Case Report Trichilemmal Cyst of the Bulbar Conjunctiva: A Rare Presentation Rajani Kadri, Devika Parameshwar, Sandhya Ilanthodi1, Sudhir Hegde

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ABSTRACT We report a rare case of trichilemmal cyst involving the bulbar conjunctiva. A 55‑year‑old female presented with a history of a painless, progressive swelling in the left bulbar conjunctiva adjacent to the nasal limbus of 3 years duration. Wide excision biopsy was performed. Histopathologic examination findings were consistent with those of trichilemmal cyst. Trichilemmal cyst should be considered as differential diagnosis in a case of limbal nodule.

Website: DOI: 10.4103/0974-9233.119999 Quick Response Code:

Key words: Conjunctiva, Limbal Nodule, Trichilemmal Cyst



trichilemmal cyst also known as pilar cyst is a common cyst that forms from a hair follicle.1 The cysts are smooth filled with keratin, a protein component found in hair, nails, and skin. Occasionally, trichilemmal cysts can become malignant. To the best of our knowledge, trichilemmal cysts involving the bulbar conjunctiva have not been reported so far. We report a rare case of trichilemmal cyst involving the bulbar conjunctiva.

CASE REPORT A 55‑year‑old female from South India of Dravidian race presented with a history of gradually progressive, painless swelling in the left bulbar conjunctiva adjacent to the nasal limbus of 3 years duration. It was not associated with redness, discharge or blurring of vision. There was no history of trauma or history of any surgery performed in the past. There was no significant family history. On clinical examination, there was a nodular mass adjacent to the nasal limbus of left eye measuring 5 mm × 5 mm, fixed to the underlying tissue, non‑tender, lying within the pterygium [Figures 1a and b]. The transillumination test was negative. Examination of the rest of the anterior

and posterior segment was unremarkable. The right eye was unremarkable. A fold of subconjunctival tissue extending from the swelling to the caruncle was observed during wide excision biopsy of the lesion. The specimen was sent for histopathological examination. Histopathology indicated the presence of sebaceous material. Microscopic examination showed a cyst lined by stratified squamous epithelium with the absence of granular cell layer, focal basal cell hyperplasia, and flakes of keratin within the cyst [Figures 2a-c]. A diagnosis of a conjunctival trichilemmal cyst was made based on the histopathological findings.

DISCUSSION A limbal nodule often presents a difficult clinical, histopathologic, and therapeutic challenge.2 It poses a diagnostic challenge because most lesions are transitions between inflammation, inflammatory hypertrophies, and true neoplasms.3 A trichilemmal cyst, also known as wen, pilar cyst or isthmus‑catagen cyst forms from a hair follicle.4 Though most often found on the scalp, they can also occur on other parts of

Departments of Ophthalmology, 1Pathology, A. J. Institute of Medical Sciences, Kuntikana, Mangalore, India Corresponding Author: Dr. Rajani Kadri, Department of Ophthalmology, A. J. Institute of Medical Sciences, Kuntikana, Mangalore ‑ 575 004, India. E‑mail: [email protected]


Middle East African Journal of Ophthalmology, Volume 20, Number 4, October - December 2013

Kadri, et al.: Trichilemmal cyst of the bulbar conjunctiva



Figure 1: (a and b) Nodular mass at the limbus

Figure 2a:Histopathology of the lesion from Figure 1. Cyst cavity filled with keratin lacking a granular cell layer in its wall (H and E, ×400)

Figure 2b: Focal Basal cell hyperplasia in the cyst wall

cysts are similar to epidermal cysts, both being keratinous cysts. However histologically trichilemmal cysts lack a granular cell layer.4 Approximately, 20% of the epithelial cysts are trichilemmal cysts and other 80% are epidermoid.8 Ver y rarely, trichilemmal cysts can undergo malignant transformation.9,10 In our case, the cyst showed basal cell hyperplasia without cell atypia or mitosis. There are a few reported cases of trichilemmal cyst and malignant trichilemmal tumor of the eyelid.11‑13 However to the best of our knowledge, no cases of trichilemmal cysts involving the bulbar conjunctiva have been reported. This case report highlights the need for considering trichilemmal cyst as differential diagnosis of the limbal nodule. Figure 2c: Absence of granular cell layer in the cyst wall


the body such as the upper lip, palpebral conjunctiva, caruncle, and pulp of the index finger.5‑7 The rare location of bulbar conjunctiva in this case could be explained as originating from the caruncle and being pushed toward the nasal limbus. These

