Pyogenic Granulomas of

the Cornea

James A. Cameron, MD, FRCSC, Muneera A. Mahmood, MD

Background: Pyogenic granulomas are vascular inflammatory lesions that represent

an aberrant wound healing response. They typically arise from mucous membranes or
skin. Pyogenic granulomas primarily involving the cornea have been rarely reported.
Methods: Between January 1983 and July 1994, 14 patients with histologically
proven pyogenic granulomas of the cornea were treated.
Results: The precipitating event was a persistent epithelial defect in nine patients.
Ocular surface disease was present in all patients. Predisposing conditions included
indolent corneal ulceration, dry eye syndrome, trachoma, trichiasis, alkali burn, multiple
topical drug use, previous orbital irradiation, and ocular cicatricial pemphigoid.
Conclusions: Ophthalmologists should be aware that pyogenic granulomas may
involve the cornea and include this entity in the differential diagnosis of tumors involving
the limbus or cornea. The typical clinical appearance, rapid growth, minimal staining
with rose bengal dye, response to topical steroids, and associated ocular surface disease
help to distinguish this lesion from a neoplastic epithelial tumor of the conjunctiva or
cornea. Ophthalmology 1995; 102: 1681-1687

Pyogenic granulomas are inflammatory lesions composed
of granulation tissue. They are an example of an overly
exuberant or aberrant wound-healing response most
commonly seen in the clinical setting of a poorly apposed
wound. Pyogenic granulomas typically are raised, red,
smooth-surfaced lesions with a narrow pedunculated base.
Involvement of the eye or ocular adnexa most commonly
occurs in association with a chalazion, after ocular or ad-
nexal surgery, or after accidental trauma.' The tissue in-
volved is typically eyelid skin or conjunctiva.
Reported cases of pyogenic granulomas involving pri-
marily the cornea are few. '-5 The lesion may be mistaken
for a neoplastic epithelial lesion arising from the con-
junctiva or cornea. Ferry and Zimmerman 6 reported a
patient with a pyogenic granuloma of the limbus which
simulated recurrent squamous cell carcinoma. This pa-
tient had enucleation of the involved eye after a pre-
sumptive diagnosis of recurrent squamous cell carcinoma.
Minckler7 reported another case of pyogenic granuloma
Originally received: August 24. 1994.
Revision accepted: June 13. 1995.
From the King Khaled Eye Specialist Hospital. Riyadh. Saudi Arabia.
Presented at the International Congress of Ophthalmology. Toronto,
Canada. 1994.
Reprint requests to James A. Cameron. MD. c/o Medical Library. King
Khaled Eye Specialist Hospital. PO Box 7191. Riyadh. Saudi Arabia
11462.
involving the cornea, which was misdiagnosed as invasive
squamous cell carcinoma. This eye also was enucleated.
In this report, the clinicopathologic features of 14 pa-
tients with pyogenic granulomas primarily involving the
cornea are reported.
Patients and Methods
The patients were treated at King Khaled Eye Specialist
Hospital between January 1983 and July 1994. Six of the
patients were referred with a presumptive clinical diag-
nosis of squamous cell carcinoma of the conjunctiva or
cornea. The diagnosis of pyogenic granuloma of the cor-
nea was confirmed by histopathologic examination in all
14 patients.
The patients ranged in age from 10 to 72 years (mean,
54 years). There were seven males and seven females.
Clinical data on the 14 patients are presented in Table 1
and Figures 1 to 6.
Selected Case Reports
Case 1. In June 1991. a 43-year-old woman had pain, redness,
and decreased vision in the left eye for 2 weeks. She was taking
0.5% timolol maleate drops twice daily, 0.1 % dipivefrin
hydrochloride drops twice daily, 2% pilocarpine hydrochloride

