a 70-year - old male patient presented with painless , gradually increasing swelling in the right lower bulbar conjunctiva for 6 months followed by redness and watering for last 3 weeks .
ocular examination revealed a 14 mm  7 mm red fleshy mass in the lower bulbar conjunctiva in the right eye [ fig . 1 ] .
clinical photograph showing 14 mm  7 mm red fleshy mass in right lower bulbar conjunctiva the conjunctival mass was clinically diagnosed to be a squamous cell carcinoma in situ , lymphoma or amyloidosis .
histopathology revealed a localized granulomatous inflammation with histiocytes around a homogeneous material along with giant cells and chronic inflammatory cells [ figs . 2 and 3 ] .
van gieson stain demonstrated the complete absence of elastic tissue at the center of the granuloma [ fig . 4 ] .
h and e stain 100 microphotograph showing giant cells , inflammatory cells , and histiocytes in the granuloma .
[ h and e stain 400 ] microphotograph showing the absence of elastic tissue in the centre of granuloma .
annular elastolytic giant cell granuloma is a condition characterized histologically by damaged elastic fibers surrounded by numerous giant cells and absence of necrobiosis , lipid , mucin , and pallisading of the granuloma .
it almost always occurs on sun exposed skin , such as face , neck , dorsum of hand , forearm , and arm and hence the previous name actinic granuloma ; however there are few reports occurring in sun - protected sites .
the term actinic granuloma was coined by o brien in 1975 , who described similar histological features in cutaneous lesions of patients with sun - damaged skin .
subsequently this concept was disputed by ragaz and ackerman , who believed that actinic granuloma was a variant of granuloma annulare .
mcgrae postulated that actinic granuloma represented a cell - mediated immune response to actinically altered elastotic fibers with a preponderance of helper t cells in the lymphocytic infiltrate .
the occurrence of conjunctival actinic granuloma in isolation is a rare entity . in the past four decades
all the previous cases were females , our case being the first such lesion occurring in a male patient .
the size of all the previous lesions varied between 2 and 3 mm occurring in nasal or temporal bulbar conjunctiva . in those cases the clinical differential diagnoses were pinguicula , pinguiculitis , bowens disease , and conjunctival nevus . in our case
14 mm  7 mm , a fleshy mass involving the whole of the lower bulbar conjunctiva .
the clinical differential diagnoses were squamous cell carcinoma in situ , mucosa associated lymphoid tumor ( maltoma ) , amyloidosis , and leukemic deposit .
the absence of caseous necrosis excludes tuberculosis and the prominent eosinophilic response invited by fungal and parasitic lesions was not present in this case .
the noninfectious granulomatous inflammation includes foreign - body giant cell reaction , granuloma annulare or pseudoheumatoid nodule , and necrobiosis lipoidica .
granuloma annulare presents with abundant mucin , partial loss of elastic fibers and radial arrangement of epithelioid histiocytes ( pallisading granuloma ) . in necrobiosis
the complete loss of elastic tissue in the central zone as documented by connective tissue stain is used as the primary basis for separating annular elastolytic giant cell granuloma from granuloma annulare and necrobiosis lipoidica .
thus actinic granuloma of conjunctiva is a distinct clinical , histological , and immunological lesion .
though rare , the clinician should consider the possibility of actinic granuloma presenting as a fish flesh mass in the conjunctiva and pathologist should consider the possibility of granulomatous inflammation in association with elastolysis and does not necessarily imply the presence of foreign bodies or infection .
regarding medical treatment hydroxychloroquine , clofazimine , dapsone , intralesional , and systemic steroid has been used in annular elastolytic giant cell granuloma ( aegg ) of skin .
 annular elastolytic giant cell granuloma is a condition characterized histologically by damaged elastic fibers associated with preponderance of giant cells along with absence of necrobiosis , lipid , mucin , and pallisading granuloma . 
 it usually occurs on sun - damaged skin and hence the previous name actinic granuloma . 
 a similar process occurs on the conjunctiva . over the past three decades 
 only four cases of conjunctival actinic granuloma have been documented . 
 all the previous patients were females with lesions in nasal or temporal bulbar conjunctiva varying 2 - 3 mm in size . 
 we report a male patient aged 70 years presenting with a 14 mm  7 mm fleshy mass on right lower bulbar conjunctiva . 
 clinical differential diagnoses were lymphoma , squamous cell carcinoma in situ and amyloidosis . surgical excision followed by histopathology confirmed it to be a case of actinic granuloma . 
 this is the first case of isolated conjunctival actinic granuloma of such a large size reported from india . 