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Unilateral Follicular Conjunctivitis With Retained Hair and Pseudomonal Infection
Arch Ophthalmol. 2001;119:901-903.
INTRODUCTION
A healthy 40-year-old woman developed redness and yellowish discharge in the right eye associated with a follicular conjunctivitis with marked preauricular adenopathy. This clinical picture was consistent with Parinaud oculoglandular syndrome. A subconjunctival mass was present in the superotemporal fornix. Conjunctival culture yielded Pseudomonas aeruginosa. The mass was removed surgically, and treatment with topical and systemic ciprofloxacin hydrochloride was instituted. Light microscopy demonstrated acute and chronic inflammatory cells surrounding a collection of hair shafts. To our knowledge, this is the first report of a case of Parinaud oculoglandular syndrome caused by a hair foreign body with an associated pseudomonal conjunctivitis.
Unilateral follicular conjunctivitis is most commonly associated with primary herpetic keratoconjunctivitis, chlamydial infection, and various causes of Parinaud oculoglandular syndrome.1 A case of follicular conjunctivitis secondary to a retained hair has not, to our knowledge, been reported previously. We treated a patient with follicular conjunctivitis secondary to a retained foreign body with pseudomonal infection.
Report of a Case
A 40-year-old African American woman with a 4-month history of chronic discharge from the right eye was referred for evaluation to the Vanderbilt Eye Center, Nashville, Tenn. She complained of sticky eyelids associated with occasional bloody tears and eye redness. Her vision was not affected, and she denied any pain. Multiple chalazion excisions had previously been performed in the upper and lower eyelids of both eyes. About a month before referral, a biopsy of the central third of the right lower fornix had been performed for possible ocular cicatricial pemphigoid. A nurse by occupation, the patient cared for patients with tuberculosis, but had negative results of purified protein derivative test and chest x-ray. She was taking azithromycin for acne rosacea.
When first examined, her right upper eyelid appeared edematous and there was a thin yellowish discharge. A mobile, nontender preauricular node was palpable on the right side, measuring approximately 1 cm in diameter. There was a mild right ptosis with a normal lid crease and levator function. On slitlamp examination, the bulbar conjunctiva on the right side was moderately injected. On eversion of both the upper and lower eyelids, large follicles were present on both the upper and lower palpebral conjunctivae with a symblepharon in the inferior fornix, possibly the result of the previous surgeries. On double eversion of the right upper eyelid, a round elevation was seen in the superior fornix, approximately 1.5 cm in diameter and covered with heavily inflamed conjunctiva (Figure 1). There was no pigmentation change to the conjunctiva and no visible foreign body. The lacrimal gland was not involved. The results of the remainder of the eye examination were normal, including slitlamp examination and dilated fundus examination in both eyes.
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Figure 1. Follicles and inflamed conjunctiva visible on eversion of the right upper eyelid.
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The conjunctival culture from the right eye yielded Pseudomonas aeruginosa. An excisional biopsy was performed on the conjunctival mass. On incision of the overlying conjunctiva, a clump of hairs, all oriented in the same direction, with a dark greenish pea-sized area of tissue surrounding their base, became visible. The hairs and associated tissue were excised and sent as a specimen. A second specimen of the surrounding tissue was also sent for pathological analysis. Because of the culture results, the patient was placed on a regimen of oral ciprofloxacin hydrochloride, 500 mg twice daily, and topical ciprofloxacin 4 times daily. Her condition improved dramatically within 4 days. The follicles receded and the preauricular node was no longer palpable.
The larger surgical specimen measured 1 x 0.5 x 0.2 cm and consisted of a soft tissue mass with attached hair (Figure 2). Its cut surfaces were light tan with a small yellowish brown necrotic center. Formalin-fixed paraffin-embedded sections were stained with hematoxylin-eosin, Congo red, phenol green, Gomori methenamine silver, and acid-fast blue.
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Figure 2. The mass exposed after conjunctival incision. A collection of hairs is visible.
