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Pyogenic granuloma after cosmetic eye whitening
Granuloma piogénico tras blanqueamiento ocular cosmético
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The presence of the lens in the vitreous cavity is evident in both eyes.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "C.E. Monera Lucas, J. Escolano Serrano, D. Romero Valero, A. Navarro Navarro, J.J. Martínez Toldos" "autores" => array:5 [ 0 => array:2 [ "nombre" => "C.E." "apellidos" => "Monera Lucas" ] 1 => array:2 [ "nombre" => "J." "apellidos" => "Escolano Serrano" ] 2 => array:2 [ "nombre" => "D." "apellidos" => "Romero Valero" ] 3 => array:2 [ "nombre" => "A." "apellidos" => "Navarro Navarro" ] 4 => array:2 [ "nombre" => "J.J." 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Where are we in 2020?" 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Romero-Morales, A. Marchese, E. Miserocchi, F. Bandello, G. Modorati" "autores" => array:5 [ 0 => array:3 [ "nombre" => "V.A." "apellidos" => "Romero-Morales" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 1 => array:3 [ "nombre" => "A." "apellidos" => "Marchese" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:4 [ "nombre" => "E." "apellidos" => "Miserocchi" "email" => array:1 [ 0 => "miserocchi.elisabetta@hsr.it" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 3 => array:3 [ "nombre" => "F." "apellidos" => "Bandello" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "G." "apellidos" => "Modorati" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Department of Ophthalmology, IRCCS Ospedale San Raffaele, University Vita-Salute San Raffaele, Milan, Italy" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Retina, Instituto Mexicano de Oftalmologia, Queretaro, Mexico" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Granuloma piogénico tras blanqueamiento ocular cosmético" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 563 "Ancho" => 750 "Tamanyo" => 50847 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Right eye exhibited avascular areas and pyogenic granuloma at nasal region.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Cosmetic Eye Whitening is a surgical procedure introduced in 2008 as a new technique for the treatment of chronic conjunctival hyperemia. Surgical steps involve a localized conjunctivectomy associated with postoperative medications such as topical mitomycin-C (MMC) 0.02% during five days, antibiotics, corticosteroids<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> and some authors described the application of subconjunctival bevacizumab injection 0.03 – 0.1 mL.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In the last 5 years, a broad range of complications from cosmetic eye whitening have been reported, including persistent conjunctival epithelial defects, scleral thinning, necrotizing scleritis<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,4,5</span></a> chronic dysfunctional tear syndrome, limbal stem cell deficiency, lymphangiectasis, infectious endophthalmitis and others.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Here we report the case of a localized pyogenic granuloma and necrotizing scleritis developed after cosmetic eye whitening procedure. To the best of our knowledge, this represents the first documented case with pyogenic granuloma after eye whitening procedure.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Case presentation</span><p id="par0020" class="elsevierStylePara elsevierViewall">A 46-year-old Caucasian male presented to our hospital complaining of redness in his right eye (OD). He noted a “red spot in the inner corner” of OD, developed during the previous two months. This appeared five years after he underwent bilateral surgical treatment of cosmetic eye whitening and postoperative topical MMC 0.02% 4 times daily for 5 days in another institution. And during the five years following the procedure he reported it was successful, with decreased conjunctival hyperemia in both eyes (OU).</p><p id="par0025" class="elsevierStylePara elsevierViewall">At the first visit, he was using lubricant eye drops and his best corrected visual acuity (BCVA) at distance was OU 20/20. Examination of the nasal sclera in OD revealed an elevated, fleshy, reddish mass with an ovoid shape (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The lesion was pedunculated, with an underlying stalk of blood vessels and connective tissue. The conjunctiva was bilaterally avascular in temporal and nasal areas adjacent to the limbo, also whitish scleral thinning with corresponding fluorescein pooling. No other signs of ocular inflammation were observed. The nasal reddish mass in OD was successfully excised without recurrence and the histopathologic analysis resulted in a pyogenic granuloma.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">More than one year after the excision surgery, the patient presented to our emergency department with severe ocular pain and decreased vision in OS. BCVA was 20/20 in OD and 20/40 in OS. The sclera in OU was whitish in the nasal and temporal sectors; moreover, in OS, the sclera showed a marked hyperemia in the superior and inferior sectors. The cornea was transparent, the anterior chamber had 1+ cells in OD and 4+ cells in OS; the vitreous was clear, and the posterior segment was normal. No synechiae or iris nodules were noted. After the excision of pyogenic granuloma, the diagnosis of bilateral necrotizing scleritis associated with acute nongranulomatous anterior uveitis was made.