Acta Scientiae Veterinariae, 2014. 42 (Suppl 1): 63.

CASE REPORT ISSN 1679-9216

Pub. 63

Corneal Epithelial Inclusion Cyst in a Dog

João Antonio Tadeu Pigatto, Luciana Vicente Rosa Pacicco de Freitas, Luciane de Albuquerque & David Driemeier

ABSTRACT

Background: Intrastromal corneal cysts are uncommon lesions caused by the implantation of corneal epithelial cells in the
stroma, and their subsequent intrastromal proliferation, which has often been secondary to trauma. Lamellar keratectomy
has been the chosen treatment and diagnosis has been confirmed by histopathology. In this report, we describe a case of
corneal epithelial inclusion cyst in a dog that was successfully treated with lamellar keratectomy.
Case: A 10 year old Yorkshire Terrier dog was referred to the Ophthalmology Section of the Veterinary Clinics Hospital
of the Federal University of Rio Grande do Sul (UFRGS), presenting an abnormal appearance in the left cornea. The
ophthalmic examination revealed a white and elevated mass, measuring approximately 3 mm in the left cornea. Thus,
a superficial keratectomy was performed by utilizing an angled ophthalmic disc knife, under general anesthesia, and an
operating microscope. In addition, a third eyelid flap was performed to protect the cornea. The postoperative treatment
involved broad-spectrum antibiotic containing tobramycin 0.3%, and a non-steroidal anti-inflammatory solution of sodium
diclofenac 0.1%, administered six times a day for two weeks. In addition, atropine sulphate 1% was applied once a day for
five days. After three weeks of follow-up, the third eyelid flap was removed, and there was no evidence of corneal ulcer.
After two years, no recurrence has been observed.
Discussion: Studies have indicated that the epithelial inclusion cyst is congenital or traumatic. In this case, the dog had a
history of previous corneal ulceration occurring at the same site of the cyst. Regarding clinical signs, studies have reported
that a corneal cyst does not cause ocular discomfort, although excessive tearing and blepharospasm have been reported. At
the moment of examination, the dog presented ocular discharge, discomfort and conjunctival congestion. Normally, a defini-
tive diagnosis is made after cytology or histopathology; however, the diagnosis of corneal cyst in this dog was confirmed
through the histopathology of the mass after surgical excision. Keratectomy has been the chosen treatment to remove cysts.
Although the recurrence of a cyst is not expected, it has been described fifteen months after the first keratectomy. The most
likely explanation for this recurrence could be an incomplete and inadequate surgical excision of the original cyst. In this
study, keratectomy was carried out and the entire cyst, along with its sac, was then removed. It is important to remove the
cyst rather than draining it, once if the cyst and sac-cover are not totally removed, there is a great possibility of the cyst
growing back and getting larger. After keratectomy pedicle conjunctiva graft, third eyelid flap, tissue adhesive, and thera-
peutic contact lens can be utilized. In this case, third eyelid flap was utilized after keratectomy. The concomitant medical
therapy was realized with the topical utilization of broad-spectrum antibiotics in order to prevent bacterial contamination.
In addition, the topical atropine sulphate 1% was utilized to dilate the pupil, helping to decrease pain associated with
secondary uveitis; non-steroidal anti-inflammatory drug was utilized to control the inflammation. Lastly, the third eyelid
flap suture was removed three weeks after surgery, and there was no evidence of corneal ulcer; periodic evaluations were
realized every three months and there were no signs of recurrence after one year. In the present case, lamellar keratectomy
associated with third eyelid flap was effective in the treatment of corneal epithelial inclusion cyst in a dog.

Keywords: corneal, lamellar keratectomy, canine.

Received: 25 April 2014 Accepted: 6 August 2014 Published: 15 August 2014

Faculdade de Veterinária (FaVet), Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil. CORRESPONDENCE: J.A.T. Pi-
gatto [pigatto@ufrgs.br - Fax: +55 (51) 3308-5131]. Avenida Bento Gonçalves n. 9090, Bairro Agronomia. CEP 91540-000 Porto Alegre, RS, Brazil.

1
J.A.T. Pigatto, L.V.R.P. Freitas, L. Albuquerque & D. Driemeier. 2014. Corneal Epithelial Inclusion Cyst in a Dog.
Acta Scientiae Veterinariae. 42(Suppl 1): 63.

INTRODUCTION performed utilizing a 4-0 nylon6 to protect the cornea.

