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Conjunctival tumors

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Conjunctival tumors

  1. 1. 1Conjunctival tumors-Primary corneal tumors are exceedingly rare, and tumors effecting the cornea are usually extensions ofconjunctival tumors.-Any conjunctival cell type can potentially lead to one or more particular conjunctival tumor(s). Themajority of conjunctival tumors are benign. Malignant tumors of the conjunctiva are relatively rare.-conjunctival epithelial (including melanocytic) tumors are more common than conjunctival stromaltumors.-Background on the Conjunctiva-Main points:- at the limbus and lid margin the conjunctival epithelial cells are stratified squamousepithelium. (cuboidal at fornices and columnar on bulbar and tarsal surfaces)-The conjunctival stroma contains arteries, veins, nerves, fibroblasts, lymphoid cells(including histiocytes), primitive “myxoid” connective tissue, fat cells, lymphatic vessels,and other tissues.-embryologically conjunctiva is derived from surface ectoderm that is enclosed by theeyelid buds. The eyelid buds fuse and later separate, and sometimes leave eyelid tissuemixed in with the conjunctival tissue, especially on the bulbar surface (forming dermoidsand sometimes eyelid colobomas).-Melanocytes (neural crest cells) are found in the basal cell layer of epidermis. Theycreate melanin which is stored in melanosomes. Melanosomes are donated tokeratinocytes and hair follicle cells. Melanin protects the skin from non-ionizingultraviolet radiation. The number of melanocytes is the same among all races. Thenumber and size of melanosomes are greater versus the distribution of melanosomeswithin keratinocyte cytoplasm is more widely spread in darker complexions. Thenumber of melanocytes decreases with age and therefore complexions and hair lightenand the incidence of skin cancer increases.-Plica semilunaris is a vertical fold of conjunctival tissue lateral to caruncle-caruncle is a medial canthal fleshy prominence with cutaneous structures underlyingmucosal structures.Where does cancer happen first?- carcinogenesis is a genetic disease- Microbial agents: found within the host cell nucleus include viruses, but not bacteria orfungi, which may be why viral causes of conjunctival tumors outnumber other microbialcauses. Chronic infectious processes of all types can cause chronic inflammation whichcan be carcinogenic. For this reason H. pylori has been determined to be a cause ofcancer. Also, an association between Chlamydia and ocular lymphoma has beensuggested. Human Papilloma Virus (HPV) (arguably according to some sources) andKaposi sarcoma herpesvirus (definitely) are infectious causes of conjunctival tumors andare mentioned below.-Carcinogenic agents other than microbial, include: chemical, ultraviolet light anddietary
  2. 2. 2-no chemical causes identified below. (Foreign bodies can cause lesions which simulatea tumor and they are mentioned below.)-ultraviolet light has been linked to ocular surface squamous neoplasia and skin cancersincluding melanoma. (“Ocular surface squamous neoplasia” has been coined as anumbrella term to include corneal and conjunctival involvement of conjunctival tumors.)In the genetic condition xeroderma pigmentosum the repair mechanism for DNAdamaged by ultraviolet light does not function, increasing the rate of skin cancer 2000fold. In another aside, the substitution of thymidine for cytosine in the tumorsuppressor gene p53 is pathognomonic for ultraviolet light induced skin damage and isfound in 90% of squamous cell carcinomas. Epidemiological studies determined thatultraviolet light exposure (and not HPV) is the main influence in the development ofsquamous cell carcinoma of the conjunctiva.-no dietary causes identified below. (Vitamin A deficiency and Bitot’s spots as a lesionsimulating a tumor is mentioned below.)- cancer: a disease of stem cells?-basal cells are stem cell-like in having proliferative capacity and a lack of differentiation.-The location of conjunctival stem cells is not known but they may be decentralized-Many of the lesions below occur at the limbus, which is believed to be a site of(corneal) stem cells.Some NomenclatureThe name of a cancer is based on the proliferating cell type (and not the cell types whichsupport the proliferating cells)When epithelium is the proliferator of a malignancy then “carcinoma” is used-squamous cell carcinoma means malignancy of squamous epithelium (as is found at theconjunctival limbus and lid margin)When stroma is the proliferator of a malignancy then “sarcoma” is used- lymphangiosarcoma means malignancy of lymphatic vessel (as is found in theconjunctival stroma)The benign tumors of both epithelium and stroma have “-oma” endings.-squamous papilloma means benign tumor of squamous epithelium-lymphangioma means benign tumor of lymphatic vesselDysplasia – is mitosis occurring in a disordered fashion in suprabasalar epithelial cells. If the fullthickness of epithelial cell layers are dysplastic it is known as “carcinoma in situ” or the closestthing to malignancy without being malignant. A malignancy would include breaking through thebasement membrane and obtaining access to the circulation and thereby potentially causingmetastasis.
