Introduction

Synthetic fibre granuloma of the conjunctiva, sometimesknown as „teddy bear granuloma” is a rare granulomatousforeign body reaction of the conjunctiva tosynthetic fibres (1). The name „teddy bear” refers tothe origin of the synthetic fibres – there are some reportedcases in the literature which were caused bymaterials used in stuffed toy animals (2). The lesionwas first described by Weinberg and associates, in1984 (3). It is often an incidental finding, most commonlyfound in children, and usually presents as a unilateralconjunctival mass of the inferior eyelid fornix.1There is only one reported case in the literature whereit is presented superiorly (2), 3).

Eighteen cases of conjunctival „teddy bear” granulomahave been reported in the literature (1). To thebest of our knowledge, we present here the first reportedcase of this condition in Hungary. In our case,the granuloma occurred in the superior eyelid fornix,which is rarity among the cases reported earlier.

Case report

The 9-year-old girl was admitted to the Department ofOphthalmology of Semmelweis University, Budapestbecause of irritation, discomfort and foreign bodysensation in her right superior eyelid for three days.She was otherwise in a good general health and shehad no history of ocular trauma, infection, surgery orplacement of a foreign body in the eye. There was nochange in visual acuity. Split-lamp examinationshowed a mulberry-like, bulging conjunctival mass ofa 5 mm diameter in the superior tarsal conjunctiva. Itwas embedded with a bunch of white, hair-like material(Figs 1-2). The lesion and the material could notbe removed during the split-lamp examination. The rest of her ophthalmological examination was otherwisenormal.

The lesion was excised under general anaesthesiaand sent for histopathological analysis. Microscopicexamination of the conjunctiva revealed a stromalgranulation tissue showing heavy chronic inflammation,mild activity (the subepithelial stroma containedinflammatory cells, mostly epithelioid macrophages,eosino phils, histiocytes), and aggregates of syntheticfibres, surrounded by foreign body giant cells (Fig 3).The refractile and colourless synthetic fibres within thelesion were identified by their strong birefringence inpolarized light (Fig 4). The picture was compatible witha diagnosis of synthetic fibre granuloma of the conjunctiva.

Postoperatively, the eye was treated with levofloxacinfive times daily for five days. For the first postoperativelyday the complaints of the patient were disappeared,there was no recurrence of the lesion at oneyear after excision.

Discussion

A close exposure of the eyes of synthetic materialused in stuffed toy animals, blankets, beddings andpullover sweaters may cause penetration of the conjunctivaby synthetic fibres. Usually, foreign bodies,that comes into contact with the ocular surface areremoved by the eye protective mechanisms as blinkingand tearing (2, 4, 5). Occasionally, foreign bodiesmay be retained in the eyelid fornix, encapsulated bythe mucous, embedded in the underlying stroma andmay induce a local inflammatory response (6, 7, 8).This may cause synthetic fibre granuloma formation inthe conjunctiva, which condition is commonly knownas „teddy bear” granuloma because of the origin ofthe synthetic fibres (1, 2).

Foreign body granulomas of the conjunctiva causedby synthetic fibres were first described by Weinbergand associates, in 1984.3 Since then eighteen caseshave been reported in the literature (1). The ages ofthe reported patients ranged from 26 months to 17years (2, 3). The granulomas usually were presented asa unilateral conjunctival mass of the inferior eyelidfornix (1, 2). To the best of our knowledge, we presenthere the first reported case of this condition in Hungaryand up to our case there is only one reported case inthe literature where it is presented superiorly (3).

The clinical appearance of the synthetic fibre granulomaof the conjunctiva is rather nonspecific. Somepatients were asymptomatic, without a history of trauma. In these cases, the patients were referred toan eye department after the granuloma was visible.

The other part of the affected children may presentwith symptoms of ocular irritation and foreign body ordiscomfort sensation (1, 2, 6, 9). Slit-lamp examinationcommonly shows a nonspecific conjunctival mass invery different colours (depending on the colour of thesynthetic material, white-yellow, blue, black, green oreven pink colour of the mass were described in the literature),associated with follicular conjunctivitis, papillaryconjunctivitis or chemosis of the conjunctiva (2, 4).

Differential diagnosis of synthetic fibre granuloma ofthe conjunctiva include chalazion, papillary hyperplasiarelated to vernal conjunctivitis, pyogenic granuloma,ophthalmia nodosa, atypical dermoid or dermolipoma,sarcoidosis and neoplasms (such as rhabdomyosarcomaand vascular tumors) (2, 4, 9) In contrastto the clinical signs, the histopathological and ultrastructuralfeatures of conjunctival granulomas arevery characteristic and usually diagnostic (2, 6). Microscopicexamination reveals granulomatous inflammatorytissue with epithelioid macrophages, lymphocytes,plasma cells, eosinophils and usually foreignbodycells surrounding the synthetic fibres (2, 10, 11).

The simplest method to confirm the diagnosis is excisionof the conjunctival granuloma and like to ourcase microscopic examination in polarized lightdemonstrating marked birefringence of the syntheticfibres (6, 12).

Surgical removal of the conjunctival granuloma andpostoperative treatment with antibiotics is recommended.In very young and anxious patients generalanaesthesia is often needed during the excision. Inthe older children with good cooperation it has beensuggested to remove the lesion during slit-lamp examinationunder topical anaesthesia with minimalbleeding and discomfort (2, 9, 10).

Although the entity of synthetic fibre granuloma of theconjunctiva was recognised more than 20 years ago,we can find only eighteen reported cases in the literature.1 Because of the low number of reports, clinicians,especially ophthalmologists and pathologistsare unfamiliar with this condition.5 An awareness ofthis condition will allow early and accurate diagnosisand treatment (surgical removal and postoperativeantibiotic therapy) (10). Seeing the results in the literature,prognosis following surgical excision is excellent (1), 4).

Declaration

No conflicts of interests were declared by authors.

Introduction: Synthetic fibre granuloma of the conjunctiva, sometimes known as „teddy beargranuloma” is a rare granulomatous foreign body reaction of the conjunctiva to synthetic fibres.The name „teddy bear” refers to the origin of the synthetic fibres. It is often an incidental finding,most commonly found in children, and usually presents as a unilateral conjunctival mass of theinferior eyelid fornix.

Case report: The 9-year-old girl was admitted to the Department of Ophthalmology of SemmelweisUniversity, Budapest because of irritation, discomfort and foreign body sensation in her rightsuperior eyelid for three days. Split-lamp examination showed a mulberry-like, bulging conjunctivalmass of a 5 mm diameter in the superior tarsal conjunctiva. It was embedded with a bunchof white, hair-like material. After surgical removal of the lesion, microscopic examination confirmeda foreign body granuloma, containing fibers showed strong birefringence in polarizedlight, which proved their synthetic origin. Postoperatively the complaints of the patient were disappeared;there was no recurrence of the lesion at one year after excision.

Conclusion: Eighteen cases of conjunctival “teddy bear” granuloma have been reported in theliterature. To the best of our knowledge, this is the first reported case of this condition in Hungary.Superior conjunctival localization of the granuloma is rare among all of the introduced cases.An awareness of this condition will allow early and accurate diagnosis and treatment.

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