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The Ocular Inflammatory Disease Review of Systems Questionnaire was applied as well as a full immunologic and infective work-up excluded specific immunologic or infectious etiologies. The Blood test demonstrated leucocytosis and neutrophilia. The other investigations were non-contributory, including hepatic and renal function, antinuclear antibodies (ANA), perinuclear and cytoplasmic anti-neutrophil cytoplasmic antibodies (P-ANCA as well as C-ANCA), angiotensin-converting enzyme (ACE), rheumatoid factor (RF), and computerized axial tomography of the brain and orbit.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The patient was prescribed aggressive lubrication with preservative-free artificial tears and ointment, topical levofloxacin and dexamethasone, and oral prednisone (1 mg/kg/day). After three weeks, ocular pain, had slowly diminished and subcutaneous methotrexate was initiated (20 mg/week). Topical therapies were continued, while oral corticosteroids gradually tapered, improvements in scleral erosion and hyperemia were also evident.</p><p id="par0045" class="elsevierStylePara elsevierViewall">At the final follow up visit, the left eye still had scleral thinning with necrotizing scleritis, without inflammation in the anterior chamber (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). BCVA was 20/20 in OU.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Discussion</span><p id="par0050" class="elsevierStylePara elsevierViewall">Pyogenic granuloma or lobular capillary hemangioma is a benign, rapidly growing vascular proliferation, classified as a vascular tumor of proliferating endothelium.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Although the concept of this lesion changed, the name has persisted in medical literature. Pyogenic granuloma is a proliferative fibrovascular response to previous inflammatory traumatic or chemical insult, either surgical or nonsurgical, as a result of tissue irritation. The traumatic insult could be as a result of surgical procedure where chemical irritation may also occur with the presence of an absorbable suture or a silicone product (tube or plug). The hypothesis is that tissue injury or inflammation sets up a wound-repair response in the adjacent tissue. The pyogenic granuloma formation results from a disruption of the healing process, with an imbalance in the several factors that stimulate, inhibit and modulate angiogenesis. The histologic exam of pyogenic granuloma shows mixed inflammatory cells, blood vessels, and connective tissue.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Regarding epidemiology, it represented the 0.7% in a clinical survey of 1643 conjunctival tumors reported by Shields et al.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">The exact etiology of this case remains uncertain because the pyogenic granuloma developed after five years from the eye whitening procedure; in other locations such as the skin or the gingival mucosa, some authors have related pyogenic granuloma to estrogens and progesterone vascular endothelial growth factor expression has also shown an association with pyogenic granuloma in gingival mucosa.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">In the presented case, pyogenic granuloma can be associated with regional conjunctivectomy combined with post-surgical topical MMC, as a result of tissue damage and vascular impairment. The iatrogenic deprivation of vessels can cause localized ischemia and epithelial defects, promoting an inflammatory reaction.</p><p id="par0070" class="elsevierStylePara elsevierViewall">About the presence of the necrotizing scleritis could be associate with the second surgery in a tissue with a previous injury, however there are many reports about complications after cosmetic eye whitening, but not with five years from the procedure, for that reason the case is interesting. Ji YW et al. reported necrotizing scleritis in 4/231 cases of cosmetic conjunctivectomy which included mitomycin, with 51 months average length of time from the procedure; all of them unilateral.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Nevertheless, Rhiu et al. described complications after cosmetic conjunctivectomy and postsurgical topical application of 0.02%MMC on the nasal and temporal conjunctiva in both eyes. They found that 44 of 48 patients (91.67%) demonstrated complications, such as 50% chronic epithelial defects, 46.67% scleral thining, 33.33% fibrovascular adhesions, 24.4% chronic dysfunctional tear syndrome, 11.11% abnormal vessel growth in the conjunctiva, 6.67% lymphangiectasis and 20% diplopia. The mean time to the onset of complications was less than 1 year.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">In conclusion, the cosmetic eye whitening treatment should be applied to patients with no systemic risk factors and a cost-benefit of the procedure should also be carried out. In addition, the patient should be informed about the possibility of presenting a conjunctival lesion even five years after the surgical cosmetic procedure, as in this case with the presentation of necrotizing scleritis, acute nongranulomatous anterior uveitis and pyogenic granuloma which can be successfully resolved with surgery, systemic and topical treatment.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Financial support</span><p id="par0085" class="elsevierStylePara elsevierViewall">None.