multiple conjunctival cysts near Schlemm's canal. Gonioscopy showed open angle with subtle blood reflux in Schlemm's canal, suggesting elevated episcleral venous pressure and structural changes in the inferior iridocorneal angle of the left eye. The right eye, which lacked significant cysts, maintained normal IOP.

Anterior segment optical coherence tomography confirmed the cysts' proximity to the aqueous outflow system. Initial management with topical aqueous suppressants, followed by selective laser trabeculoplasty, failed to achieve adequate IOP control. Surgical excision of the conjunctival cysts is now being considered to relieve episcleral vessel engorgement and normalize IOP levels.

Systemic evaluation revealed scattered intradermal cysts and a left renal oncocytoma associated with haematuria, highlighting the possibility of an underlying systemic condition.

This case underscores the importance of considering conjunctival cysts as a potential cause of elevated intraocular pressure that may be initially mistaken for conjunctival chemosis. Accurate diagnosis through comprehensive ophthalmic examination and imaging is crucial. When medical management is insufficient, timely surgical excision of the cysts may effectively restore normal IOP and prevent secondary glaucoma caused by mechanical obstruction of aqueous outflow. Clinicians should maintain a high index of suspicion for such anatomical anomalies in patients with unexplained IOP spikes to ensure early diagnosis and optimal management.