a 2-year - old boy presented to us with a reddish fleshy mass protruding from the inner side of the left eye for 8 months .
he underwent an incisional biopsy at a local dispensary 2 months ago , following which there was an increase in the size of mass , spontaneous bleeding episodes , and epiphora .
he was a diagnosed patient of classical lamellar ichthyosis and was using skin emollients . on local examination ,
a 15 mm  12 mm , strawberry - like polypoidal mass was observed in the left caruncular region [ fig .
the inferior fornix revealed multiple , gelatinous , frond - like lesions originating from both forniceal and tarsal conjunctiva , along its entire length [ fig .
the child was not cooperative for superior bulbar , palpebral , and forniceal conjunctival examination .
( a ) left eye shows reddish , strawberry - like mass in the caruncular region .
the inferior orbital sulcus appears full with blood stained matting of temporal eyelashes indicating spontaneous bleeding episodes .
( b ) on inferior conjunctival examination , florid growth of similar lesions is observed along whole length of tarsal conjunctiva with an old blood clot present medially .
( c ) inferior sulcus pressure reveals massive involvement of forniceal conjunctiva with similar lesions .
multiple pinhead - sized hemorrhages are seen on the surface a clinical diagnosis of diffuse , multifocal cp was made , and topical fortified eye drops of inf-2b ( injection zavinex , zydus cadila , india ) was started qid ( 1 million iu/1 ml ) .
the child was kept under regular weekly follow - up for 6 weeks , but there was no mass reduction .
however , the mass vascularity and spontaneous bleeding episodes reduced markedly after the topical treatment . in view of no reduction in mass size , a near - total surgical excision of the papillomas with cryo application at each site ( 2  freeze - thaw - freeze 
intraoperatively , similar lesions were noted at the superior tarsal and forniceal conjunctiva [ fig .
the gelatinous exophytic masses were excised with westcott scissors , keeping its blades flush with the conjunctival surface .
after cryo application , total 1 ml ( 3 million iu ) of inf-2b was injected subconjunctivally at multiple sites [ fig . 2c and d ] .
( a ) intraoperative double eversion of upper eyelid revealed multiple foci of similar gelatinous lesions over medial tarsal and forniceal conjunctiva .
( c ) after near - total excision with westcott scissors , application of cryo ( 2 freeze - thaw - freeze cycles ) is being demonstrated .
( d ) subconjunctival injection of interferon-2b being administered at multiple foci after the cryotherapy the histopathology of excised mass revealed multiple pedunculated papillomatous figures with central core of fibrovascular tissue covered by nonkeratinizing epithelium . there was no cellular atypia , and nuclear - cytoplasmic ratio was normal , ruling out any evidence of malignancy .
postoperatively , topical 0.5% moxifloxacin ( qid ) and 1% carboxymethyl cellulose ( 2 hourly ) were prescribed along with topical fortified inf-2b ( 1 iu / ml qid ) eye drops . in the 1 postoperative week , the child had mild eyelid edema and nasal subconjunctival hemorrhage [ fig .
3a and b ] . topical steroid ointment ( hs ) was prescribed for 1 week to reduce cryotherapy - induced inflammation .
at 14-month follow - up , the child is symptom - free ( no epiphora and spontaneous bleeding episodes ) , and there are no signs of local recurrence [ fig .
( a ) early postoperative period shows diffuse medial subconjunctival blood staining with no evidence of residual papillomas over inferior conjunctiva and caruncle .
( b ) superior tarsal conjunctiva is free from the papillomas with few subconjunctival hematoma spots .
one small pinpoint hemorrhage presents temporal to plica semilunaris ( resolved in 1 week ) .
( d ) at 14-month follow - up , no recurrence of mass and the tumor epicenter appears normal .
the infs are naturally produced glycoprotein molecules in our body secondary to viral infections and tumors .
of late , these molecules have been employed with significant success in various human diseases , including cp , an uncommon ophthalmological condition . in children , due to the diffuse , multicentric nature , and inferior fornix predilection , the topical fortified inf-2b eye drops has a potential role .
this drug has shown satisfactory results in primary and recurrent cp cases . in the past , many drugs such as oral cimetidine , 5-fluorouracil , mitomycin - c , local inf-2b ( topical or injection ) , and long - acting pegifn-2b have been used in the management of primary and recurrent cp .
all these therapeutic agents mainly played the role of an adjunct to the surgical intervention than isolated therapeutic agents .
no - touch technique , excisional biopsy  cryotherapy , is the surgery of choice .
surgical debulking not only provides instant relief but also reduces the viral load which is rather a difficult job for a short - acting , fortified drug such as inf-2b .
hence , it is a good option in management armamentarium of surgeon handling recurrent cases . even after these treatment modalities ,
have described specific clinical tumor details which might be helpful in monitoring the treatment response , for example , tumor epicenter location ( clockwise and quadrant wise ) , basal dimensions and thickness ( in millimeters ) , configuration , pigmentation , and vascularity ( intrinsic and feeder vessels ) . on pubmed search with keywords - ichthyosis and cp , only single case report in literature is available from year 1988 though no association has been established . in our patient with classical lamellar ichthyosis and unilateral recurrent cp , the topical inf-2b eye
drops mildly reduced the tumor vascularity which probably eliminated spontaneous bleeding but did not show any regression in tumor size .
cp showed remission after near - total surgical excision and cryotherapy along with local subconjunctival injection of inf-2b .
we postulate that the postoperative topical inf-2b eye drops prevent the dislodged viruses to establish and form a nidus at other conjunctival sites , which might lead to multifocal recurrences specifically in pediatric cp .
 a 2-year - old boy presented with a recurrent strawberry - like reddish mass arising from the left caruncular region for 8 months . an incisional biopsy was performed elsewhere 2 months earlier , followed by an increase in size of mass , significant epiphora , and intermittent bleeding . on examination , 
 exuberant exophytic gelatinous mass with multifocal origin was observed arising from inferior forniceal conjunctiva and caruncle . 
 clinical differential of multifocal conjunctival papilloma was kept , and topical interferon alfa-2b 
 ( inf-2b ) was started . 
 no clinical reduction in mass or symptomatology was observed over 6 weeks . 
 excision biopsy with cryotherapy and subconjunctival injection of inf-2b was performed over all foci . 
 conjunctival papilloma was confirmed on histopathology , and topical inf-2b was continued in postoperative period for 3 months . at 14 months of follow - up , no recurrence , epiphora , or bleeding was noticed . 
 we advocate a possible role of local inf therapy in managing and preventing recurrences of conjunctival papillomatosis . 
Case Report
Discussion
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