Q. I have a 38-year-old male patient with a history of chalazion removed from his lower left lid about a year ago. He didnt have any problems until a few weeks ago, when he felt a bump on the lid and noticed the lesion seen in the accompanying photo. Whats the diagnosis?
A. Retained conjunctival foreign body, chalazion, conjunctival hemangioma, conjunctival papilloma and pyogenic granuloma are the possible causes for this patients condition. The likely diagnosis, based on this patients history, is pyogenic granuloma, says Edward Waslowski, O.D., of Omni Eye Specialists in Baltimore. Histology will help you determine the final diagnosis.
Pyogenic granulomas are common after oculoplastic procedures, especially following a chalazion or previous adnexal surgery.1,2 The site of the surgery, however, does not seem to affect the site of the inflammation.2 Though the pathogenesis is not entirely clear, this type of granuloma is caused by a vasoproliferative response and composed of granulation tissue. Any granuloma represents an aberrant wound healing response, and typically arises from mucous membranes or skin.3
A pyogenic granuloma typically presents with rapid growth, often accompanied by inflammatory cells. It shows minimal staining with rose Bengal dye and often responds to topical steroids.3 These symptoms, along with associated ocular surface disease, help to differentiate these lesions from a neoplastic epithelial tumor of the conjunctiva or cornea.3
Left: An external view of the bump under this patients eyelid. Right: The lesion that was revealed upon pulling the lid down.
A recent study at the University of Ottawa Eye Institute in Ottawa, Ontario, evaluated 16 cases of pyogenic granuloma that occurred after various oculoplastic procedures. The researchers discovered that capillaries are a predominant component of wound healing and pyogenic granulomas. The growth and development of new capillaries follows an orderly sequence of events that is highly regulated by a variety of angiogenic factors. They hypothesize that an imbalance in angiogenesis regulation is the common pathway for the development of a pyogenic granuloma.2
Q. Whats the best treatment plan for this patient? Should I refer him for surgery?
A. I would recommend excision for this patient, says Dr. Waslowski. A coservative first step, however, would be topical steroids qid or a steroid injection. This may minimize or totally eliminate the lesion in a small percentage of cases. If this does not help, the patient should be referred for an excisional biopsy.
Pyogenic granulomas in the past have been treated with cryosurgery, curettage, electrodesiccation, chemical cauterization and laser surgery. However, the therapeutic effects of all these options are limited.
Japanese researchers have found that a local injection of the sclerosing agent monoethanolamine oleate effectively treats pyogenic granuloma when a conservative approach is in order.4
1. Jordan DR, Brownstein S, Lee-Wing M, Ashenhurst M. Pyogenic granuloma following oculoplastic procedures: an imbalance in angiogenesis regulation? Can J Ophthalmol 2001 Aug;36(5):260-8.
2. Papadopoulos M, Snibson GR, McKelvie PA. Pyogenic granuloma of the cornea. Aust N Z J Ophthalmol 1998 May;26(2):185-8.
3. Cameron JA, Mahmood MA. Pygenic granulomas of the cornea. Ophthalmology 1995 Nov;102(11):1681-7.
4. Matsumoto K, Nakanishi H, Seike T, et al. Treatment of pyogenic granuloma with a sclerosing agent. Dermatol Surg 2001 June;27(6):521-3.
