<b><i>Purpose:</i></b> Surgical intervention is indicated for large primary iris pigment epithelial cysts that significantly affect vision or compromise adjacent structures. Methods described in the literature include laser photocoagulation, needle aspiration, and complete resection. <b><i>Methods:</i></b> We describe a novel surgical technique in which a surgical cystotomy is created for a large, symptomatic iris pigment epithelial cyst using microsurgical instruments for a patient in whom needle aspiration was unsuccessful. <b><i>Results:</i></b> The patient’s visual symptoms had largely resolved within 1 week postoperatively, no complications were encountered, and there was no clinical or sonographic evidence of cyst recurrence after 14 months. <b><i>Conclusion:</i></b> Surgical cystotomy with microinstrumentation may be an effective tool for management of primary iris pigment epithelial cysts, especially as an alternative after needle aspiration fails