Corneal epithelial inclusion cyst, involving any
of the four layers of the cornea, has been reported in
human and dogs [4,8,12]. Epithelial cysts are caused
by the implantation of corneal epithelial cells in the
stroma and their subsequent intrastromal proliferation,
which has often been secondary to trauma [1,3,8,12].
Furthermore, there is no breed known as predisposed
to the epithelial inclusion cyst formation [1,4], and the
inclusion of epithelial cysts occur as an increasing vol-
ume of white to pinkish color and high benign corneal,
being most often unilateral [4,6-8]. Recently, in a study,
cyst formation was typically located only in dorsolateral
region or central cornea, which has been rarely reported
as involving the sclera [11]. However, the same study re-
ported the first case of multiple epithelial inclusion cysts
in the cornea of a dog [11] and the differential diagnosis
included corneal neoplasm, abscess, dermoid, bullous
keratopathy, and iris prolapse [1,11]. The diagnosis has
been confirmed by histopathology and keratectomy has
been the chosen treatment [3,6,11,12]. A case is reported
here in which a corneal epithelial inclusion cyst in a
dog was successfully treated with lamellar keratectomy.
CASE
All excised tissue was placed in buffered 10% forma-
lin, processed for light microscopy, and sections were
stained with hematoxylin eosin. The histopathological
evaluation was performed by the Sector of Veterinary
Pathology (SVP), Department of Veterinary Clinical Pa-
thology, Faculdade de Veterinária (FaVet), Universidade
Federal do Rio Grande do Sul (UFRGS), Porto Alegre,
RS, Brazil (Figure 2). Moreover, the postoperative treat-
ment involved broad-spectrum antibiotic (Tobramycin
0.3%)7 and a non-steroidal anti-inflammatory solution
(sodium diclofenac 0.1%)8, administered six times a day,
for two weeks. In addition, atropine sulphate 1% (atro-
pine 1%)9 was applied once a day, for five days. Lastly,
the third eyelid flap suture was removed three weeks
after surgery, and there was no evidence of corneal ulcer.
Periodic evaluations were realized every three months
and there were no signs of recurrence of the cyst after
one year (Figure 3).

A 10 year old Yorkshire Terrier dog was referred

to the Ophthalmology Section of the Veterinary Clinics
Hospital of the Federal University of Rio Grande do Sul
(UFRGS), Porto Alegre, RS, Brazil, presenting an abnor-
mal appearance in the left cornea. The history revealed
epiphora and blepharospasm seven days previously.
Although on examination the dog demonstrated good Figure 1. Appearance of corneal cyst in the left cornea of the dog. Perile-
clinical condition, its owner reported that the animal had sional oedema and vascularization on and around the cyst were observed.
a corneal ulcer six months prior to this consultation at
the hospital, exactly where the cyst was located then.
Schirmer tear test1 values were 19 and 17 mm in the left
and right eye, and intraocular pressure2 was 16-17 mm
Hg in its left and right eye, respectively. Fluorescein3 dye
test was negative. Blepharospasm and photophobia were
not present. Portable slit lamp4 examination showed
white and elevated mass measuring approximately 3 mm
in the left cornea with involvement of the epithelium and
upper stroma (Figure 1).
The results of a complete blood count and serum
biochemical profile were within normal reference range.
Thus, a superficial keratectomy was performed utilizing
an angled ophthalmic disc knife5, under general anesthe- Figure 2. Histopathological section of the cornea stained with hematoxylin and
sia, and an operating microscope. A third eyelid flap was eosin (x100). The cyst lining consists of variably thick squamous epithelium.

2
J.A.T. Pigatto, L.V.R.P. Freitas, L. Albuquerque & D. Driemeier. 2014. Corneal Epithelial Inclusion Cyst in a Dog.
Figure 3. Aspect of the eye one year after keratectomy. No recurrence
has been observed.
DISCUSSION
Corneal cysts are uncommon and have been
reported in human, dogs and llamas [1,4,8,10,11].
Corneal cysts have typically traumatic or congenital
origin [1,4,10], and most referred canine cases present a
history of ocular lesions [1,4]. In this case, the dog had
a history of corneal ulceration occurring at the same
site of the cyst. Recurrent corneal ulcer and previous
keratectomy have been mentioned as possible causes
for this cystic formation [1,3,7].
A previous study demonstrated that there is a
relation between the formation of the cyst and trauma
[1]. There is not know breed predisposition to epithelial
[1]. In this report, the dog was the Yorkshire breed and
had a history of prior corneal ulcer. Although some
authors have reported that dogs with epithelial inclu-
sion cyst do not present history of ocular discomfort
[1,6,9], in the ophthalmic examination, blepharospasm,
conjunctival congestion and mucous secretion, were
then perceived. As in this report, other studies have
demonstrated that the cysts and the region of the cornea
are vascularized. In addition, as it has been observed,
these cystic formations usually do not interfere with
the results of other eye exams as a proof of fluorescein,
tonometry, and direct and indirect ophthalmoscopy
[1,3,9,11]. In a report on a large corneal epithelial
inclusion cyst, intraocular pressure was not possible
to be measured due to a large cyst [4].
In terms of clinical features, this case was
similar to previous ones reporting corneal cysts in
dogs, and corneal mass was presumptively diagnosed
as a corneal epithelial inclusion cyst based on clinical
3
Acta Scientiae Veterinariae. 42(Suppl 1): 63.
examinations. Therefore, histopathology was neces-
sary to make a definitive diagnosis and mostly for
differentiating corneal cysts from corneal neoplasia,
bullous keratitis, corneal abscess, dermoid and iris
prolapse [1,11]. In this case, the diagnosis was based
on history and clinical signs, being confirmed by the
histopathology of the mass after keratectomy.
Thus, cytological examination has shown that
the fluid inside the cystic necrotic material has been
present as well as occasionally cellular debris calcium
crystals [1], related to the cyst wall, this may have intact
or degenerated epithelial cells.
Histopathology usually reveals that epithelial
inclusion cyst is formed by a stratified squamous epi-
thelium note. The cells, in the basal epithelium melanin
granules, may contain the cytoplasm, while the lumen
of the cystic structure can present amorphous substance,
eosinophilia homogeneous material, cellular debris,
macrophages and erythrocytes [1,6,9,11]. Histological
examination revealed the presence of corneal tissue with
cystic area containing keratin and absence of inflamma-
tion, presenting outbreaks of corneal epithelial prolifera-
tion in several layers, and confirming the diagnosis of
epithelial inclusion cysts. The histological appearance
was similar to that previously described.
For dogs with corneal cysts, the chosen treatment
has been the superficial keratectomy [1,3,4,6,8,11,12].
After keratectomy pedicle conjunctiva graft, third eyelid
flap, tissue adhesive, amniotic membrane, therapeutic
contact lens can be, then, utilized [2,3].
In this report, the corneal cyst was removed
from the dog, through lamellar keratectomy, and, as
J.A.T. Pigatto, L.V.R.P. Freitas, L. Albuquerque & D. Driemeier. 2014. Corneal Epithelial Inclusion Cyst in a Dog.
Acta Scientiae Veterinariae. 42(Suppl 1): 63.

