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Golf-Ball Granuloma of the Eyelids and Conjunctiva
GOLF-BALL GRANULOMA O F T H E EYELIDS AND CONJUNCTIVA RICHARD O'GRADY, M.D.,
AND DAVID SHOCH,
M.D.
Chicago, Illinois
The physical and psychological hazards associated with one of our most popular pastimes—golf—exist generally in and about the area of play. Occasionally, human inquisitiveness produces a golf-related in jury that is difficult to recognize and treat if the essential history of trauma is unavailable. The sudden opening of the pressurized liq uid center still found in many of today's golf balls can inject, painlessly at times, various substances into the face and eyes of the un suspecting dissector. The clinical and histo logie features of a case involving foreignbody granulomas of skin and conjunctiva following the opening of a liquid-center golf ball are presented in this report.
Fig. 1 (O'Grady and Shoch). The granuloma presents as a protuberant, crusted inflammatory mass involving the outer canthal area.
C A S E REPORT
A 13-year-old girl inserted a golf ball (brand unknown) into a vise and began to cut away with a linoleum knife. Suddenly, as the liquid center was opened, its contents escaped, striking her in the face and coating the garage ceiling. Several days later her parents noted a crusted mass at the outer canthus and a smooth white mass over the temporal aspect of the right eye (Figs. 1 and 2). The skin lesion enlarged and drained over a two-month inter val despite'local and systemic antibiotics, while the conjunctival mass remained the same. Visual acuity was normal at all times. When first seen by one of us in consultation, the child finally related the golfball incident. X-ray films demonstrated radiopaque material in the skin at the site of the injury only (Fig. 3). The child was admitted to the hospital and under general anesthesia the entire temporal canthal area was excised and a plastic repair done. The material embedded in the conjunctiva was ex cised separately. The postoperative course was un eventful and the cosmetic appearance has been ex cellent.
Fig. 2 (O'Grady and Shoch). The adjacent placoid conjunctival lesion is well demarcated and rela tively free of inflammation.
stained paraffin sections. On hematoxylin and eosin staining, however, the foreign material consisted of brown granules located in the subepithelial areas. Much of it was found in the cytoplasm of macrophages and giant cells (Fig. 4), although large extracellular aggre gates were scattered throughout the area HISTOLOGICAL E X A M I N A T I O N (Fig. 5). Islands of lymphocytes and plasma In the laboratory, the excised material ap cells were interspersed throughout the gran peared cheesy white both grossly and on un- uloma. While the particles appeared brown From the Department of Ophthalmology, North under ordinary light, they exhibited a pecu liar whitish glow, or birefringence, under western University Medical School. Reprint requests to Richard O'Grady, M.D., De polarized light (Fig. 6 ) . Iron and melanin partment of Ophthalmology, Northwestern Univer stains were negative, and permanganate sity Medical School, 303 East Chicago Avenue, Chi bleaching failed to alter their color. Diagnocago, Illinois 60611. 148
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Fig. 3 (O'Grady and Shoch). Radiograph demon strates soft tissue opacification (arrows) that cor responds to the skin lesion.
sis was foreign-body granuloma of the eye lid and conjunctiva. DISCUSSION
A number of reports involving golf-ball injuries to the eyes and surrounding tissues have been made during the past decade.1"4 Generally, the ocular injuries have been rela tively minor, although recurrent corneal abrasion, traumatic iritis, and hyphema have occurred. The material within the liquid cen ters varies and can include barium salts, zinc sulfide, gelatin, silicone, sulfuric acid, so dium hydroxide, lead, ethylene glycol, and
Fig. 4 (O'Grady and Shoch). Distinct granules fill the cytoplasm of macrophages and an occasional giant cell (arrow) (hematoxylin-eosin, X200).
ISO
AMERICAN JOURNAL OF OPHTHALMOLOGY
J U L Y , 1973
Fig. S (O'Grady and Shoch). In some areas there is extensive tissue necrosis associated with heavy ac cumulation of pigment granules (hematoxylin-eosin, X200).
