Conjunctival Pyogenic Granuloma

A 4-year-old girl was referred to the ophthalmology clinic for evaluation of a conjunctival mass. She had a 4-month history of thrice daily topical instillation of 0.05% levofloxacin hydrate and 0.02% fluorometholone for a hordeolum. She had no history of ocular surgery or trauma. A pedunculated, pinkish, smooth-surfaced mass was observed to originate from the lateral side of her right upper tarsal conjunctiva (Figure, A), which was diagnosed as pyogenic granuloma. Continuation of the topical corticosteroid for a week resulted in the mass becoming hemorrhagic (Figure, B). Complete resolution was achieved the next day with minimal scarring (Figure, C). There was no recurrence for 6 months.

Figure.

Clinical course of conjunctival pyogenic granuloma. A, Initial presentation. A pedunculated, pinkish, smooth-surfaced mass on the lateral side of her right upper tarsal conjunctiva. B, Presentation one week after the initial visit. Hemorrhagic appearance of the conjunctival mass. C, Spontaneous resolution of the lesion on the day after the bleeding.

A pyogenic granuloma is often misdiagnosed as a hordeorum or chalazion. A hordeolum is an acute, localized swelling of the eyelid that may be external or internal and usually is a pyogenic infection or abscess. Most hordeola are external and result from obstruction and infection of an eyelash follicle and adjacent glands of Zeis or Moll glands. Typically, a small yellowish pustule develops at the base of an eyelash, surrounded by hyperemia, induration, and diffuse edema in the initial phase. After that, the lesion ruptures and discharges material, thereby relieving pain and resolving the lesion.

A chalazion is a chronic noninfectious obstruction of a Meibomian gland causing extravasation of irritating lipid material in the eyelid soft tissues with focal secondary granulomatous inflammation. Initially, the eyelid is diffusely swollen. Typically, a small nontender nodule or lump develops. After that, the lesion usually drains through the inner surface of the eyelid or is absorbed spontaneously. In contrast, a pyogenic granuloma is a vasoproliferative inflammatory response composed of granulation tissue.1, 2, 3, 4, 5 Capillaries are a predominant component of wound healing as a complication of ocular surgery or trauma.1, 2, 3 Therefore, pyogenic granulomas are often friable and prone to bleeding. In a previous review of ocular pyogenic granulomas, 87 of 100 cases had predisposing factors, and 13 cases had unknown etiologies.¹ If the specific etiologies are unknown, it is important to carefully observe the morphology of the mass. We would like to emphasize as a point of differentiation from chalazion and hordeolum is whether they are pedunculated or lobulated appearance. In addition, it is also necessary to recognize that pyogenic granulomas are often friable and prone to bleeding over time.

Conservative management with topical corticosteroid is generally successful.1, 2, 3, 4, 5 Surgical excision is effective in patients who do not improve with topical medication; however, it mandates at least local anesthesia or general anesthesia in children and poorly cooperative patients. The present case implies that surgical excision might not be necessary in certain cases.