1681
.......
0\ Table 1. Data from 14 Patients with Pyogenic Granulomas of the Cornea
00
N
Case Age(yrs)/
No. Sex Location/Size (mm) Precipitating Event Other Ocular Abnormalities or Diagnoses Clinical Course and Outcome
44/F OS central cornea/8 X 7 Indolent corneal ulcer Glaucoma treated by Tim 0.5% drops bid, Pro 0.1% Increased corneal scarring, thick symblepharons,
drops bid, Pilo 2% drops qid, and methazolamide 50 dry eye, and visual acuity of light perception
mg po daily; trachoma stage IV; trichiasis at time of
presentation with pyogenic granuloma, fine symbleph-
arons
2 72 / F OD inferior cornea/4 X 4 Unknown Glaucoma treated by Tim 0.5% drops bid and Pilo 2% No recurrence over the next 5 mos
drops qid; symblepharons
3 56/ F OD peripheral cornea spar- Trichiasis with recurrent Glaucoma treated by Tim 0.5% drops bid, Pro 0.1% Lid-corneal adhesions; progressive symblepha-
ing only central 4 X 5mm punctate keratitis drops bid, Pilo 2% drops qid, and acetazolamide se- rons
quels 500 mg daily; symblepharons
4 71 / M OD peripheral cornea/ Unknown Dry eye syndrome with keratinized conjunctiva OU; Lost to follow-up after excision of pyogenic
3 X4 symblepharons OU, ankyloblepharon OD, trachoma granuloma; hand movements vision
stage IV
5 41 / F OD peripheral corneal Indolent corneal ulcer Chronic glaucoma therapy OD for 3 yrs, on Tim, Pilo, Lost to follow-up
3 X 12 (herpetic) Pro, and acetazolamide
6 60/ M OD central cornea/ 4 X 3 Traditional medicine Vascularized corneal scarring OU; symblepharons Graft rejection OD 10 mos after PKP
OS peripheral cornea and
limbus/3 X 3
7 62/F OD peripheral corneal Persistent epithelial defect Glaucoma OU treated by Pilo 4% drops qid and Tim Vascularized corneal scar; visual acuity counting
5X4 0.5% drops bid; pannus 00 increasing since 1988; tra- lingers
choma stage IV
8 50/ M OD superior cornea and lim- R ecurrence after recent Trachoma stage IV; superior corneal scarring and vascu- Recurrence after second excision; no recurrence
bus/3 X 3 removal of pyogenic larization OU; dry eye syndrome with Schirmer's test after third excision; counting fingers vision
granuloma of cornea o mm OD; symblepharon superiorly OD
9 25/ M 00 superior and inferior pe- Alkali burn 2 mos previ- Symblepharons OU; blind OS due to corneal perfora- Patient discharged himself with 70% corneal ep-
ripheral cornea/ 9 X 3su- ously with total cor- tion after alkali burn; total corneal epithelial defect ithelial defect 00; lost to follow-up
periorly, 5 X 2 inferiorly neal epithelial defect 00 with stromal haze and limbal ischemia
10 60/M OD all of cornea except for Unknown Symblepharons OU; previous use of "many eye drops" Progressive conjunctival shrinkage followed by
3 mm central descemeto- for years for ocular irritation; dry eye syndrome OU corneal keratinization despite systemic ste-
cele roids and azathioprine; negative immunoglob-
OS peripheral cornea 360 0 ulin deposition on conjunctival biopsy; light
with 6 mm uninvolved perception vision OU
central cornea
11 68/ F 00 central cornea/ 4 X 4 Epithelial defect Dry eye syndrome OU; vascularized corneal scars OU ; Progressive conjunctival shrinkage, negative im-
symblepharons munoglobulin deposition on basement mem-
brane of conjunctiva; lost to follow-up after 4
mos; hand movements vision
12 65/ F OS central cornea/ 6 X 5 Delayed healing of a cen- Glaucoma OU treated by "many drops" for years, tra- Vascularized corneal scar with increased sym-
tral corneal epithelial choma stage IV, symblepharon OS inferiorly blepharons, visual acuity light perception
defect
13 66/M OD superior cornea/5 X 4 Recurrence after recent Superior symblepharon; dry eye syndrome with filamen- Recurrence X 1with resulting visual acuity 20/
removal of small cor- tary keratitis; contralateral eye blind from sequelae of 80
neal pyogenic granu- smallpox in childhood
lorna
14 IO/ M OS central cornea/5 X 5 Persistent epithelial defect Epithelial defect 2 mos after 4600 rads to orbit and che- Epithelial healing after excision, cautery, tarsor-
for 7 mos motherapy for embryonal rhabdomyosarcoma involv- rhaphy, and antibiotic-steroid ointment; vi-
ing left orbit sual acuity light perception

00 = right eye; OS = left eye; OU = both eyes; PKP = penetrating keratoplasty; Pilo = pilocarpine hydrochloride; Pro = dipivefrin hydrochloride; Tim = timolol maleate; po = per OS; bid = twice a
day; qid = four times a day.
 Cameron and Mahmood . Pyogenic Granulomas of the Cornea

Top, Figure I. Case I. Left, indolent corneal ulcer with persistent epithelial defect and corneal vascularization. Right, 3 months later with elevated
lesion involving most of the cornea with extension onto the conjunctiva.

