Introduction

Conjunctival cysts are vesicles full of fluid, varying in size and location on the ocular surface [1]. Large conjunctival cysts may need removal treatment to relieve patients from foreign body sensation, dry eye symptoms, blinking issues, and cosmetic dissatisfaction [2]. Besides the primary conjunctival cysts that are congenital, secondary cysts can be a consequence of other systemic diseases such as Fabry disease, or any ocular inflammatory conditions such as chronic keratoconjunctivitis and pyogenic granuloma, or trauma, or any eye surgeries. [3-5]. Mainly, cosmetic problems will lead patients to excision of cysts. Every surgical technique could be effective, but they cause risks and complications such as orbital inflammation and corneal damage in doxycycline injection, thermal burns of surrounding tissues in thermal cautery, or recurrence in methods like YAG laser. [6-8]. In 2020, an office-based approach with no recurrence or complications was introduced by Nejat et al., named Plasma Assisted Noninvasive Surgery (PANIS), which utilized the benefit of low-temperature plasma for sublimating conjunctival cysts [9]. In this recent study, our team aims to report the effect and safety of the PANIS method on the ablation of a large conjunctival cyst measuring 21.68 mm in length and 10.5 mm in width.

Case Presentation

A 78-year-old woman was diagnosed with a large conjunctival cyst characterized by a solitary, non-tender, soft, cystic mass measuring 21.68 × 10.5 mm on the inferior fornix in her left eye when she visited the Vision Health Research Center in 2021. This study was identified with the ethics committee of Semnan University of Medical Sciences. After the patient signed informed consent and was informed of all possible side effects and complications, the plasma-assisted noninvasive surgery (PANIS) began. This technique was initiated after three consecutive instillations of tetracaine 0.5% (Sina Darou, Tehran, Iran) in the targeted eye with a 5-minute interval. The patient was seated behind the slit lamp, and one surgeon (F.N.) performed all the procedure steps. Atmospheric low-temperature plasma was generated when the white handpiece of the PLEXR PLUS (GMV, srl, Rome, Italy) ionized the air between the tip of the device and the targeted tissue (Table 1). The sublimation mechanism caused the complete removal of the cyst. Intentionally, to prevent future recurrence and conjunctival tissue fusion, scar formation was induced with more plasma spots on the base of the cyst (Supplemental video 1). For post-operative medications, chlobiotic 0.5% (Raha Pharma Co, Isfahan, Iran) was prescribed every six hours for one week, and betamethasone

0.1% (Sina Darou, Tehran, Iran) was prescribed every four hours during the first week. The dosage of betamethasone was tapered off over a month. Visual parameters, including uncorrected visual acuity (UCVA), best-corrected visual acuity (BCVA), refractive errors, and intraocular pressure (IOP) by Topcon CT-80 noncontact tonometer (NCT), were measured before, six months, and one year after the PANIS procedure. All slit-lamp examinations were conducted during every ophthalmic visit with a photo slitlamp (SL9900 ELITE 5X-D, CSO, Firenze, Italy), and the ocular surface disease index (OSDI) questionnaire was administered before, six months, and one year after the PANIS procedure. The OSDI score decreased from 42 to 0 in the 1-year period of followup. The UCVA and BCVA significantly improved by 2 lines. As expected, IOP did not change remarkably. The surgical procedure was done with no intraoperative or postoperative complications, including pain during and after the surgery. Photo slit-lamp examinations showed complete large conjunctival cyst removal with no recurrence in the 1-year follow-up (Figure 1).

Table 1: PLEXR PLUS Characteristics.

Figure 1: Photo slit-lamp images before, 6 months, and 1 year after the treatment with the PANIS method.

Table 2: Patients measured parameters.