  3. 3. 3Acanthotic – means thickened epitheliumLeukoplakia – keratin formed on mucosal surfaces in white plaquesMajor Types of Conjunctival TumorType SubtypesEpidermal Non-melanocytic MelanocyticStromal Vascular Fibrous TissueNeural HistiocyticMyxoid MyogenicLipomatous LymphoproliferativeCongenital Hamartoma ChoristomaCaruncularMetastaticSecondarySimulating LesionsClassification of Epidermal Tumors of the ConjunctivaType SubtypesNon-melanocytic Benign Squamous papillomaKeratotic plaqueKeratocanthomaReactive Hyperplasia(pseudoepitheliomatoushyperplasia)Inverted Follicular keratosisHereditary intraepithelialdyskeratosisOncocytomaDacryoadenomaPremalignant and malignant Actinic (solar) keratosisConjunctival intraepithelialneoplasiaSquamous cell carcinomaXeroderma pigmentosumMelanocytic Benign Junctional nevusCompound nevusSpitz NevusBlue NevusPAM without atypiaCongenital melanosisRacial melanosisPremalignant and malignant PAM with atypiaMelanoma arising from neviMelanoma arising in PAMMelanoma arising de novo
  4. 4. 4Classification of Stromal Tumors of the ConjunctivaCategory SubtypesVascular Capillary hemangioma Cavernous hemangiomaVarix Racemose malformationHemangiopericytoma lymphangiectasiaKaposi’s Sarcoma lymphangiomaMalignant hemangioendotheliomaFibrous Nodular fasciitis FibromaBenign fibrous histiocytoma Malignant fibrous histiocytomaNeural Neurofibroma (localized) Neurofibroma (diffuse)Schwannoma (neurilemmoma) Granular cell tumorHistiocytic Xanthoma Juvenile xanthogranulomareticulohistiocytomaMyxoid myxomaMyogenic rhabdomyosarcomaLipomatous Lipoma Herniated orbital fatliposarcomaLymphoproliferative Benign reactive lymphoidhyperplasialymphomaLeukemic infiltratesCongenital tumors of the conjunctiva (hamartomas and choristomas)DermoidDermolipomaOsseous choristomaLacrimal gland choristomaComplex choristoma
  5. 5. 51. History – check old photographsa. If Since Childhood and….then consider…..i. Deep (Scleral), immobile, Flat, Uniform pigment, can be patchy, Bilateral, bulbar,interpalpebral1. congenital melanosisii. contains cysts ,Elevated, +/- pigment, suspicious if not Interpalpebral, feeder?,well circumscribed, mobile1. nevusiii. Limbal, Raised, White1. Dermoid (hairs) or other choristomasb. If Acquired and…i. Pigmented and… then consider…1. Variable pigmentation, flat, poorly circumscribed, mobilea. Primary Acquired Melanosis (PAM)2. Nodular, var. pig., +/- surr. flat pigment, Feeder v., immobilea. Malignant Melanomaii. Nonpigmented and…1. Anywhere and…a. Subepithelial, clear colorless fluidi. Epithelial cyst (not a tumor)b. Solid and…i. Single or multiple, hx of systemic malignancy1. Metastasisii. Reddish, velvety, hx of surgery or trauma1. Pyogenic granuloma (not a tumor)2. Palpebral and…a. Multiple, small, whitishi. Consider: sarcoidb. Rock hard, waxy, brittlei. Amyloidc. Salmon Pink , fleshy, solid, elevated, smooth, elderly pti. Lymphoma3. Bulbar and…a. Bilateral, keratinized, shiny plaquesi. Family hx (autosomal dominant), “V” shape1. Benign intraepithelial dyskeratosis (Haliwa)ii. Vitamin A deficiency1. Bitot’s spots (leukoplakia)b. Older adult, yellowish, 3 and 9 oclock locations, fibrovascular(drags conjunctiva onto cornea), can be bilateral, wing shaped,smooth surfaced (rare keratosis), very slow growth, iron line,can be bilateral and nasal and temporali. Pinguecula/Pterygium
