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dermoid cysts , mucocele , and congenital ocular anomalies are the most common orbital cystic lesions in children . however , cysts arising from the lacrimal duct are less frequently encountered [ 25 ] .
lacrimal duct cysts can retain communication with the lacrimal system or be completely separated from it .
the most common presentation is that of a cystic mass located in the inferior medial orbit , occasionally associated with signs and symptoms of secondary nasolacrimal duct obstruction .
most lesions are small in size and asymptomatic soon after birth ; however with time they may enlarge considerably , potentially causing globe compression which requires early resection . in order to prevent local recurrence ,
it is necessary to remove the entire cyst at the time of surgery without leaving any residual cyst tissue . on occasions , this may be challenging since cyst boundaries are not easily apparent , especially posteriorly .
indocyanine green ( icg - akorn inc . , lake forest , il 66045 , usa ) is a coloring dye that has numerous uses in ophthalmology with established intraocular , topical , and intravenous safety .
reports on the use of icg during resection of conjunctival cysts were published ; however , to the best of our knowledge , there is only one case report on the use of this dye during removal of orbital lesions .
the purpose of the study is to report on our experience in using icg during removal of pediatric orbital cysts , raising the awareness of surgeons for the possibility of its use during such surgery .
we reviewed all cases of pediatric orbital lacrimal cysts that were operated using intralesional icg injection at the time of surgery .
data collection included demographics , clinical history , localization of the lesion , imaging findings , surgical technique , and complications .
pathological analysis , surgical outcome , and duration of follow - up were also recorded .
the study was approved by the irb committee of our medical center and its compliance was in agreement with rules and regulations .
after the cystic lesion was identified , if leakage was recognized along with loss of cyst volume , icg dye was injected into the lesion with a 25-gauge needle .
cyst borders were readily apparent even though there was immediate loss of volume subsequent to the injection . following delineation of the cyst capsule with the green dye , complete excision was performed .
the skin or conjunctiva was closed using 7/0 vicryl sutures and the surgical site was bandaged with a topical antibiotic ointment .
all children were seen one week after surgery and final assessment of surgical outcome was made at least 6 months afterwards .
six children ( 3 boys ) were included in this study . all children had orbital imaging preoperatively ; two children had computerized tomography ( ct ) , one had magnetic resonance imaging ( mri ) , and 3 children had orbital ultrasound .
all lesions were unilateral ( 4 in the right orbit ; 2 in the left orbit ) , always located in the inferomedial orbital quadrant . four cysts were diagnosed soon after birth due to the presence of medial subcutaneous swelling seen at the area of the lacrimal system , accompanied by cystic sensation upon palpation ; however all surgeries were performed after the age of 3 years ( mean age 4.2 years  0.84 , range 35 years ) when there was evidence of progressive enlargement causing globe compression or cosmetic disfigurement unacceptable to the parents .
surgical excision was performed through the skin in two cases and through the conjunctiva in the remaining four cases .
none of the cysts were connected to the nasolacrimal duct , and all showed patency of the lacrimal system on syringing after cyst removal , with no evidence of any leakage to the surgical site .
the pathology report confirmed complete excision of a cystic lesion lined with epithelium of lacrimal duct origin .
none of the children had cyst recurrence during follow - up ( mean follow - up 9 months ) or any evidence of nasolacrimal duct obstruction .
the patient was followed up regularly and when the lesion was growing considerably , an orbital ct was performed demonstrating a 2  cm hyperdense homogeneous mass in the inferomedial aspect of the right orbit , with mild compression of the right eye ( figure 1(a ) ) .
the patient had no symptoms or signs of nasolacrimal duct obstruction . at the time of surgery a horizontal skin incision over the cyst was made and the cyst was exposed ( figure 1(b ) ) . upon further exposure ,
the cyst started to lose volume , and therefore icg was injected into the cyst , which allowed improved visualization of the lesion boundaries ( figures 1(c ) and 1(d ) ) permitting its complete excision ( figure 1(e ) ) .
the patient was treated twice a day with maxitrol ointment ( dexamethasone with polymyxin b and neomycin ) over the surgical wound .
pathology examination identified complete excision of a cyst lined with epithelium of lacrimal duct origin .
a second patient was examined in the clinic for evaluation of a left inferomedial orbital cyst that was recognized since the age of 3 months .
the patient had a doppler ultrasound examination which identified a cystic lesion with a clear liquid content . during follow - up
orbital mri performed shortly before surgery demonstrated a 0.7  1.5  cm oval mass with clear fluid contents located in the left inferomedial orbit , causing mild globe compression ( figure 2(a ) ) .
icg was injected into the cyst at the time of surgery when loss of volume was noted by the surgeon ( figures 2(b)2(d ) ) .
pathological analysis identified a cyst lined with epithelium of lacrimal duct origin . during the 6-month follow - up period no surgical complications or cyst recurrence
by using intralesional icg injection , we were able to completely remove lacrimal duct orbital cysts in children , even though unintentional volume loss occurred earlier , without any complications or recurrence .
this dye is frequently used in ophthalmology , including during orbital surgery , with an established safety profile in humans .
they noted that following intralesional injection the cyst became clearly visible , and staining remained even after an inadvertent perforation of the cyst capsule that caused immediate collapse .
chan et al . also reported on the use of icg during similar conjunctival surgery .
others reported on the use of different substances , including sodium hyaluronate or healon v and trypan blue during excision of conjunctival cysts [ 11 , 12 ] .
however , according to our experience there is no need to use a viscoelastic material as well , since it may not be readily available for all orbital surgeons and it increases the cost of surgery . to the best of our knowledge
, our study is the first to report on the use of icg for demonstration of orbital cysts during pediatric orbital surgery , although its use has been reported earlier in an adult . using this dye
, we were able to completely remove the cysts even though partial or complete collapse of the lesion typically occurred . in conclusion
, we believe that icg has a role in pediatric orbital lacrimal cyst surgery , helping with improved visualization of the cyst capsule and allowing complete cyst removal , especially with unintentional rupture of the cyst and volume loss that occurred earlier .
aim . to report on the use of indocyanine green ( icg ) during surgical removal of pediatric orbital lacrimal duct cysts 
 . method . 
 we conducted a retrospective review of our cases of surgical excision of orbital lacrimal duct cysts using intraoperative injection of indocyanine green ( icg ) , which was used following inadvertent cyst rupture and volume loss . 
 the dye allowed complete cyst visualization and complete excision despite volume loss or cyst rupture . 
 results . the study included 6 children ( 3 boys , 
 mean age of 4.2    0.84 years , range 35 years ) . 
 mean follow - up period was 9.3 months . 
 all cysts were located in the inferonasal quadrant of the orbit ( 4 in the right side ) . in all cases , 
 icg was injected into the cyst at the time of surgery following unintentional cyst rupture . 
 after the dye injection , it was easy to identify the borders of the cyst , permitting complete cyst removal , without any intra- or postoperative complications . 
 pathological examination revealed that all cysts were of lacrimal duct origin . 
 conclusion . 
 intraoperative injection of icg into orbital cysts in children can aid surgeons in identifying cyst borders following inadvertent rupture , allowing complete removal .