Synthetic fiber granulomas, also known as “Teddy Bear” granulomas or “Fuzz Ball granulomas,” are usually seen in childhood. We present a case of a 5-year-old child with a “Fuzz Ball” granuloma of the conjunctiva. The resected specimen was processed routinely. The use of polarized light during microscopic examination of the resected tissue made the diagnosis evident due to the prominent birefringence of the synthetic foreign material fibers.

Synthetic fiber granulomas have been reported in the literature as “Teddy Bear” granulomas or “Fuzz Ball” granulomas [1-9]. This entity usually presents unilaterally in the inferior fornix of children. Blankets, fabric toys (teddy bears for instance), and clothing in proximity to the eye are believed to cause inoculation of the fibers into the conjunctiva. Given time, the body reacts to the foreign material eliciting a granulomatous response. Synthetic fiber granulomas are uncommon but thankfully are easily removed by simple excision, without major surgery. During microscopic examination of resected specimens, the use of polarized light considerably enhances the appearance of synthetic foreign material. We present a case of a “Fuzz Ball” granuloma in a child where the diagnosis was facilitated by a clinical suspicion and polarizing microscopy of the resected specimen.

A 5-year-old male presented to an acute care facility with a foreign body sensation of the left eye for several days. The patient had been given a stuffed cat toy, which he had been sleeping with for about 2–3 weeks (Fig. 1). The physician noticed a papule in the left lower eyelid and attempted to remove it but was not able to do so. Thus, the patient was referred to the ophthalmology clinic of a tertiary care facility for further management. Signed informed consent to report this case was obtained from this patient’s mother.

Evaluation of the patient’s left conjunctiva revealed 1 + injection, and in the lower, fornix was a 0.3 × 0.2 cm fleshy pink lesion with a single eyelash attached. This was removed in its entirety with forceps and sent to the pathology laboratory for routine processing.

The anatomic pathology laboratory received a tan soft piece of tissue measuring 0.2 × 0.2 × 0.1 cm. The specimen was entirely submitted and processed for hematoxylin and eosin (H&E) staining. Microscopic examination revealed a portion of conjunctiva with a prominent chronic inflammatory infiltrate and a few neutrophils. Also noted was a granulomatous response to synthetic fibers (Fig. 2). With polarized light, the synthetic fibers were prominently birefringent (Fig. 3). After removal of the lesion, the patient was treated with topical tobramycin-dexamethasone drops, and the recovery was uneventful. Unfortunately, no gross photograph is available of the lesion in situ. At the time of removal, it was decided not to take a photograph due to the patient’s increased anxiety during the procedure.

Fig. 2.

Granulomatous response to synthetic fibers.

Fig. 2.

Granulomatous response to synthetic fibers.

Close modal
Fig. 3.

Synthetic fibers with polarized light.

Fig. 3.

Synthetic fibers with polarized light.

Close modal

The diagnosis of a synthetic fiber granuloma depends on a clinical suspicion and microscopic examination of the resected specimen. Routine H&E processing is sufficient for an adequate assessment of the sample. During examination of the H&E slides, the granulomatous process is usually evident; however, the synthetic fibers are not readily apparent since they do not stain with routine H&E. The same microscopic slide when examined with a polarizing microscope makes the highly birefringent fibers very prominent thus facilitating the diagnosis of a “Fuzz Ball” granuloma. Being aware of such entity can facilitate the diagnosis for ophthalmologists and pathologists alike.

We gratefully acknowledge Shannon L. Sheikh for her assistance in the submission of this manuscript.

Signed informed consent to report this case was obtained from this patient’s mother.

The authors have no conflicts of interest to declare.

No funding was received in relation to the preparation of this report.

Andrew R. Dorion: drafting of the manuscript and literature review. Gordon Crabtree: patient assessment a treatment and manuscript review. R. Patrick Dorion: pathologic examination of tissue, obtaining photographs of the case, and manuscript review.

1.
Aliakbar-Navahi
R
,
Roozitalab
MH
,
Ashraf
MJ
,
Hakimzadeh
A
.
Synthetic fiber “Teddy Bear” conjunctival granuloma; a case report. Aliakbar-Navahi R, Roozitalab MH, Ashraf MJ
.
J Ophthalmic Vis Res
.
2015
Jul-Sep
;
10
(
3
):
342
4
.
[PubMed]
2008-2010
2.
Mak
ST
,
Lui
YH
,
Li
KK
.
Synthetic fibre granuloma of the conjunctiva
.
Hong Kong Med J
.
2015
Feb
;
21
(
1
):
77
9
.
[PubMed]
1024-2708
3.
Farooq
MK
,
Prause
JU
,
Heegaard
S
.
Synthetic fiber from a teddy bear causing keratitis and conjunctival granuloma: case report
.
BMC Ophthalmol
.
2011
Jun
;
11
(
1
):
17
.
[PubMed]
1471-2415
4.
Schmack
I
,
Kang
SJ
,
Grossniklaus
HE
,
Lambert
SR
.
Conjunctival granulomas caused by synthetic fibers: report of two cases and review of literature. Schmack I, Kang SJ, Grossniklaus, Lambert SR
.
Journal of Aapos: American Association for Pediatric Ophthalmology and Strabismus.
2005
Dec
;
9
(
6
):
567
71
.
5.
Enzenauer
RW
,
Speers
WC
.
Teddy bear granuloma of the conjunctiva
.
J Pediatr Ophthalmol Strabismus
.
2002
Jan-Feb
;
39
(
1
):
46
8
.
[PubMed]
0191-3913
6.
A conjunctival synthetic fibre granuloma in a child. Yang YF, James CR. Eye 10 (Pt-1): 143-5,
1996
.
7.
Lueder
GT
,
Matsumoto
B
,
Smith
ME
.
Pathological case of the month. Synthetic fiber granuloma (“Teddy Bear Granuloma”)
.
Arch Pediatr Adolesc Med
.
1996
Mar
;
150
(
3
):
327
8
.
[PubMed]
1072-4710
8.
Lueder
GT
.
Synthetic fiber granuloma
.
Arch Ophthalmol
.
1995
Jul
;
113
(
7
):
848
9
.
[PubMed]
0003-9950
9.
Ferry
AP
.
Synthetic fiber granuloma. ‘Teddy bear’ granuloma of the conjunctiva
.
Arch Ophthalmol
.
1994
Oct
;
112
(
10
):
1339
41
.
[PubMed]
0003-9950
Open Access License / Drug Dosage / Disclaimer
This article is licensed under the Creative Commons Attribution-NonCommercial 4.0 International License (CC BY-NC). Usage and distribution for commercial purposes requires written permission. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.