  6. 6. 6c. Elderly pt, limbal, +/- adjacent corneal haze, unilateral,single(noninfectious), gelatinous, leukoplakic (minimal or absent inCIN), or papillary (strawberry-like)i. Conjunctival intraepithelial neoplasia (CIN) (Alsoconsider Keratotic plaque, Actinic keratosis, andSquamous cell carcinoma)d. Youth, non-limbal , strawberry-like , can be bilat./multiple(infectious)i. Squamous papilloma
  7. 7. 7ii.Classification of Epidermal Tumors of the ConjunctivaNon-melanocytic Benign1. Squamous papillomaA solitary sessile squamous papilloma of the bulbar conjunctiva.Two forms:A. adult papilloma – LIMBAL; not infectious/not associated with HPV, so unilateral, solitary.sometimes may be difficult to distinguish from squamous cell carcinoma. Can be pigmented andsimulate melanoma. Can develop in young adults who are immunosuppressed. One raresubtype has an inverted growth pattern involving underlying connective tissue. Tx with Excision.B. childhood papilloma – NON-LIMBAL; HPV associated so can be multiple, bilateral. Singh: can bemanaged by observation alone. Usually there is spontaneous resolution. Shields: remove orfreeze but avoid incomplete excision due to aggressive reoccurrence. Appears to have nomalignant potential.2. Keratotic plaque (and actinic (solar) keratosis which is listed below under premalignant)
  8. 8. 8Keratotic plaque in bulbar conjunctiva posterior to the limbus in a 19-year-old man.Keratotic plaques are all leukoplakic. Impossible to differentiate from actinic keratosis. Difficult todifferentiate benign from malignant. Only small chance of evolving into squamous cell carcinoma.Indistinguishable from CIN, which has slightly greater potential to convert to squamous cell carcinoma.Therefore the finding of leukoplakia in the conjunctiva is a relative indication for excision andcryotherapy, however it is acceptable to follow until progression is documented.Actinic Keratosis develops slowly and often occurs within epithelium overlying existing pinguecula orpterygium. Believed to be due to prolonged ultraviolet exposure.3. KeratocanthomaKeratoacanthoma of bulbar conjunctiva temporally showing leukoplakia.
  9. 9. 9Shields classifies keratoacanthoma as a form of reactive hyperplasia (pseudoepitheliomatous hyperplasia). Thislesion is more inflammatory, with more rapid onset and more rapid progression, than its malignant counterpartsquamous cell carcinoma.Because Squamous Cell Carcinoma cannot be ruled out Tx- Excision4. Reactive Hyperplasia (pseudoepitheliomatous hyperplasia)Reactive Hyperplasia (Pseudoepitheliomatous hyperplasia) of the conjunctiva at the limbus inferotemporally. Notethe leukoplakia secondary to hyperkeratosis.Reactive hyperplasia is secondary to chronic inflammation often due to pterygium or pinguecula or at site of priorforeign body. This lesion is more inflammatory, with more rapid onset and more rapid progression, than itsmalignant counterpart squamous cell carcinoma.Because Squamous Cell Carcinoma cannot be ruled out Tx- Excision5. Inverted Follicular keratosis (no image)6. Hereditary intraepithelial dyskeratosis
  10. 10. 10Associated with the Northeastern North Carolina Native American tribe, The Haliwa. Has also beenfound in individuals not of Haliwa ancestry.Bilateral elevated fleshy plaques in a “V” shape. It has no known malignant potential. Basementmembrane is intact. Tx – ocular lubricants, corticosteroids if needed.7. Oncocytoma (caruncular was only image available)Caruncular oncocytoma. Note the blue color and cystic appearance.A Common lesion of lacrimal gland. Asymptomatic, slowly enlarging swellings in older individuals. Tx Excision8. Dacryoadenoma