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Conflict of interest</span><p id="par0090" class="elsevierStylePara elsevierViewall">VR, AM, EM and GM have no disclosures. FB has the following disclosures: Allergan (S), Alimera (S), Bayer (S), Farmila-Thea (S), Schering Pharma (S), Sanofi-Aventis (S), Novagali (S), Pharma (S), Hoffmann-La roche (S), Genetech (S), Novartis (S).</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres1456421" "titulo" => "Abstract" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Clinical case" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Result" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1327704" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1456422" "titulo" => "Resumen" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "abst0020" "titulo" => "Caso clínico" ] 1 => array:2 [ "identificador" => "abst0025" "titulo" => "Resultado" ] 2 => array:2 [ "identificador" => "abst0030" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1327703" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case presentation" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Financial support" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-02-24" "fechaAceptado" => "2020-06-18" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1327704" "palabras" => array:5 [ 0 => "Pyogenic granuloma" 1 => "Necrotizing scleritis" 2 => "Mitomicyn C" 3 => "Cosmetic eye whitening" 4 => "Eye whitening" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1327703" "palabras" => array:5 [ 0 => "Granuloma piógeno" 1 => "Escleritis necrotizante" 2 => "Mitomicina C" 3 => "Blanqueamiento ocular cosmético" 4 => "Blanqueamiento ocular" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Clinical case</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A 46-year-old Caucasian male with a history of chronic conjunctival hyperemia, presented at our clinic 5 years after he underwent the surgical procedure of cosmetic eye whitening. On examination we observed pyogenic granuloma in the right eye; besides acute nongranulomatous anterior uveitis and necrotizing scleritis in both eyes.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Result</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Complete clinical evaluation and full work-up exclusion of systemic diseases was done. The pyogenic granuloma was treated with surgical resection, as well as anterior uveitis and necrotizing scleritis were successfully treated with systemic corticoesteroids and methotrexate.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conclusion</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">The surgical cosmetic eye whitening could have as complication the pyogenic granuloma in addition to necrotizing scleritis and nongranulomatous anterior uveitis; and be present 5 years after the procedure. The surgical resection is a successful treatment for this presentation of pyogenic granuloma.</p></span>" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Clinical case" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Result" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Caso clínico</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Hombre caucásico de 46 años con antecedente de hiperemia conjuntival crónica acude a nuestra clínica 5 años después de realizar el procedimiento quirúrgico de blanqueamiento ocular cosmético. En la exploración observamos granuloma piógeno en el ojo derecho además de uveítis anterior no granulomatosa aguda y escleritis necrosante en ambos ojos.</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Resultado</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se realizó una evaluación clínica con exclusión de enfermedades sistémicas completas. El granuloma piógeno se trató con resección quirúrgica y la uveítis anterior y escleritis necrotizante se trataron con éxito con corticoesteroides sistémicos y metotrexato.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusión</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El blanqueamiento ocular cosmético quirúrgico podría tener como complicación el granuloma piógeno además de la escleritis necrosante y la uveítis anterior no granulomatosa y presentarse 5 años después del procedimiento. La resección quirúrgica es un tratamiento exitoso para esta presentación de granuloma piógeno.</p></span>" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "abst0020" "titulo" => "Caso clínico" ] 1 => array:2 [ "identificador" => "abst0025" "titulo" => "Resultado" ] 2 => array:2 [ "identificador" => "abst0030" "titulo" => "Conclusión" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Romero-Morales VA, Marchese A, Miserocchi E, Bandello F, Modorati G. Granuloma piogénico tras blanqueamiento ocular cosmético. Arch Soc Esp Oftalmol. 2021;96:89–92.</p>" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 563 "Ancho" => 750 "Tamanyo" => 50847 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Right eye exhibited avascular areas and pyogenic granuloma at nasal region.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 563 "Ancho" => 750 "Tamanyo" => 57692 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Right eye at the most recent follow-up visit, one year after topical, systemic and surgical treatment, without sings of ocular inflammation.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cosmetic Eye Whitening by Regional Conjunctivectomy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "B.H. 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