Second row left, Figure 2. Case 2. Right cornea with red, smooth-surfaced pyogenic granuloma.

Second row right, Figure 3. Case 3. Central epithelial defect followed by elevated granulation tissue and lid-corneal adhesion with progressive
symblepharons in the right eye only. Presumed diagnosis was drug-induced ocular pseudo pemphigoid related to glaucoma medication used only in
this eye.

Bottom left, Figure 4. C ase 4. Right eye of a patient with ankyloblepharon, symblepharon, keratinized conjunctiva temporally, and pyogenic granuloma
of peripheral cornea. Dry eye syndrome present and scarring from previous trachoma.

Bottom right, Figure 5. Case 5. Arcuate pyogenic granuloma in eye with previous Microtrak-positive herpetic indolent ulcer and receiving chronic
glaucoma therapy for 3 years. A lash is present at the base of the lesion.

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 Ophthalmology Volume 102, Number 11, November 1995

Figure 6. Case 6. Right (top left) and left (top right) eyes of patient using traditional medicine for years. Bottom left, right eye-corneal button
shows large vessels most apparent at the base of the lesion above a coiled Bowman layer (asterisk). Inflammatory cells are scattered throughout lesion.
No epithelial coverage is present over central portion of the pyogenic granuloma (hematoxylin-eosin; original magnification, XIOO). Bottom right,
superficially, prominent capillary-like channels and predominantly mononuclear cell inflammatory response (hematoxylin-eosin; original magnification,
X 4(0).

drops four times daily, and methazolamide tablets (50 mg) twice
daily for the last 2 years. Visual acuity had ranged from 20/80
to 20/100 in the left eye while being followed in the glaucoma
clinic. The patient had lost vision suddenly in her right eye 25
years previously after an unknown eye disease. On examination,
visual acuity was no light perception in the right eye and counting
fingers at 3 feet in the left. The right globe was phthisic.
Intraocular pressure in the left eye was 18 mmHg measured by
pneumotonometry. A corneal ulcer with a white infiltrate was
present in the left eye. Alpha-hemolytic Streptococcus was present
on culture of the ulcer. The patient was treated with vancomycin
hydrochloride drops (50 mg/ml hourly). The infiltrate resolved
with healing of the ulcer and epithelium after 3 weeks.
During the next year, the patient was admitted on three
occasions for treatment of a recurrent epithelial defect in the
same area as the previous corneal ulcer. Repeated cultures were
negative for microorganisms. Treatment with a bandage contact
lens and lubricants was helpful; however, the defect would return
after removal of the lens.
On June 7, 1992, the patient presented again with a superficial
corneal ulcer (Fig I, top left). There was both superficial and
deep vascularization in the inferonasal sector of the cornea.
Corneal scrapings and cultures were negative for micro-
organisms. The defect persisted despite treatment with lubricants
and topical antibiotic drops four times daily. Intraocular pressure
was controlled with 0.5% betaxolol hydrochloride drops twice
daily and acetazolamide sequels (500 mg daily).
On September 2. 1992. the patient had an elevated
vascularized lesion on the cornea covering the area of the
previous ulcer. Trichiasis was present superiorly as well as fine
symblepharons inferiorly. The trichiasis was treated by
cryotherapy. Results of follow-up examination on September
16, 1992, showed an increase in the size of the corneal lesion
with further extension onto the conjunctiva (Fig I, top right).
There was some pooling of rose bengal dye in depressions within
the lesion but no stippling or staining of the lesion itself.
Prednisolone acetate drops were started every 2 hours and
dexamethasone ointment at night. After I week, the lesion had
decreased markedly in size. The remaining central elevated lesion
was excised. Results of histopathologic examination showed
fibrovascular tissue infiltrated by mostly lymphocytes and plasma
cells. The epithelium healed over the next 4 weeks with
gentamicin sulfate drops twice daily and sodium sulfacetamide
ointment at night. On January 24, 1993, visual acuity was light
perception. The cornea was scarred and vascularized. Thick
symblepharons were present superiorly and inferiorly.
Case 2. A 64-year-old woman was examined in March 1984.
She had a history of using mUltiple drops for glaucoma. Visual
acuity was counting fingers in the right eye and no light
perception in the left. The right eye was aphakic. The cornea