  11. 11. 11Rare, Tx ExcisionNon-melanocytic Premalignant and malignant9. Actinic (solar) keratosis (See Keratotic Plaque above)10. Conjunctival intraepithelial neoplasia (CIN)Small gelatinous conjunctival intraepithelial neoplasia near limbus, simulating inflammation, in a 77-year-old man.Can also be leukoplakic like keratotic plaque or papillomatous like squamous papilloma. (Beginning of acontinuum, with the mildest form being squamous papilloma and the most extreme form of whichtransgresses the basement membrane and is called squamous cell carcinoma.) Predisposing factorsinclude sunlight and HPV. Occurs frequently in immunosuppressed. Leukoplakia is absent or minimal inthis particular lesion, but may be present in others. Extensive leukoplakia should raise suspicion ofsquamous cell carcinoma. Tx – Excision
  12. 12. 12The umbrella term OCULAR SURFACE SQUAMOUS NEOPLASIA (OSSN) includes dysplasia, CIN andsquamous cell carcinoma of cornea and conjunctiva. OSSN: Use of 1% toluidine blue: One study of47pts, presented earlier this year by Dr. Valle, showed that 90% of pts with premalignant and 100% ofpts with malignant OSSN lesions showed positive staining.11. Squamous cell carcinomaSessile papillomatous squamous cell carcinoma at nasal limbus in elderly patient. Note the slight corneal invasionand the feeder vessels.Tx Excision. Occurs with much less frequency than CIN. Incidence 0.2-3.5 per 100,000. 75% in men and75% in ages > 60yrs and >75% at limbus. Large dilated blood vessels frequently feed and drain the mass.Locally invasive but metastasizes in only 1-2%. Intraocular invasion may necessitate enucleation.Mucoepidermoid and spindle cell forms are less common but aggressive. Mucoepidermoid mayoriginate in caruncle with a tendency toward orbital extension. Spindle cell form has a greater tendencyto metastasize.12. Xeroderma pigmentosum (no image) systemic condition with numerous lesions affecting sunexposed areas like the face.Melanocytic Benign13. Junctional nevus14. Compound nevusJunctional and Compound nevi discussed together:
  13. 13. 13Characteristic conjunctival nevus showing subtle clear cystic spaces.Amelanotic nevus:Light pink conjunctival nevus in a 13-year-old boyEvolution of a nevus: Generally becomes clinically apparent in 1stor 2nddecade of life. The nevus begins as a smallnest of cells in the basal layer (junctional) and in the 2ndto 3rddecade the cells migrate to underlying stroma(compound) and at this stage characteristic pseudocysts form. By the 3rdor 4thdecade the lesion has migratedentirely into the stroma (subepithelial). Usually no systemic associations, though rarely can be associated with
  14. 14. 14Carney Complex (includes heart problems) and dysplastic nevus syndrome (high incidence of cutaneousmelanoma).Usually discrete, mobile lesion on bulbar surface. Can be deeply pigmented or amelanotic. Can become morepigmented with time.-In contrast to melanoma, which is usually adherent to the globe, melanoses and nevi are movable withthe conjunctiva.Initial Mgt-periodic observation with photographs. If growth, consider excision, especially if family hx ofmelanoma.15. Spitz Nevus (no image)16. Blue NevusDark episcleral blue nevus in a 45-year-old woman.Blue nevus is deeper, may be attached to the sclera.Initial Mgt-periodic observation with photographs. If growth, consider excision, especially if family hx ofmelanoma.