water. The liquid center is contained under pressures up to 2,500 pounds per square inch —a force sufficient to drive substances through the skin and conjunctiva without leaving a detectible surface mark or produc ing any discomfort. Although solid golf balls are now marketed, those with liquid centers are and will be available for a long time. The paraffin blocks were submitted to the laboratory of Dr. Frank Johnson at the Armed Forces Institute of Pathology where x-ray diffraction and histochemical tech niques identified the material. It contained at least zinc sulfide and barium sulfate. Not surprisingly, the barium salts permitted radi ographie visualization of the skin lesion in this case. The granular birefringence of the particles under polarized light is striking and provides a most important clue in differenti ating them quickly from the melanin gran ules of nevi and melanomas. Unlike melanin,
they do not take a melanin stain nor can they be bleached by ordinary bleaching solutions. Previous reports1"4 emphasize the disparity between the amount of foreign material and the relatively low-grade inflammatory re sponse. While this was also true in this case, there were focal lymphocytic infiltrations throughout the area that could have resulted from secondary infection rather than the primary injury. As in other cases, the major cellular response consisted of macrophages and foreign-body giant cells. These micro scopic features provide sufficient informa tion to diagnose golf-ball granuloma even when corroborating clinical evidence is un available. SUMMARY
The explosive release of the liquid con tents from a golf-ball center produced a typ ical foreign-body granuloma in the eyelid
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GOLF-BALL GRANULOMA
151
Fig. 6 (O'Grady and Shoch). polarized light reveals large (intracellular) and small (extracellular) areas of biréfringent granules. Cell nuclei appear dark (hematoxylin-eosin, X800).
and conjunctiva of a 13-year-old girl. The injected material appeared white grossly, but brown on paraffin sections. Polarized light produced a peculiar white glow or birefrin gence of the granules that were free in tissue and inside macrophages and giant cells. Histochemical and x-ray diffraction techniques identified barium sulfate and zinc sulfide in the material. The clinical appearance, while nonspecific, can be alarming and it resem bles severe inflammatory or even neoplastic disease. The microscopic features are suffi
ciently characteristic to suggest one of golf's less wellknown hazards. REFERENCES
1. Johnson, F. B., and Zimmerman, L. E. : Bar ium sulfate and zinc sulfide deposits from golf-ball related injury to the conjunctiva and eyelid. Am. J. Clin. Path. 44:533, 1965. 2. Penner, R.: The liquid center golf ball: A po tential ocular hazard. Arch. Ophth. 75:68, 1966. 3. Slusher, M., Jaegers, K., and Annesley, W. : Liquid-center golf balls and ocular injury. Am. J. Ophth. 64:736, 1967. 4. Nelson, C. : Eye injury from exploding golf balls. Brit. J. Ophth. 54:670, 1970.
AND DAVID SHOCH,
M.D.
Chicago, Illinois
The physical and psychological hazards associated with one of our most popular pastimes—golf—exist generally in and about the area of play. Occasionally, human inquisitiveness produces a golf-related in jury that is difficult to recognize and treat if the essential history of trauma is unavailable. The sudden opening of the pressurized liq uid center still found in many of today's golf balls can inject, painlessly at times, various substances into the face and eyes of the un suspecting dissector. The clinical and histo logie features of a case involving foreignbody granulomas of skin and conjunctiva following the opening of a liquid-center golf ball are presented in this report.
Fig. 1 (O'Grady and Shoch). The granuloma presents as a protuberant, crusted inflammatory mass involving the outer canthal area.
C A S E REPORT
A 13-year-old girl inserted a golf ball (brand unknown) into a vise and began to cut away with a linoleum knife. Suddenly, as the liquid center was opened, its contents escaped, striking her in the face and coating the garage ceiling. Several days later her parents noted a crusted mass at the outer canthus and a smooth white mass over the temporal aspect of the right eye (Figs. 1 and 2). The skin lesion enlarged and drained over a two-month inter val despite'local and systemic antibiotics, while the conjunctival mass remained the same. Visual acuity was normal at all times. When first seen by one of us in consultation, the child finally related the golfball incident. X-ray films demonstrated radiopaque material in the skin at the site of the injury only (Fig. 3). The child was admitted to the hospital and under general anesthesia the entire temporal canthal area was excised and a plastic repair done. The material embedded in the conjunctiva was ex cised separately. The postoperative course was un eventful and the cosmetic appearance has been ex cellent.