1684
 Cameron and Mahmood . Pyogenic Granulomas of the Cornea
was moderately scarred and vascularized and the optic nerve
appeared pale. The intraocular pressure was 32 mmHg, and the
visual field was constricted. The left eye was blind secondary to
glaucoma. She was treated with 0.5% timolol maleate drops twice
daily and 2% pilocarpine hydrochloride drops four times daily
to the right eye. She was followed by her local ophthalmologist
after October 1988.
She presented to the emergency room October 1992 with
increasing pain in the right eye for the last 3 months. She had
not used her glaucoma medication for the last 2 days. Visual
acuity was poor light perception in the right eye. The intraocular
pressure was 25 mmHg in the right eye. An elevated, smooth
vascular lesion was present on the lower half of the cornea (Fig
2). The lesion did not stain with rose bengal dye. Symblepharons
were present inferiorly in the right eye only. The lesion was
excised on November 3, 1992. Results of histopathologic
examination showed granulation tissue heavily infiltrated by
lymphocytes and plasma cells. The surface of the lesion was
covered by fibrinous material. Postoperatively, the epithelial
defect healed slowly over a 4-week interval. Results of the last
examination in February 1993 showed no recurrence of the
lesion.
Case 3. A 54-year-old woman was referred for cataract surgery
in March 1990. She had a history of gradual progressive decrease
in visual acuity in both eyes for 2 years. Visual acuity was 20/
200 in the right eye and counting fingers in the left. Intraocular
pressure was 24 mmHg in the right eye and 34 mmHg in the
left. Gonioscopy showed closed angles in both eyes. Immature
cataracts were present in both eyes. Arcuate scotomas were
present on visual field examination. Laser iridotomies were
performed in both eyes. Intraocular pressure was eventually
controlled with 0.1 % dipivefrin hydrochloride drops twice daily
to both eyes, 0.5% timolol maleate drops twice daily to both
eyes, 4% pilocarpine hydrochloride drops four times daily to
both eyes and acetazolamide sequels (500 mg orally daily). In
July 1990, the patient had an extracapsular cataract extraction
with posterior chamber lens implant and trabeculectomy
performed on the left eye. Subsequently, visual acuity improved
to 20/40 in the left eye, and intraocular pressure was 10 mmHg
without medication.
Between September 1990 and July 1992, the patient was seen
on a number of occasions with a punctate keratitis and trichiasis
of the right eye. This was treated with lubrication by drops of
balanced salt solution and hyfrecation of the lashes. On October
4, 1992, the patient had had pain in the right eye for 3 months.
Visual acuity was reduced to counting fingers in the right eye.
Symblepharons were present superiorly and inferiorly in the right
eye. There was a central 4 X 5-mm epithelial defect surrounded
by a raised vascularized lesion extending to the limbus. The
raised lesion did not stain with rose bengal dye. The impression
was drug-induced ocular pseudopemphigoid. Dipivefrin
hydrochloride and timolol maleate drops were discontinued and
balanced salt solution:Healon 10: I drops were given hourly.
Excision of the raised granulation tissue on the cornea was
performed to encourage healing of the cornea. Results of
histopathologic examination showed granulation tissue heavily
infiltrated by plasma cells and lymphocytes. Immunofluorescent
tests were not available to confirm a diagnosis of cicatricial
pemphigoid. The patient continued to have an epithelial healing
problem of the right cornea, and she had a recurrence of elevated
granulation tissue on the right cornea. She was maintained with
acetazolamide sequels for control of intraocular pressure and
non preserved artificial tears. Prednisolone acetate drops with no
preservatives were used four times daily to decrease the raised
granulation tissue. Results of examination in April 1993 showed
a lid-corneal adhesion with raised granulation tissue surrounding
a central corneal defect (Fig 3). A conjunctivallimbal transplant
from the left to right eye with release of adhesions and a
symblepharon ring was discussed with the patient; however,
further treatment was refused.
Case 6. A 60-year-old man initially was examined in 1989
due to pain and foreign body sensation in both eyes for 6 months.
He had noticed a progressive, gradual decrease in vision in both
eyes for 3 years. The patient had instilled a traditional medicine
mixed with goat urine in both eyes for years for "eyc irritation."
Visual acuity was hand motions in the right eye and counting