  15. 15. 1517. PAM without atypiaPrimary acquired melanosis in temporal conjunctiva in a 46-year-old womanMild PAM (less than 1 clock hour of conjunctival involvement)Tx – Monitor for progression18. Congenital melanosis (of the sclera)
  16. 16. 16Scleral melanocytosis showing diffuse patchy brown pigment in superior aspect of the right eye.Though not conjunctival included here since in differential for PAM and conjunctival nevus.No mgt necessary19. Racial melanosisFigure 19.61. Patchy complexion-related conjunctival pigmentation in right eye. Note the characteristic linearspokelike deposits of pigment oriented perpendicular to limbus.No mgt necessary.Melanocytic Premalignant and malignant20. PAM with atypia
  17. 17. 17Diffuse primary acquired melanosis inferiorly in a 48-year-old woman.Moderate PAM with documented progression should be biopsied.Relative indications for biopsy (Shields)-lesion diameter >/= 5mm; documented progression, thickness of lesion, distinct nodule arising withinlesion (pigmented or not), nutrient vessels to lesion, involvement of cornea, involvement of palpebral conjunctiva,dysplastic nevus syndrome in pt or close relative, personal hx of cutaneous or uveal melanoma, pt fear of cancer.-Any nodule in PAM should be removed completely.21. Melanoma arising from nevi
  18. 18. 18Circumscribed melanoma at limbus, arising from a preexisting nevus in a 51-year-old woman. She gave a history ofa prior nevus at that site for many years, confirmed with inspection of prior photographs.Tx Excision22. Melanoma arising in PAMDiffuse primary acquired melanosis in inferior fornix with forniceal and medial canthal melanoma.Tx Excision23. Melanoma arising de novoIrregular melanoma near temporal limbus in a 45-year-old man.Tx Excision
  19. 19. 19Classification of Stromal Tumors of the ConjunctivaVascularPyogenic granuloma (not part of the classification scheme, but discussed here as part of vascular lesions)Small pyogenic granuloma in inferior fornix.Stains with Fluorescein.Tx with steroid early, or excision24. Capillary hemangioma
  20. 20. 20Capillary hemangioma of the conjunctiva in a 6-month-old child. The lesion had grown progressively for severalweeks.Mgt – observation since usually regresses. If amblyogenic tx with oral or intralesional steroid may hastenresolution. If other tumors like rhabdomyosarcoma cannot be excluded exisional biopsy is appropriate.25. Cavernous hemangiomaCavernous hemangioma attached to the scleral surface. This teen-aged girl first noticed the lesion while insertinga contact lens.Can occur in associated with Sturge-Weber syndrome, blue rubber bleb nevus syndrome, and diffuse neonatalhemangiomatosis.Mgt – periodic observation or local resection. Important to be sure not extension of orbitalhemangioma.26. Varix
  21. 21. 21Varix in superior bulbar conjunctiva in a 44-year-old woman. The lesion extended posteriorly into the anteriorportion of the orbit.Mgt – observe. if symptomatic or cosmetic, excision is possible with the understanding that the lesioncan have posterior orbital component.27. Racemose malformation (no image)28. HemangiopericytomaHemangiopericytoma arising from the inferior fornix in a 40-year-old woman.Neoplasm of vascular pericytesTx – excision.29. Lymphangiectasia
  22. 22. 22Conjunctival lymphangiectasia in a 24-year-old woman.May resemble cavernous hemangioma if filled with blood causing a blue-red or chocolate colored cyst.Usually represents a superficial component of deeper orbital lymphangioma.Tx resection and cautery30. Kaposi’s SarcomaConjunctival KS in an older patient who is presumably immunocompetent. He had a prior failed corneal transplantin the contralateral right eye. There is a slight anterior bulging of left lower eyelid secondary to the inferiorconjunctival mass.Can be the first sign of AIDS. Can resemble hemorrhagic conjunctivitis.Mgt – chemotherapy and low dose radiation31. Lymphangioma (also see Lymphagiectasia)
  23. 23. 23Hemorrhagic lymphangioma involving the nasal conjunctiva in the caruncle of a 40-year-old man.Tx resection and cautery32. Malignant hemangioendothelioma (no image)Other vascular lesions to be aware of:MacrovesselsEpiscleral macrovessel located inferiorly in an otherwise normal eye. This vascular lesion is presumed to be acongenital malformation and is not associated with ciliary body melanoma. However, detailed examination to
  24. 24. 24exclude a ciliary body melanoma is mandatory in such cases. Such a vessel can also be seen with an irisarteriovenous communicaion.Shown for comparison is an episcleral sentinel blood vessel overlying a ciliary body malignant melanoma.Fibrous33. Nodular fasciitisNodular fasciitis in epibulbar tissues superotemporally in an 11-year-old boy.
