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PHOTO ESSAY
Year : 2021  |  Volume : 1  |  Issue : 1  |  Page : 32-33

Solitary limbal nodule in a child: An unusual presentation in pediatric vernal keratoconjunctivitis


1 Consultant Anterior Segment and Oculoplasty, Lions Club of Hyderabad Sadhuram Eye Hospital, Hyderabad, Telangana, India
2 Consultant Pediatric Ophthalmology, Strabismus and Neuro-Ophthalmology, Lions Club of Hyderabad Sadhuram Eye Hospital, Hyderabad, Telangana, India
3 Consultant Anterior Segment and Pediatric Ophthalmology, Lions Club of Hyderabad Sadhuram Eye Hospital, Hyderabad, Telangana, India
4 Head, Ocular Pathology, National Reporting Centre for Ocular Pathology, Centre For Sight, Hyderabad, Telangana, India

Date of Submission03-Jun-2020
Date of Acceptance30-Aug-2020
Date of Web Publication31-Dec-2020

Correspondence Address:
Dr. Deepika Khurana
A-102, Royalton Block, Aditya Empress Towers, Shaikpet, Hyderabad, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_1695_20

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  Abstract 


Keywords: Limbal nodule, pediatric presentation, surgical management, vernal keratoconjunctivitis


How to cite this article:
Khurana D, Chandrasekharan A, Angula M, Mulay K. Solitary limbal nodule in a child: An unusual presentation in pediatric vernal keratoconjunctivitis. Indian J Ophthalmol Case Rep 2021;1:32-3

How to cite this URL:
Khurana D, Chandrasekharan A, Angula M, Mulay K. Solitary limbal nodule in a child: An unusual presentation in pediatric vernal keratoconjunctivitis. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2021 Feb 25];1:32-3. Available from: https://www.ijoreports.in/text.asp?2021/1/1/32/305500



A 5-year-old girl presented with a reddish mass in her right eye since 2 months. She had associated redness and itching in both eyes since 6 months. There was no history of ocular trauma/surgeries. She was on fluorometholone 0.1% eye drops and olopatadine 0.1% eye drops on presentation. Her best-corrected visual acuity was 20/20, N6 in both eyes. Examination revealed mild tarsal conjunctival papillary hypertrophy, extensive limbal conjunctival hypertrophy [Figure 1] in both eyes, consistent with vernal keratoconjunctivitis (VKC). Right eye [Figure 2] had a nasal limbal nodule measuring 4 mm maximally. It was sessile, erythematous with fine intrinsic vessels and overlying whitish deposits. A tortuous “feeder” vessel was noted and the mass was slightly mobile over the underlying episclera. Rest of the ophthalmic examination was unremarkable in both eyes.
Figure 1: Slit-lamp photograph of left eye showing extensive limbal conjunctival hypertrophy and diffuse conjunctival congestion

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Figure 2: Slit-lamp photograph of right eye, showing a reddish nodule (4 × 4 × 2 mm) on the nasal limbus with fine intrinsic vasculature and overlying whitish deposits (yellow arrow). A prominent “feeder” vessel (black arrow) is noted. Limbal conjunctival hypertrophy may also be noted in the surrounding limbus

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Clinical diagnosis of pyogenic granuloma with VKC was considered. To control the surface inflammation, topical steroids were stepped up to Prednisolone acetate 1%; and Olopatadine 0.1% eye drops were continued. The steroid eye drops were tapered over four weeks. However, there was no regression in the size/vascularity of the nodule. To obtain a final histopathological diagnosis and to possibly facilitate regression of the disease, surgical excision of the mass, followed by an autologous conjunctival graft was done.

Histopathology revealed eosinophilic conjunctivitis with ulceration covered with fibrinous exudates [Figure 3]a. There was underlying granulation tissue with mixed inflammatory infiltrate and proliferating vascular channels [Figure 3]b and [Figure 3]c.
Figure 3: Histophotographs (H and E stain; original magnification 10×, 40×, 100×) showing (a) Partially ulcerated conjunctival tissue covered with fibrinous exudates; (b) Stratified squamous epithelium with mild hyperplasia; (c) Substantia propria with mixed inflammatory infiltrate (lymphocytes, plasma cells, eosinophils) and dense vascular channels

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After a course of topical corticosteroid eye drops and anti-histaminic eye drops postoperatively, her allergy resolved and there was no recurrence of the mass at 3 months follow-up visit.


  Discussion Top


Literature review shows only two case reports of a solitary limbal mass in children with VKC.[1],[2] These masses were described to be pale pink or translucent in color and avascular. Our case is unique because the limbal nodule was unusually vascular with a tortuous 'feeder' vessel along with overlying deposits. A clinical diagnosis of pyogenic granuloma was thus considered.

Another possibility could be a giant papilla, which is known to occur in VKC, but in the tarsal conjunctiva. Limbal Pseudo-Epitheliomatous Hyperplasia (PEH) as a diffuse mass has also been reported in VKC, albeit in an adult.[3] Such limbal nodules in the setting of VKC have been managed medically[2] and surgically.[1],[3],[4]

The general ophthalmologist should be aware of solitary limbal nodule as one of the unique presentations in children with VKC. We recommend that surgical excision of the mass in such cases should be considered as an effective treatment modality, after adequate control of ocular surface inflammation with topical anti-inflammatory drugs; as this facilitates regression of the disease.[4]

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 Top

1.
Schwab IR, Schwab L, Cavender JC. Limbal vernal keratoconjunctivitis with a hypertrophic limbal mass lesion. Ann Ophthalmol 1987;19:79-80.  Back to cited text no. 1
    
2.
Sugandhi P, Arora R. Isolated large limbal nodule as the presenting feature of vernal keratoconjunctivitis. J Pediatr Ophthalmol Strabismus 2007;44:49-50.  Back to cited text no. 2
    
3.
Malhotra C, Jain AK, Thapa B. Limbal pseudoepitheliomatous hyperplasia mimicking ocular surface squamous neoplasia in palpebral vernal keratoconjunctivitis. Case Rep Ophthalmol Med 2013;2013:527230.  Back to cited text no. 3
    
4.
Kobayashi A, Nagata A, Shirao Y, Kawasaki K, Ohta T, Amaya-Ohkura Y, et al. Surgical treatment of limbal vernal keratoconjunctivitis by resection of a limbal lesion. Jpn J Ophthalmol 2002;46:679-81.  Back to cited text no. 4
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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