fingers in the left. Symblepharons were present superiorly and
inferiorly in both eyes. The cornea of both eyes was scarred and
vascularized. An elevated vascular lesion was present centrally
on the right cornea (Fig 6, top left) and a pedunculated vascular
lesion was situated peripherally on the left cornea (Fig 6, top
right). A biopsy of the right corneal lesion was done, and the
left corneal lesion was excised. A conjunctival biopsy from the
left eye was negative for immunologlobulin deposition along the
basement membrane. The histopathologic diagnosis of both
corneal lesions was pyogenic granuloma.
After 3 months when the right eye was less inflamed, a
penetrating keratoplasty and cataract extraction were performed
in the right eye. The corneal button showed an elevated,
vascularized lesion with inflammatory cell infiltration within
edematous connective tissue (Fig 6, bottom left). The surface
was covered incompletely by epithelium. Large blood vessels
were most apparent at the base of the lesion above Bowman
layer, and capillary-like channels were more common
superficially. Lymphocytes and plasma cells were the most
common inflammatory cells present (Fig 6, bottom right).
Postoperatively, the patient maintained a clear graft for 10
months. He subsequently had graft rejection after running out
of topical steroid drops 2 weeks previously.
Results
Clinical Findings
Nine of the 14 patients had epithelial defects before de-
velopment of the pyogenic granuloma. The other patients
initially had the elevated lesion without information de-
scribing the ocular findings immediately before devel-
opment of the pyogenic granuloma. All involved eyes had
abnormal corneal vascularization in the involved area of
the cornea. Associated ocular disorders involving the af-
fected eye were glaucoma treated by multiple drug use in
6 patients, dry eye syndrome in 5, trachomatous scarring
in 4, conjunctival scarring in 12, trichiasis in 2, alkali
burn sequelae in 1, and radiation keratopathy in 1.
Histopathologic Findings
The histopathologic findings of the 18 specimens from
the 14 patients were similar and included the following:
1. The surface of the lesion was covered incompletely
by epithelium. That part of the lesion not covered
by epithelium had a covering layer of fibrinous ma-
terial with occasional inflammatory cells or eryth-
rocytes.
2. Diffuse infiltration by lymphocytes and plasma cells
was present. The numbers of neutrophils varied
among the different specimens but were much less
1685
 Ophthalmology Volume 102, Number 11, November 1995
frequent than the number of lymphocytes and
plasma cells.
3. Numerous blood vessels with abundant small cap-
illaries. Larger blood vessels were most apparent at
the base of the lesion.
4. Fibroblasts and edematous connective tissue.
Treatment and Outcome
All 14 pa~ients had excisional biopsy of the lesions. Topical
steroids were used in some patients to decrease the size
of the lesion and decrease vascularization before surgical
excision. Therapy after excision was directed at treatment
of the underlying ocular surface disorders or removal of
the ocular irritant as well as encouraging re-epitheliali-
zation by medical (e.g., preservative-free lubricants; topical
steroids; therapeutic soft contact lens; changing, decreas-
ing, or stopping glaucoma medication) or surgical methods
(e.g., punctal occlusion, hyfrecation for trichiasis, tarsor-
rhaphy).
Three patients had recurrent pyogenic granulomas, and
re-epithelialization subsequently occurred in two of these
patients after repeated excisions.
Visual outcome was poor, with a resulting visual acuity
ofiess than 20/80 in 13 of 14 eyes. Poor visual acuity was
attributed to corneal scarring associated with the ocular
surface disorders, increased corneal scarring resulting from
the inflammation associated with the pyogenic granuloma,
and/or pre-existing glaucomatous optic nerve damage.
Discussion
Poncet and Dor8 in 1897 were the first to describe a pyo-
genic granuloma in humans and referred to its as human
botryomycosis. It was thought at this time the lesion was
due to a fungal infection, whereas others later thought it
was due to pyogenic bacterial infection, usually Staphy-
lococcus aureus. In 1925, Michelson 9 suggested that the
term pyogenic granuloma "should include all sharply cir-
cumscribed granulation tissue growths occurring on cu-
taneous or mucous membrane surfaces and having the
appearance of a tumor." Although misnamed, the term
pyogenic granuloma has persisted in the medical literature.
Although there may be occasional polymorphonuclear
