A rare case of conjunctival granuloma in Aurolab aqueous... : Indian Journal of Ophthalmology - Case Reports (2024)

Conjunctival granuloma (CG) can be caused by a foreign body, surgery-related inflammation, infectious organisms, etc. It is etiologically classified into infectious, immunological aberrations, hypersensitivity (HS), etc.^[1] However, the most reported cases are of pyogenic granuloma. The term “pyogenic granuloma” is misleading; it is not pyogenic but an exuberant granulation tissue.^[2]

Supramid is a non-absorbable suture used as an intraluminal stent in a non-valve implant such as AADI to prevent an early postoperative hypotony. Either a 3-0 silk suture or a 5-0 synthetic monofilament polypropylene suture can be used. We are reporting the first case of CG related to a 5-0 prolene suture as supramid with AADI.

Case Report

A 70-year-old female, a diagnosed case of primary open-angle glaucoma, with no systemic comorbidities and allergy presented in the outpatient department. Her best-corrected visual acuity was 6/9 in both eyes (BE). Anterior-segment findings were unremarkable. Intraocular pressure (IOP) was 26 mmHg in the right eye (RE) and 15 mmHg in the left eye (LE), with maximal medical therapy (MMT) in BE. Cup: disc ratio of 0.9 with bipolar rim thinning in RE and 0.85 superior rim thinning in LE were observed. Field defect in RE showed inferior arcuate, and LE showed paracentral scotoma. Gonioscopy showed 180° peripheral anterior synechiae in RE and one quadrant in LE. Central corneal thickness was 491 microns in RE and 492 microns in LE. The advanced disc damage on MMT and inability to achieve the target IOP prompted for AADI with supramid in RE. The surgery was uneventful. On postoperative day 1, the AADI end-plate was placed well in the supratemporal quadrant with a well-apposed conjunctiva and supramid suture buried subconjunctivally, with its end placed at 7.30 clock hours and the tube in the anterior chamber, neither touching the corneal endothelium nor the iris. The patient was discharged with a tapering dose of steroids, cycloplegics, antibiotics, and two antiglaucoma eye drops. At the 2-week post-op follow-up, RE had an IOP of 19 mmHg with two anti-glaucoma medications and vision of 6/9. At the 6^th-week follow-up, IOP dropped to 8 mmHg with maintained anterior chamber depth and visual acuity of 6/9 following the tube opening. She was apparently asymptomatic till the 4^th-month post-op follow-up, when she had mild irritation and redness in her RE. On slit-lamp examination, a localized conjunctival congestion and a small inflamed, sessile, corrugated mass buried at around 7 to 8 clock hours were noted at the end of the supramid tip [Fig. 1a and b] were noted.

There were no suppurations or discharges, but it appeared to be reactionary in nature. It was diagnosed as a case of CG secondary to the supramid suture. A topical steroid and antibiotic combination eye drops were started four times a day and tapered every 7 days. Congestion was persistent even after 2 weeks of medications [Fig. 2]. Suture removal was done under local anesthesia in the operation theater under full aseptic conditions. A small nick was given in the conjunctiva around 7.30 clock hour to expose the supramid, and it was gently pulled out. The conjunctiva was closed with a 10-0 vicryl suture. On the 2-week follow-up, the granuloma had resolved completely with minimal tissue scarring [Fig. 3].

Discussion

AADI is a non-valved implant that needs the adjunct of ab-interno or ab-externo techniques to impede the immediate postoperative flow of aqueous humor and prevent hypotony. In advanced glaucoma, one-eyed or a high-risk case, we need to titrate the flow of aqueous and prevent the untoward catastrophes of post-op hypotony,^[3] sudden collapse of the anterior chamber, and choroidal detachments. Supramid sutures are used to occlude the AADI tube lumen to prevent sudden hypotony following suture lysis at 6 weeks postoperatively.^[4] We used 5-0 prolene as supramid (monofilament) because braided sutures may promote bacterial adherence and colonization of other sterile areas by capillary action, thereby enhancing the infection process.^[5] CG is believed to be represented by an abnormal wound-healing reaction and has a multifactorial cause.^[6] Many non-synthetic and synthetic exogenous materials may play a vital role in causing foreign-body CG.^[7] To date, several studies have indicated synthetic fiber as a possible cause of CG in children. It is sometimes called “teddy bear.”^[8] Suture material placed in human tissue represents a foreign body, provoking an immunologic response. The tissue response depends on the suture material, the type of tissue receiving sutures, and the immune system. The most frequently implicated agents are macrophages, which are responsible for the cell-mediated response (type-IV delayed HS reaction). CG in our case is due to the supramid suture, which is a non-absorbable monofilament polypropylene suture.^[9] Our patient presented in the fourth month postoperatively, indicating a delayed type of HS reaction. HS due to suture is also a result of an exaggerated immunologic response^[10] or blind inflammatory response, which might be a possibility in our patient as she had no signs of a compromised immune system. An infectious etiology can be ruled out as it was not associated with discharge or suppuration. Histopathological examination was not done as the condition subsided with medical treatment and removal of the suture material without any grave impact on conjunctival health.

Conclusions

Supramid-related CG is a rare occurrence and is commonly related to HS reactions that resolve with medications and the removal of inciting factors.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship: Nil.

Conflicts of interest: There are no conflicts of interest.

References