Jelly petrolatum conjunctival granuloma: a case report

A 44 year old caucasian woman, was seen by us with a complaint ofbilateral conjunctival blisters and redness of the left eye. Approximately four months previously, she had undergone pansinu­ sectomy for chronic sphenoid and eth­ moid sinusitis . During surgery the ethimoid bones, which were described as "paper thin" by the surgeon, were fractured on both sides. At the end of surgery the nasal cavity was firmly packed with vaseline gauze permeated with polysporon ointment . ln the first day post-operative the patient had marked bilateral swelling and ecchy­ mosis of her eyelids and a left exo­ tropia. She was treated with prednisone (40mg/day) and Keflex ( 1 . 0 gram a day) and had marked resolution within 8 days. Four weeks after surgery she noticed white blisters on her nasal con­ junctiva bilaterally, more prominent in the left eye. Her best corrected visual acuity was 20/20 in both eyes; the pupils and ex­ tra-ocular muscles were within normal limits. Slit lamp examination of the palpebral conjUIlctiva OU revealed a mild papillary reaction superiorly. The bulbar conjUIlctiva revealed a firm, ge­ latinous, sub-conjunctival/inter-con­ junctival mass in the medial aspect of the right eye (Fig. I) , surroUIlded by several , much smal ler, oily-Iooking masses; the nasal bulbar conjUIlctiva of the left eye revealed a similar but larger mass. The rest of her examination was UIlremarkable, with intra-ocular pres­ sures of 1 8 mmHg OU and Hertel measurements of 16 mm OU, with a base of 1 05 mm. Attempts to remove the material from UIlder the conjUIlctiva using fine needle pUIlcture was rela­ tively successful cosmetically in the right eye only. The material which was removed was identified as petrolatum. One year after sinus surgery the patient had developed a large inflamed gra­ nuloma of the nasal bulbar conjUIlctiva in the left eye (fig) . This large sub­ conjunctival mass was surgically re­ moved and during the operation the left


INTRODUCTION
The use of jelly-petrolatum (vase line) gauze , and vaseline ointments and antibiotics is common in paranasal si nus procedures.We are UIlaware of any ocular complications having been re ported in association with this tech nique.Herein we report a case of con jUIlctival granulomas and extrusion of vaseline UIlder the conjunctiva fo llow ing such a procedure.

CASE REPORT
A 44 year old caucasian woman, was seen by us with a complaint ofbilateral conjunctival blisters and redness of the left eye.Approximately four months previously, she had undergone pansinu sectomy for chronic sphenoid and eth moid sinusitis.During surgery the ethimoid bones, which were described as "paper thin" by the surgeon, were fractured on both sides.At the end of surgery the nasal cavity was firmly packed with vaseline gauze permeated with polysporon ointment.ln the first day post-operative the patient had marked bilateral swelling and ecchy mosis of her eyelids and a left exo tropia.She was treated with prednisone (40mg/day) and Ke flex (1.0 gram a day) and had marked resolution within 8 days.Four weeks after surgery she noticed white blisters on her nasal con junctiva bilaterally, more prominent in the left eye.
Her best corrected visual acuity was 20/20 in both eyes; the pupils and ex tra-ocular muscles were within normal limits.Slit lamp examination of the palpebral conjUIlctiva OU revealed a mild papillary reaction superiorly.The bulbar conjUIlctiva revealed a firm, ge latinous, sub-conjunctival/inter-con junctival mass in the medial aspect of the right eye (Fig. I), surroUIlded by several, much smaller, oily-Iooking masses; the nasal bulbar conjUIlctiva of the left eye revealed a similar but larger mass.The rest of her examination was UIlremarkable, with intra-ocular pres sures of 18 mmHg OU and Hertel measurements of 16 mm OU, with a base of 105 mm.Attempts to remove the material from UIlder the conjUIlctiva using fine needle pUIlcture was rela tively successful cosmetically in the right eye only.The material which was removed was identified as petrolatum.One year after sinus surgery the patient had developed a large inflamed gra nuloma ofthe nasal bulbar conjUIlctiva in the left eye (fig).This large sub conjunctival mass was surgically re moved and during the operation the left Figura 1 medial rectus muscle was fo und to be infiltrated.The mass in this area was partially ressected, and it was also identified as petrolatum jelly.The mi croscopic examination revealed numer ous cystic spaces lined by relatively flattened cells, associated with an infil trate of lymphocytes, plasma cells, epithelioid cells, and ocasional giant cells; in one area there was a well de fined lymphoid fo Uicle with reticulum cells in the center and well differen tiated lymphocytes around the edge.(Fig. 2)

D1SCUSSION
The use of vaseline gauze and vaseline based ointment is common practice after sinus surgery.Ocular complications have not been reported.However, we are aware ofthree reports of vaseline-like products in the eyelids.ln one case, self-inoculation of vaseline in the lower lids, bilaterally, was per fo rmed for cosmetic reasons (I).ln two cases infiltration of the lower lid occured iatrogenically during radio-360 Jelly Petrolatum conjuntival granuloma: a case report graphic exploration of the lacrimal ex cretory system (2 , 3) .Previous studies with silicone and petrolatum jelly have not demonstrated acute inflammatory responses (405.6).Normally the material causes a granulomatous fore ign body reaction only.
Given the history of fracture of both ethmoid bones and extensive nasal packing with vaseline gauze, the subconjunctival vaseline probably arose from that source.We fe el the vaseline probably extruded into the or bit through the fr actures of the ethmoid bones and along with blood was extrud ed between the conjunctiva and Tenon's capsule.
The conjunctiva granuloma was ex cised mostly for cosmetic reasons.Careful ressection was necessary to prevent damage to the extra-ocular muscles.