The authors would like to acknowledge the editorial assistance and constant encouragement of Dr. Asha Achar, Senior Resident, Dr. Ajay Kudva, Associate professor, Dr. Vandana Serrao Assistant Professor, Department of Ophthalmology, A. J. Institute of medical sciences, Mangalore, India.

Middle East African Journal of Ophthalmology, Volume 20, Number 4, October - December 2013


Kadri, et al.: Trichilemmal cyst of the bulbar conjunctiva




4. 5. 6.




Meena M, Mittal R, Saha D. Trichilemmal cyst of the eyelid: Masquerading as recurrent chalazion. Case Rep Ophthalmol Med 2012;2012:261414. Farah S, Tad D, Baum, Conlon MR, Alfonso EC, Starck T, Albert DM. Tumors of cornea and conjunctiva. In: Albert and, Jakobeic, Azar, Gragoudaseditors. Principles and Practice of Ophthalmology. 2nd ed. Vol. 2. W.B. Saunders Co Philadelphia; 2000. p. 1002‑16. Duke–Elders S. Tumors. In: System of Ophthalmology. Diseases of the Outer Eye. Vol. VIII. Part 2. Cornea and Sclera Henry Kimpton; St Louis, CV Mosby. 1965. p. 1144‑241. Trichilemmal cyst‑Wikipedia, the free encyclopedia. Accessed at htttp:// cyst. Jakobiec FA, Mehta M, Sutula F. Keratinous cyst of the palpebral conjunctiva. Ophthal Plast Reconstr Surg 2009;25:337‑9. Jakobiec FA, Mehta M, Greenstein SH, Colby K. The white caruncle: Sign of a keratinous cyst arising from a sebaceous gland duct. Cornea 2010;29:453‑5. Ikegami T, Kameyama M, Orikasa H, Yamazaki K. Trichilemmal cyst in the pulp of the index finger: A case report. Hand Surg 2003;8:253‑5.


10. 11. 12.


Satyaprakash AK, Sheehan DJ, Sangüeza OP. Proliferating trichilemmal tumors: A review of the literature. Dermatol Surg 2007;33:1102‑8. Rutty GN, Richman PI, Laing JH. Malignant change in trichilemmal cysts: A study of cell proliferation and DNA content. Histopathology 1992;21:465‑8. Lai TF, Huilgol SC, James CL, Selva D. Trichilemmal carcinoma of the upper eyelid. Acta Ophthalmol Scand 2003;81:536‑8. Kang SJ, Wojno TH, Grossniklaus HE. Proliferating trichilemmal cyst of the eyelid. Am J Ophthalmol 2007;143:1065‑7. Lee SJ, Choi KH, Han JH, Kim YD. Malignant proliferating trichilemmal tumor of the lower eyelid. Ophthal Plast Reconstr Surg 2005;21:349‑52. Mendoza PR, Jakobiec FA, Yoon MK. Keratinous cyst of the palpebral conjunctiva: New observations. Cornea 2013;32:513‑6.

Cite this article as: Kadri R, Parameshwar D, Ilanthodi S, Hegde S. Trichilemmal cyst of the bulbar conjunctiva: A rare presentation. Middle East Afr J Ophthalmol 2013;20:366-8. Source of Support: Nil, Conflict of Interest: None declared.

Middle East African Journal of Ophthalmology, Volume 20, Number 4, October - December 2013

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Trichilemmal cyst of the bulbar conjunctiva: a rare presentation.

We report a rare case of trichilemmal cyst involving the bulbar conjunctiva. A 55-year-old female presented with a history of a painless, progressive ...
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