leukocytes on the surface, the lesion is not typically pyo-
genic, unless there is secondary infection. The lesion is
not a granuloma because granulomatous inflammation
with epithelioid cells and giant cells are not histologic fea-
tures of a pyogenic granuloma.
Most articles describing pyogenic granulomas involving
the eye or ocular adnexa have been isolated case reports.
In contrast, Ferry' in 1989 reported on 100 consecutive
cases involving the eye or ocular adnexa on file from two
ophthalmic pathology laboratories. In that series, 42 cases
were associated with chalazion, 40 with ocular or adnexal
surgery, 5 with accidental trauma, and 13 were undeter-
mined. Only one patient with a pyogenic granuloma in-
volving the cornea was noted. Googe et al 2'described three
patients with pyogenic granuloma primarily involving the
1686
cornea. All three patients had antecedent corneal trauma
and inflammation.
Clinical characteristics of the pyogenic granulomas in
this series varied among patients. Some of the lesions had
a smooth surface (case 2, Fig 2), whereas others had a
rough, irregular surface (case 1, Fig 1, top right). The shape
of the lesion varied from a mushroom-like contour with
a more narrow base to a broad-based attachment with
the base as broad as the body of the pyogenic granuloma.
Round, oval, and crescentic lesions were present in this
series. All the lesions were red, reflecting the marked vas-
cularization. Some of the patients had a history of rapid
increase in size of the lesion over days to weeks. Subjective
discomfort was surprisingly minimal, despite the large size
of the lesions, possibly relating to the coincident ocular
surface disease.
Results of histopathologic examination of the pyogenic
granulomas were similar. All lesions were covered incom-
pletely by epithelium. Characteristic features were nu-
merous blood vessels and newly formed capillaries, an
inflammatory infiltrate composed mainly ofiymphocytes
and plasma cells with variable amounts of neutrophils,
and fibroblasts interspersed in edematous connective tis-
sue. There were some variations in the amount of new
vessel growth, inflammatory reaction, and fibrosis in dif-
ferent histopathologic specimens and even in different
areas of the same lesion (Fig 6, bottom left).
Common clinical findings of patients in this series that
were probably important in the formation of the pyogenic
granuloma of the cornea were an epithelial defect in com-
bination with corneal neovascularization and an ocular
surface disease or chronic irritant. All patients, who were
examined just before development of the pyogenic gran-
uloma of the cornea, had epithelial defects. Corneal neo-
vascularization was present in all the patients. Abnormal
corneal blood vessels are the source for the newly formed
proliferating capillaries. Altered vascular permeability of
these new vessels results in edematous connective tissue
and inflammatory cells. In our adult population, trachoma
sequelae with pannus is very common and may provide
the vascular supply for a pyogenic granuloma in the ap-
propriate clinical setting. An ocular surface disorder or
chronic irritant was present in each patient in this series.
Many patients had multiple disorders that may have been
responsible for the epithelial defect and delayed healing.
Case 1 had an indolent corneal ulcer, trachomatous scar-
ring, long-term use of multiple glaucoma medications,
and trichiasis. It is noteworthy that 6 of the 14 patients
in this series were receiving multiple glaucoma medica-
tions. Glaucoma medications (the drug and/or the pre-
servative) have been implicated in a spectrum of ocular
surface disorders ranging from punctate lO to ulcerative"
keratopathy and drug-induced pseudopemphigoid.'2
Conjunctival scarring and symplepharon formation were
present in many of the patients in this series. Immuno-
fluorescent studies on a conjunctival biopsy should be
done to support a diagnosis of cicatricial pemphigoid in
patients with progressive conjunctival scarring of un-
known etiology.
An exuberant granulation tissue lesion results from the
delayed healing of the epithelial defect in the presence of
 Cameron and Mahmood . Pyogenic Granulomas of the Cornea
corneal vascularization and an ocular surface disease or
chronic irritant. Prevention and treatment of this lesion
should be directed at all contributing and interrelated fac-
tors. First, the underlying ocular surface disease should
be treated and/or the ocular irritant removed. Chronic
epithelial defects should be managed actively by medical