Fig. 2 (O'Grady and Shoch). The adjacent placoid conjunctival lesion is well demarcated and rela tively free of inflammation.
stained paraffin sections. On hematoxylin and eosin staining, however, the foreign material consisted of brown granules located in the subepithelial areas. Much of it was found in the cytoplasm of macrophages and giant cells (Fig. 4), although large extracellular aggre gates were scattered throughout the area HISTOLOGICAL E X A M I N A T I O N (Fig. 5). Islands of lymphocytes and plasma In the laboratory, the excised material ap cells were interspersed throughout the gran peared cheesy white both grossly and on un- uloma. While the particles appeared brown From the Department of Ophthalmology, North under ordinary light, they exhibited a pecu liar whitish glow, or birefringence, under western University Medical School. Reprint requests to Richard O'Grady, M.D., De polarized light (Fig. 6 ) . Iron and melanin partment of Ophthalmology, Northwestern Univer stains were negative, and permanganate sity Medical School, 303 East Chicago Avenue, Chi bleaching failed to alter their color. Diagnocago, Illinois 60611. 148
VOL. 76, NO. 1
GOLF-BALL GRANULOMA
149
Fig. 3 (O'Grady and Shoch). Radiograph demon strates soft tissue opacification (arrows) that cor responds to the skin lesion.
sis was foreign-body granuloma of the eye lid and conjunctiva. DISCUSSION
A number of reports involving golf-ball injuries to the eyes and surrounding tissues have been made during the past decade.1"4 Generally, the ocular injuries have been rela tively minor, although recurrent corneal abrasion, traumatic iritis, and hyphema have occurred. The material within the liquid cen ters varies and can include barium salts, zinc sulfide, gelatin, silicone, sulfuric acid, so dium hydroxide, lead, ethylene glycol, and
Fig. 4 (O'Grady and Shoch). Distinct granules fill the cytoplasm of macrophages and an occasional giant cell (arrow) (hematoxylin-eosin, X200).
ISO
AMERICAN JOURNAL OF OPHTHALMOLOGY
J U L Y , 1973
Fig. S (O'Grady and Shoch). In some areas there is extensive tissue necrosis associated with heavy ac cumulation of pigment granules (hematoxylin-eosin, X200).
water. The liquid center is contained under pressures up to 2,500 pounds per square inch —a force sufficient to drive substances through the skin and conjunctiva without leaving a detectible surface mark or produc ing any discomfort. Although solid golf balls are now marketed, those with liquid centers are and will be available for a long time. The paraffin blocks were submitted to the laboratory of Dr. Frank Johnson at the Armed Forces Institute of Pathology where x-ray diffraction and histochemical tech niques identified the material. It contained at least zinc sulfide and barium sulfate. Not surprisingly, the barium salts permitted radi ographie visualization of the skin lesion in this case. The granular birefringence of the particles under polarized light is striking and provides a most important clue in differenti ating them quickly from the melanin gran ules of nevi and melanomas. Unlike melanin,
they do not take a melanin stain nor can they be bleached by ordinary bleaching solutions. Previous reports1"4 emphasize the disparity between the amount of foreign material and the relatively low-grade inflammatory re sponse. While this was also true in this case, there were focal lymphocytic infiltrations throughout the area that could have resulted from secondary infection rather than the primary injury. As in other cases, the major cellular response consisted of macrophages and foreign-body giant cells. These micro scopic features provide sufficient informa tion to diagnose golf-ball granuloma even when corroborating clinical evidence is un available. SUMMARY
The explosive release of the liquid con tents from a golf-ball center produced a typ ical foreign-body granuloma in the eyelid
VOL. 76, NO. 1
GOLF-BALL GRANULOMA
151
Fig. 6 (O'Grady and Shoch). polarized light reveals large (intracellular) and small (extracellular) areas of biréfringent granules. Cell nuclei appear dark (hematoxylin-eosin, X800).
and conjunctiva of a 13-year-old girl. The injected material appeared white grossly, but brown on paraffin sections. Polarized light produced a peculiar white glow or birefrin gence of the granules that were free in tissue and inside macrophages and giant cells. Histochemical and x-ray diffraction techniques identified barium sulfate and zinc sulfide in the material. The clinical appearance, while nonspecific, can be alarming and it resem bles severe inflammatory or even neoplastic disease. The microscopic features are suffi
ciently characteristic to suggest one of golf's less wellknown hazards. REFERENCES
1. Johnson, F. B., and Zimmerman, L. E. : Bar ium sulfate and zinc sulfide deposits from golf-ball related injury to the conjunctiva and eyelid. Am. J. Clin. Path. 44:533, 1965. 2. Penner, R.: The liquid center golf ball: A po tential ocular hazard. Arch. Ophth. 75:68, 1966. 3. Slusher, M., Jaegers, K., and Annesley, W. : Liquid-center golf balls and ocular injury. Am. J. Ophth. 64:736, 1967. 4. Nelson, C. : Eye injury from exploding golf balls. Brit. J. Ophth. 54:670, 1970.