keratectomy was superficial, the third eye flap was SOURCES AND MANUFACTURERS
1
Schirmer Tear Strips®, Ophthalmos, SP, Brazil.
chosen to protect the cornea. Third eyelid flap is an 2
Tonopen XL®, Mentor Medical Systems, NY, USA.
excellent form of protection for the corneal epithelium 3
Fluorescein strips®, Ophthalmos, SP, Brazil.
4
during healing. Kowa SL15®, Kowa Company Ltd, Aishi, Japan.
5
Ophthalmic disc knife, Alcon, SP, Brazil.
Usually, as in the case reported, recurrence of 6
Mononylon Ethicon®, Johnson & Johnson, SP, Brazil.
the CEIC has not been expected [9]. However, another 7
Tobrex® ophthalmic solutions, Alcon, SP, Brazil.
8
Still®, Allergan, SP, Brazil.
case reported two smaller CEIC appearing fifteen 9
Atropine eye drops 1%®, Allergan, SP, Brazil.
months after the first keratectomy. Thus, lamellar
keratectomy associated with third eyelid flap was ef- Declaration of interest. The authors report no conflicts of
interest. The authors alone are responsible for the content and
fective in the treatment of corneal epithelial inclusion
writing of the paper.
cyst in a dog.

REFERENCES

1 Bedford P.G.C., Grierson I. & Mckechnie N.M. 1990. Corneal epithelial inclusion cyst in the dog. Journal of Small
Animal Practice. 31(3): 64-68.
2 Barros P.S.M., Garcia J.A., Laus J.L., Ferreira A.L. & Salles T.L. 1998. The use of xenologous amniotic membrane
to repair canine corneal perforation created by penetrating keratectomy. Veterinary Ophthalmology. 1(2): 119-123.
3 Campos C.F., Talieri I.C., Vicenti F.A.M & Laus J.L. 2002. Corneal epithelial inclusion cyst in a dog. Ciência Rural.
32(3): 521-523.
4 Choi U.S. 2010. Successful treatment of an unusually large corneal epithelial inclusion cyst using equine amniotic
membrane in a dog. Veterinary Ophthalmology. 12(2): 122-125.
5 Cullen C.L. & Granh B.H. 2001. Diagnostic ophthalmology epithelial inclusion cyst of the right cornea. The Canadian
Veterinary Journal. 42(3): 230-231.
6 Gelatt K.N. 2003. Doenças e cirurgia da córnea e esclera do cão. In: Manual de oftalmologia veterinária. 2.ed. São
Paulo: Manole, pp.125-164.
7 Gelatt K.N. 2003. Exame oftálmico e procedimentos diagnósticos. In: Manual de oftalmologia veterinária. 2.ed. São
Paulo: Manole, pp.1-26.
8 Koch S.A., Langloss J.M. & Schmidt G. 1974. Corneal epithelial inclusion cyst in four dogs. Journal of the American
Veterinary Medical Association. 164(12): 1190-1191.
9 Martin-Suarez E.M, Galan A. & Molleda J.M. 2009. Re-incident corneal epithelial inclusion cyst in a dog: a case
report. Veterinary Medicine. 54(2): 84-88.
10 Pirie C.G., Pizzirani S. & Parry N.M. 2008. Corneal epithelial inclusion cyst in a llama. Veterinary Ophthalmology.
11(2): 111-113.
11 Simonazzi B. 2009. A case of multiple unilateral corneal epithelial inclusion cysts in a dog. Journal of Small Animal
Practice. 50(7): 373-376.
12 Slatter D. 2005. Córnea e esclera. In: Fundamentos de Oftalmologia Veterinária. 3.ed. São Paulo: Roca, pp. 283-338.

CR 63
www.ufrgs.br/actavet