  25. 25. 25Thought to originate from tenon’s capsule. Nodular, not encapsulated. Round or oval. Composed offibroblasts. Can be misdiagnosed as sarcoma due to numerous mitotic figures.Tx - Excision34. FibromaInvolvement of left conjunctiva with diffuse fibroma in a 74-year-old woman.Rare. Slowly progressive stromal tumor acquired in adulthood. Composed of fibroblasts and collagen.Tx - Excision35. Benign and malignant fibrous histiocytoma
  26. 26. 26Localized fibrous histiocytoma at limbus superonasally in an 8-year-old boyGenerally in adults, but a case of fibrous histiocytoma in a child with xeroderma pigmentosum has beenreported. Amelanotic mass ranging from well-circumscribed to diffuse. Often at limbus. Mixture ofspindle shaped fibroblasts and lipid-laden histiocytes formed from primitive mesenchyme. Malignanttypes are extremely rare can show marked pleomorphism, many mitotic figures, and multinucleatedgiant cells. Can metastasize to regional lymph nodes and hematogenously to distant organs causingdeath.Tx- Excision if benign, radical surgery if malignantNeural36. Neurofibroma (localized) (Neuroma is included here as well)Circum scribed episcleral neurofibrom a in a 22-year-old woman. Although initially reported as beingunassociated with neurofibrom atosis, the patient eventually developed NF-2Peripheral nerve sheath (Schwann cell) tumor. Stromal solitary pink-yellow circumscribed or plexiform mass.Solitary type not usually associated with systemic disease, but plexiform type associated withneurofibromatosis type 1.Tx – excise solitary lesion, debulk plexiform lesion
  27. 27. 2737. Neurofibroma (diffuse)Very subtle diffuse neurofibroma of the inferior bulbar conjunctiva in a young girl with NF-1.Neurofibroma of eyelid
  28. 28. 28Plexiform subconjunctival neuroma; Characteristic features of MEN-2B syndrome38. Schwannoma (neurilemmoma)Epibulbar schwannoma in a 15-year-old boy. The lesion appeared and enlarged slowly over several weeks.
  29. 29. 29Benign rare. Can arise in any part of conjunctiva. Pink-yellow elevated stromal mass. Schwann cellproliferation. Malignancy has not been reported.Tx- Excision39. Granular cell tumorGranular cell tumor arising inferotemporally in the left eye of a 5-year-old girl.Also known as myoblastoma. Very rare benign. Of disputed origin. Possibly Schwann cell. Pink elevatedsmooth well circumscribed stromal mass.Tx - ExcisionHistiocytic40. Xanthoma (no image)Yellow, subepithelial, epibulbar mass. In a case of xanthoma disseminatum, multiple lesions foundincluding on limbus of both eyes. Infiltrate of Lipid-laden histiocytes and other cells.41. Juvenile xanthogranuloma
  30. 30. 30Conjunctival juvenile xanthogranuloma located at limbus in a 12-year-old girlSolitary orange-pink stromal mass.42. reticulohistiocytomaLocalized reticulohistiocytosis at the limbus in a 21-year-old woman.
  31. 31. 31Histopathology of lesion showing large histiocytes with a granular cytoplasmMyxoid43. myxomaConjunctival myxoma of nasal conjunctiva in a 31-year old man.
  32. 32. 32Myogenic44. rhabdomyosarcomaTHE MOST COMMON MALIGNANT OCULAR TUMOR OF CHILDHOODLipomatous45. LipomaConjunctival lipoma in a child with familial hypercholesterolemia.46. Herniated orbital fat (no image)47. Liposarcoma (no image)
  33. 33. 33Lymphoproliferative48. Benign reactive lymphoid hyperplasiaConjunctival benign reactive lymphoid hyperplasia presenting as a sessile lesion in the vicinity of the medial rectusmuscle in an 83-year-old woman.49. LymphomaLEADING CAUSE OF CANCER DEATHS in <55yo groupOrbital lymphoma
  34. 34. 34Conjunctival lymphom a presenting as a circum scribed mass near the limbus in a 43-year-old woman.Diffuse lymphoma affecting medial aspect of conjunctiva in a 39-year-old woman
  35. 35. 3550. Leukemic infiltratesDiffuse conjunctival leukemic infiltrate in right eye of a 60-year-old man with chronic lymphocytic leukemia.
  36. 36. 36Congenital tumors of the conjunctiva (hamartomas and choristomas)Fusion of lid folds (9thweek of embryonic development)51. DermoidTypical round conjunctiva at the corneoscleral lim bus inferotemporally.
  37. 37. 3752. DermolipomaSessile dermolipoma superotemporally in right eye of a 5-year-old girl53. Conjunctival and corneal dermoids – embryological events
  38. 38. 38Epibulbar dermoid and facial pit (lower left cheek) (and dermolipoma- not seen here)in Goldenhar syndromePreauricular skin appendages in the patient showing in Figure 16.4. The patient also had hearing loss, consistentwith Goldenhar syndrome.54. Osseous choristomaTypical epibulbar osseous choristoma in a 25-year-old woman.
