Abstract

A patient presenting with repeated attacks of bleeding from the right eye; on examination of which a friable warty mass arising from the palpebral conjunctiva of the upper lid for which excision was done.

Introduction

A pyogenic granuloma is a fast growing vascularized proliferation of granulomatous tissue which is usually antedated by surgery trauma or infection or sometimes it is idiopathic.1 It is the most common vascular lesion to involve the eyelids.
Occasionally exuberant polypoid conjunctival masses which histologically show changes of granuloma pyogenicum can develop in a chalazia. These lesions are characterized by the granulation tissue that contains fine capillary vessels and inflammatory cells: including plasma cells and neutrophils. Granuloma pyogenicum can occur elsewhere in the bulbar, fornicial and palpebral conjunctiva secondary to trauma or infection as stated above and is considered by some to be a form of vascular tumour.²

Case History

Eighteen year old female c/o repeated episodes of bleeding from the right eye 2 months back with history of tiny painless swelling on the right upper lid for which incision and curettage was done.

Two months later the patient presented again with bleeding from the right eye with tiny painless swelling from the right upper lid.

No h/o of trauma. No h/o bleeding from any other site in body.

No h/o systemic illness.On examination there was fullness of the right upper lid. Vision both eyes was 6/6 and the anterior segment and fundus were within normal limits.

On lid eversion a filiform warty fleshy tissue (Fig. 1) which was fragile and bled on touch. The bleeding was controlled by pressure dressing and patient was prescribed ciprofloxacin eye ointment for ten days.

All routine blood investigations including Sr. HIV, bleeding time and clotting time were within normal limits.

Ten days later similar bleeding episodes started from right eye and during this time complete excision and curettage of the swelling was done by clamping the lesion at the base. Pressure pad dressing given and tissue was sent for histo pathology. Patient given a 7 days course of tablet doxycycline and anti- inflammatory tablets with topical gatifloxacin eye drops. On follow up patient had a small scar. There was no recurrence or lid deformity till the end of 3 months (Fig. 2).

Fig. 1 : Upper lid pyogenic granulating chalazion		Fig. 2 : Small scar at end of 3 months with no recurrence
Fig. 3 : Histopathology slide (HE staining showing e/o proliferative capillaries with lymphocytic infiltrate) 10X

Histopathology Report

This 5 by 5 mm black firm mass on histopathology showed a lesion lined by flat cuboidal lining. The wall of lesion showed proliferating capillaries and the Intervening stroma showed chronic infiltrate including PMN cells, Lymphocytes and few plasma cells (Fig. 3).

All these features were suggestive of pyogenic granuloma.

Discussion

The differential diagnosis includes Kaposi’s sarcoma and intra vascular papillary endothelial hyperplasia a rare endothelial proliferation (a kind of hamartoma).³

Also a few cases of ocular tuberculosis can present with conjunctival granulomas with a cock’s comb appearance.⁴
Very rare cases of vicarious menstrual bleeding from the normal conjunctiva have been reported.⁵ No references were found for the incidence rates and recurrence rates of formation of a pyogeni granuloma in a recurrent chalazion.

Conclusion

Recurrence in a curetted chalazion with bleeding should arouse the suspicion of such an entity that is “pyogenic granuloma”. This patient had developed these changes in a chalazion. As such Malignancy is not the only cause of recurrence in a chalazion and this entity of pyogenic granuloma should be kept in mind, hence the case report.

References

1. Kanski Jack. Benign tumors eye lids: in clinical ophthalmology a systematic approach, Butterworth Heinemann, 5th edition 2003; 16.
2. Peymen GA, Saunders Donald, Goldbey Morton. III principles and practice of ophthalmology 1st edition; 2234.
3. Font RL. Eyelids and lacrimal drainage system. In Spencer WH ed. Ophthalmology pathology on atlas and text book vol 4. ed 4. Philadelphia WB Saunders 1996; 2218-437.
4. Tabbara KF. Ocular tuberculosis in ophthalmic clinic. 2005; 45 (2).
5. Tarasova LA, Briukhing EU. A case of vicarious menstrual bleeding from the conjunctiva Vestn ophthal 1991; 107 (1) : 59.

*Registrar; **Associate Professor; ***HOD; +Observer; LTMGH Sion Hospital, Mumbai 400 022