Akshay Gopinathan Nair, Ronnie Jacob George, Sundaram Natarajan, Vandana Jain
Purpose: To report the clinical outcomes of 0.5% timolol maleate eye drops for the treatment of conjunctival pyogenic granuloma (PG) and its effect on intraocular pressure (IOP). Methods: In this retrospective study, consecutive patients with conjunctival pyogenic granuloma between January 2019 and September 2019 were prescribed 0.5% timolol maleate eye drops twice a day and followed up for 8 weeks. IOPs were measured before treatment, while on treatment and 6 weeks after treatment. Results: A total of 12 patients with conjunctival PGs were treated with 0.5% timolol maleate eye drops. Patients ranged from 7 to 72 years with a mean age of 31.1 years. Eleven (11/12; 91.6%) patients had complete resolution of pyogenic granulomas after a mean duration of treatment of 4.4 weeks (range: 3–6 weeks). One patient had a persistent PG, which showed sub-optimal resolution at 6 weeks of treatment and was surgically excised. The mean IOP of the affected eye at presentation was 15.1 mm Hg (range: 10 to 20 mm Hg; SD: ±2.9 mm Hg). One week after initiating therapy, the mean IOP was 12.1 mm Hg (range: 8–16 mm Hg; SD: ±2.4 mm Hg). The mean reduction IOP compared to the baseline IOP was statistically significant (p = 0.02). No adverse events were noted in any of the patients. Conclusion: Topical timolol is effective in the treatment of conjunctival pyogenic granulomas with no major side effects. There is a significant reduction in IOP while on treatment which is reversible and returns to baseline following completion of therapy.
Dhivya Ashok Kumar, Heba Thajudeen, Amar Agarwal
A 23-year-old primigravida (37 weeks) complained of bleeding from the right eye for 15 days. The patient denied any history of trauma or surgery. On examination, the right upper lid revealed a well-defined, nontender, red, polypoidal smooth-surfaced 5 mm mass in the palpebral conjunctiva with active bleeding [Figure 1]. Visual acuity was 20/20 in both eyes and fundus was normal. After gynecologist consultation and basic systemic workup (bleeding time 3 minutes and clotting time 6 minutes), she underwent excision biopsy [Figure 2]a and [Figure 2]b with cauterization of the base under 0.5 cc local infiltration of 2% lignocaine. The histopathology showed a lesion with lobules of thin-walled vessels with intervening stromal foci of lymphoplasmacytic infiltration [Figure 3].
Pyogenic granuloma, also known as lobular capillary haemangioma, is a benign vascular tumour which is commonly found in children, young adults and pregnant women. In pregnant women they are usually found on mucosal surfaces such as the gums and are thought to be related to the hormonal changes associated with gestation. Here we describe a case of a three‐times recurrent pyogenic granuloma in the unusual location of the eyelid in a 34‐year‐old breast‐feeding patient. The patient required three excisional procedures. It was felt that the likely cause of the growth was due to hormonal changes related to the prolonged period of lactation. To date only three other cases have been reported of pyogenic granuloma in the gestational or post‐partum period in the eyelid with this being the first case in a breast‐feeding patient to the best of our knowledge. This case highlights the difficulty in managing these lesions and contributes further evidence towards the hypothesised relationship between the hormonal changes associated with pregnancy, breast‐feeding and this lesion.
Martina C Herwig-Carl, Hans E Grossniklaus, Philipp L Müller, Lisa Atzrodt, Karin U Loeffler, Claudia Auw-Haedrich
Aims To systematically describe the clinical and histopathological features of a case series of conjunctival carcinomatous lesions underlying as—and also masquerading—pyogenic granuloma.
Methods Nine cases of conjunctival carcinomatous lesions underlying a pyogenic granuloma (which were clinically predominant) were retrospectively identified. Patients’ records were analysed for demographic data, clinical appearance and the postoperative course. Formalin-fixed paraffin-embedded specimens were routinely processed and stained with H&E and periodic acid-Schiff. Immunohistochemical stains for cytokeratin were performed in selected cases.
Results All nine tumours were located in the conjunctiva (bulbar, tarsal, limbal conjunctiva) of patients between 44 and 80 years. The lesions exhibited clinical features of pyogenic granuloma which dominated the clinical appearance. Additional features comprised a papillomatous appearance of the adjacent conjunctiva, a more whitish aspect of the lesion and a history of squamous cell carcinoma (SCC) respectively surgery for other entities. Histopathological analysis revealed a carcinomatous lesion (conjunctival intraepithelial neoplasia or SCC) at the base of a classic pyogenic granuloma in all nine cases. Surgical removal (R0 resection) was performed. Three cases received adjuvant mitomycin C or interferon α2b treatment. Two lesions locally recurred within 2 years after initial presentation.
Conclusion Carcinomatous lesions may be accompanied by a pyogenic granuloma which may dominate the clinical pictures. As the tumour is usually located at the base of the lesion, a complete surgical excision followed by histopathological analysis is mandatory for each lesion appearing as conjunctival pyogenic granuloma.