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Histologic examination demonstrated pink amorphous necrotic debris and scattered fragments of polarizable foreign material surrounded by numerous neutrophils (Figure 3). The material was consistent with mammalian hair. Sections of the smaller biopsy specimen, taken from the surrounding tissue, showed granulation tissue with marked edema and abundant dilated capillaries. There were also numerous plasma cells, neutrophils, and lymphocytes in the stroma (Figure 4). The pink amorphous material was negative on Congo red staining. Special stains did not show any organisms.
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Figure 3. Section of the mass showing the amorphous necrotic debris and scattered fragments of polarizable foreign material (solid arrows) surrounded by numerous neutrophils (hematoxylin-eosin, original magnification x40).
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Figure 4. Section from surrounding tissue showing granulation tissue with markedly dilated capillaries. Numerous plasma cells, neutrophils, and lymphocytes are present (hematoxylin-eosin, original magnification x120).
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Comment
We could not find a previous report in the literature of mammalian hair inciting a follicular conjunctivitis; however, ocular inflammation caused by hair fibers, either human or nonhuman, has been reported. Caterpillar hairs have a tendency to migrate into the eye and cause various kinds of inflammation, including conjunctivitis with the formation of conjunctival nodules, iritis, vitritis, and papillitis.2-3 Spina et al4 described a tuft of hair located within the conjunctiva.
Hunts et al5 reported 3 cases of patients with cilia entrapped in the bulbar or forniceal conjunctiva. Each had some degree of preexisting conjunctival scarring. In none, however, were the cilia completely contained within the conjunctiva. The conjunctival response was papillary rather than follicular. All cases resolved on removal of the cilia. Mawn et al6 described a patient who developed pseudomonal dacryoadenitis shortly after clipping his long eyebrows. A stone formed around a collection of hairs, clogging the ductule. The infection resolved with removal of the stone and the administration of antibiotics.
The source of the conjunctival hair mass in this case is unknown. It is unlikely that cilia could have entered at the time of a previous chalazion removal, since the last surgery predated her symptoms by years. It is conceivable that, as a result of many previous surgeries, the conjunctival surface became uneven, predisposing to retention of cilia. Over time, these might become completely buried in the conjunctiva, or minor periocular trauma with a hairbrush or mascara wand could have implanted the hair in the conjunctiva.
Pseudomonas aeruginosa is an unusual cause of bacterial conjunctivitis. In 2 recent studies evaluating quinolone drugs in the treatment of acute bacterial conjunctivitis, P aeruginosa was the pathogen in 0.8% to 7% of cases.7-8 Pseudomonal ocular surface infection has also been associated with the use of contaminated eyelid hygiene solutions9 and eyedrops.9-10
In the absence of organisms or an abscess in the tissue in this case, the pseudomonal infection was most likely secondary to the chronic inflammation caused by the retained hair. The follicular conjunctivitis is difficult to explain except as being caused by a chronic inflammation induced by the foreign body. In this case, the initial diagnosis was Parinaud oculoglandular syndrome because of the large preauricular node and follicular conjunctivitis. It was only revised when double eversion of the eyelid revealed a conjunctival mass in the superior fornix. The diagnosis was confounded further by the isolation of P aeruginosa before biopsy. Because of the findings in this unusual case, we believe a retained conjunctival foreign body should be considered when a patient is seen with an apparent Parinaud oculoglandular syndrome.
AUTHOR INFORMATION
This study was supported in part by an unrestricted grant from Research to Prevent Blindness Inc, New York, NY.
Corresponding author: Louise A. Mawn, MD, Department of Ophthalmology and Visual Sciences, Vanderbilt University School of Medicine, 8000 Medical Center E, 2115 21st Ave S, Nashville, TN 37232-8808 (e-mail: louise.mawn{at}mcmail.vanderbilt.edu).
Adrian M. Laviña, MD;
Louise A. Mawn, MD;
Xuemo Fan, MD, PhD;
Denis M. O'Day, MD
Nashville, Tenn
REFERENCES
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SECTION EDITOR: W. RICHARD GREEN, MD
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