and/or surgical methods. 13 Topical steroids may cause
some shrinkage of corneal blood vessels as well as decrease
the exudative response of the inflammatory reaction. In
the future, research may show that laser photocoagulation
of corneal blood vessels or topical anti-angiogenesis agents
may be helpful in preventing or treating this condition.
Small pyogenic granulomas of the cornea should be fol-
lowed closely and excised if there is no response to therapy.
As illustrated in case I, there is a possibility of rapid growth
of the lesion and extension to the conjunctiva with blind-
ing sequelae.
Although only a handful of patients with pyogenic
granuloma of the cornea have been reported, the lesion
is probably more common than suggested by a review of
the literature. Pyogenic granuloma should be considered
in the differential diagnosis of red limbal or corneal tu-
mors. The lesion has been mistaken for a squamous cell
carcinoma of the conjunctiva, resulting in inappropriate
enucleation. 6 .7 Six of the patients in this series were re-
ferred with the presumptive clinical diagnosis of squamous
cell carcinoma.
The lesion usually can be distinguished readily from
squamous cell carcinoma of the conjunctiva or cornea by
the history and clinical findings. Pyogenic granulomas
typically are preceded by a persistent epithelial defect.
There may be a history of rapid growth of the lesion and,
as demonstrated in case I, a marked change in the clinical
findings between examinations. Results of slit-lamp ex-
amination show a deep, red lesion, indicative of the
marked vascularity of the pyogenic granuloma. The sur-
face of the lesion is more typically smooth with no rose
bengal dye staining. In patients with recent rapid growth,
the surface may be irregular with pooling of rose bengal
dye within the troughs ofthe lesion. The associated ocular
surface disease in these patients also provides a clue as to
the reactive nature of this lesion. Topical steroid drops
may cause a marked reduction in the size of a pyogenic
granuloma and a complete regression of smaller lesions.
By contrast, squamous cell carcinoma of the conjunc-
tiva or cornea is a slower growing lesion. Almost all lesions
of patients with squamous cell carcinoma of the con-
junctiva are located in the interpalpebral fissure and have
contact at the limbus. Although the clinical appearance
may vary from gelatinous to papillary to leukoplakia
forms,14 the color of the tumor typically is not as red as
that observed with pyogenic granulomas. Neoplastic ep-
ithelial tumors at the limbus also may show typical ex-
tensions onto the corneal epithelium in the form of fim-
briated gray plaques. The two reported cases of isolated
squamous cell carcinoma of the cornea without limbal
involvement both demonstrated leukoplakia caused by
keratinization. IS Squamous cell neoplasia of the con-
junctiva or cornea typically shows diffuse stippling with
rose bengal dye. 15 ,16 Papanicolaou stain of scrapings also
may demonstrate neoplastic cells. 17 Finally, biopsy readily
will distinguish squamous cell carcinoma of the conjunc-
tiva or cornea from a pyogenic granuloma.
Although pyogenic granulomas are considered "be-
nign" lesions, the effect on the eye may be devastating.
Many of the eyes in this series had markedly increased
symblepharon formation and corneal scarring associated
with the onset of the pyogenic granuloma. The end-result
may be a dry eye with shortened fornices and corneal
scarring amenable only to visual rehabilitation with a ker-
atoprosthesis. Aggressive medical and/or surgical therapy
of persistent epithelial defects and nonhealing stromal ul-
cers may prevent formation of a pyogenic granuloma and
its blinding sequelae.
References
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2. Googe JM, Mackman G, Peterson MR, et al. Pyogenic
granulomas of the cornea. Surv Ophthalmol 1984; 29: 188-
92.
3. De Potter P, Tardio DJ, Shields CL, Shields JA. Pyogenic
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4. Bargeton J. Un cas de botryomycose de la cornee (These).
Lyon: A. Rey & Cie, 1905.
5. Proia AD, Small KW. Pyogenic granuloma of the cornea
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6. Ferry AP, Zimmerman LE. Granuloma pyogenicum of
limbus simulating recurrent SQuamous cell carcinoma. Arch
Ophthalmol 1965; 74:229-30.
7. Minckler D. Pyogenic granuloma of the cornea simulating
squamous cell carcinoma. Arch Ophthalmol 1979; 97:516-
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8, Poncet A, Dor L. De la botryomycose humaine. Rev Chir
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