  39. 39. 3955. Lacrimal gland choristomaSmall lacrimal gland choristoma located near the limbus in a 40-year-old woman. The lesion had apparently beenpresent since birth. It was excised because of a foreign body sensation. The diagnosis was not suspected clinically.56. Complex choristoma
  40. 40. 40Epibulbar complex choristoma in a child with the organoid nevus syndrome. The diffuse lesion covers the lateralthird of the cornea.View of preauricular area showing tan sebaceous nevusCaruncular
  41. 41. 41Papilloma of caruncle in a 31-year-old woman.Small noncystic caruncular nevus in a 40-year-old woman.
  42. 42. 42Caruncular melanoma with involvement of the adjacent eyelid skin.Lymphoma affected mainly the caruncle with some involvement of the adjacent conjunctiva in a 54-year-old man.Metastatic
  43. 43. 43Lung cancer metastatic to the conjunctiva in a 55-year-old man. Subsequent systemic evaluation revealed theprimary lung cancer.Breast cancer metastatic to the conjunctiva in a 55-year-old woman.
  44. 44. 44Tan-colored mass in bulbar conjunctiva of a 48-year-old woman with a history of cutaneous melanom a. She had noknown metastasis at time of ocular presentation, but was subsequently found to have widespread metastases.Everted right upper eyelid showing multiple foci of metastatic melanoma on the tarsal conjunctivaSecondary
  45. 45. 45Sebaceous carcinoma of the caruncle in a 68-year-old woman. Note the clinical similarity to the sebaceous glandhyperplasiaSimulating LesionsInferotemporal epithelial inclusion cyst in bulbar conjunctiva in a middle-aged woman.
  46. 46. 46Pigmented epithelial inclusion cyst simulating a conjunctival melanoma in a 62-year-old African American patient.Large, gray-black conjunctival lesion in a 24-year-old m an referred w ith the diagnosis of conjunctival m elanoma. History revealed that he had been hit in the eye with a pencil at age 7 years. The lesion had gradually enlargedover the last 5 years.
  47. 47. 47Histopathology of the lesion showing inflam m atory reaction around lead foreign bodyBulbar conjunctiva of right eye of another patient. The lesion was removed and documented to be a metallicforeign body.
  48. 48. 48M ascara deposit (m ascarom a) near lim bus sim ulating conjunctiva melanoma in a patient who used excessivemascara.Diffuse episcleritis in a 67-year-old man. Acute-onset and Irritation.
  49. 49. 49Nodular scleritis near the limbus in a 25-year-old woman. Gradual or acute. Painful.Thickening and hyperemia of the upper tarsus in a 64- year-old man with Churg-Strauss syndrome.
  50. 50. 50Ligneous conjunctivitis involving the palpebral and limbal conjunctiva in a 68-year-old woman. She had cataractsurgery and pterygium about 5 months before the onset of these lesions.Rare. Characteristic “woody,” thick membrane formation. Due to plasminogen deficiency, often autosomalrecessive, may be sporadic.Spontaneous staphylococcal abscess in a 47-year-old woman. The lesion extended through the sclera necessitatinga scleral graft. The patient had an excellent recovery after antibiotic treatment. Acute. Painful.
  51. 51. 51Solitary lesion of molluscum contagiosum at the inferior limbus in a patient with acquired immunodeficiencysyndrome. Domed. May be chronic irritation.Sarcoidosis was confirmed on conjunctival biopsy. The patient had systemic sarcoidosis but no other ocularinvolvement.
  52. 52. 52Serratia marscesens abscess simulating a conjunctival lymphoma. This yellow-pink lesion is in the bulbarconjunctiva of an elderly man who had prior cataract and glaucoma surgery. AcuteConjunctival amyloidosis in inferior conjunctival fornix in a 50-year-old w om an, appearing as a subtle pinkthickening of the affected tissue. The first clinical diagnosis was lymphoma, but amyloidosis was a secondaryconsideration.
  53. 53. 53Slightly inflamed pinguecula nasally in a 51-year-old man.Pterygium with severe secondary inflammation.
  54. 54. 54Congenital uveal staphyloma in an 11-year-old boy.Calcified scleral plaque in a 75-year-old woman
  55. 55. 55Extraocular extension of uveal melanoma. Note the adjacent sentinel vessels

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