A rare case of symptomatic ocular pyogenic granuloma in pregnancy

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 [Fig. 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 [Fig. 2a and 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 [Fig. 3].Figure 1: Actively bleeding upper palpebral conjunctival mass lesion on the day of presentationFigure 2: Inactive mass on the day of surgery (a) and after excision with base cautery (b)Figure 3: Histopathology micrograph with 10X magnification stained with Haematoxylin and eosin of lobulated capillary hemangioma. The histopathology showed fibro-collagenous tissue covered by mucosa, epithelium showed acanthosis and areas of ulceration and dermis showed a lesion with lobules of thin walled vessels with intervening stromal foci of lymphoplasmacytic infiltrationDiscussion Angelopoulos AP described the lesion as “Hemangiomatous Granuloma” due to the presence of numerous blood vessels and inflammatory pictures histologically.[1] In a case series of 7 pregnant women who developed hemangiomas during pregnancy, it was proposed that hormonal alterations, changes in blood volume contributed to their occurrence.[2] Yuan et al. described the relationship between pyogenic granulomas and angiogenic factors in pregnancy.[3] According to the authors, female hormones not only enhance the expression of angiogenic factors such as basic fibroblast growth factor (FGF) and vascular endothelial growth factor (VEGF) but also decrease cell apoptosis by lessening the expression of tissue necrosis factor-alpha (TNF-alpha).[4] A pregnancy tumor has a prevalence of 0.2–9.6% during gravidity.[5] They commonly appear after the first trimester, grow rapidly, and typically regress after delivery. Complete excision with Histopathological examination (HPE) is the treatment of choice in persistent lesions with bleeding, painful or excessively large. The overall risk of recurrence is about 7% more following prior surgery and warrants close monitoring. The case thus highlights the management of a distressing lid hemangioma in a third-trimester primigravida. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.