DeMaria, Lauren N.; Silverman, Nora K.; Shinder, Roman
Purpose: Topical timolol has been increasingly demonstrated to be an effective treatment for pyogenic granulomas (PG). The authors review the treatment outcomes of 17 patients with ocular PG treated with topical timolol.
Methods: Retrospective interventional study of 17 patients with ocular PGs treated with timolol 0.5% solution. Patient demographics, clinical features, treatment response, and recurrence were noted.
Results: Nine females and 8 males with a mean age of 23 years (range, 3–67 years) were included. Mean duration of disease prior to treatment was 3.81 months (range, 0.25–11 months). Etiologies included chalazia (12 cases, 71%), postsurgical (4, 24%) and trauma (1, 6%). Five patients (29%) had treatment with topical steroids prior to presentation. Fifteen patients (88%) had PG located on the palpebral conjunctiva and 2 (12%) involving the bulbar conjunctiva. Mean lesion size was 5.06 × 6.06 mm (range, 3–8 × 3–18 mm). Fifteen patients (88%) had complete lesion resolution with a mean treatment duration of 3.07 weeks (range, 2–5 weeks) and no adverse events or recurrences with a mean follow up of 9.47 months (range, 6–27 months). Two patients (12%) underwent lesion excision after 6 weeks of timolol failed to yield resolution.
Conclusion: Topical timolol appears to be a well-tolerated nonsurgical treatment of ocular PG in both children and adults. Clinicians may wish to consider topical timolol to treat PG as opposed to topical steroids, given the inherent risk of steroid response ocular hypertension and the difficulty to measure intraocular pressure in younger children who require general anesthesia for excision.
Li, Guosheng; Adams, Emily; Eshleman, James R.; Eberhart, Charles G.
Purpose: BRAF V600E mutations were recently identified in some pyogenic granulomas of skin, particularly lesions arising in patients with port wine stains. In this study, the authors analyzed BRAF gene status in 28 periocular pyogenic granulomas to determine its role in their pathogenesis.
Methods: Retrospective review of ophthalmic pathology archives from 2007 to 2016 was used to identify pyogenic granulomas of the conjunctiva, eyelid, and orbit. Three eyelid nevi were also analyzed as positive controls. BRAF V600E status was assessed by pyrosequencing of DNA extracted from excess formalin-fixed, paraffin-embedded surgical material.
Results: Microscopic examination of the periocular pyogenic granuloma specimens revealed proliferative vascular lesions, with radiating capillary channels surrounded by variable degrees of acute and chronic inflammation. Sequencing did not identify a BRAF V600E mutation in any of the 28 sporadic pyogenic granulomas, including 13 on the eyelid. In contrast, mutation analyses performed in parallel in melanocytic nevi of the eyelid identified BRAF V600E alterations in all 3 cases.
Conclusions: The lack of BRAF V600E mutations in 28 sporadic pyogenic granulomas of the conjunctiva and eyelid suggests that such alterations are not a common driver in the pathogenesis of these periocular vascular lesions.
Pavindran Gounder, Minh Lam, Carl Vinciullo & Jean-Louis de Sousa
A 68-year-old gentleman presented with a lesion that resembled a pyogenic granuloma in his inferior fornix. The lesion was excised and biopsy demonstrated a proliferation of malignant spindle cells. Three weeks following initial excision, the lesion recurred and was removed via wedge excision of the eyelid. Definitive clearance was achieved through Mohs micrographic surgery. The patient received adjuvant postoperative radiotherapy and remains disease-free. This case demonstrates the need to consider sinister pathology in the setting of recurrent periocular lesions.
Marback E.F, Espinheira Fonseca Jr. L, Marback R.L
Aim: The aim of this paper was to report a rare presentation of adenoid cystic carcinoma. Method: This is a case report presenting clinical, radiographic, and histopathologic findings. Results: A 72-year-old female with no reported ocular symptoms was found to have an incidental right orbital mass on imaging. Additional studies revealed multiple liver lesions, which were biopsied and found to be consistent with adenoid cystic carcinoma. She was then referred to the ophthalmology service, where ocular examination demonstrated 2.5 mm of right proptosis with elevation and abduction deficits. Diplopia could be elicited in extreme upgaze and right lateral gaze. An excisional biopsy of the orbital mass was performed, with histopathology confirming the diagnosis of primary adenoid cystic carcinoma of the lacrimal gland, thereby also supporting the initial suspicion that the hepatic adenoid cystic carcinoma lesions represented metastases. Conclusion: The authors describe a rare presentation of adenoid cystic carcinoma of the lacrimal gland, initially asymptomatic, with metastatic lesions restricted to the liver at the time of diagnosis. Three previous cases of adenoid cystic carcinoma with isolated metastatic hepatic lesions at the time of diagnosis have been reported; all of these cases localized the primary tumor to the salivary glands.