Treatment of large conjunctival nevus by resection and reconstruction using amniotic membrane

Background Nevus of the bulbar conjunctiva is a benign pigmented lesion of the ocular surface. Unless a biopsy is required for ruling out malignant melanoma, a nevus is usually excised for cosmetic reasons only. However, with large lesions involving two or more quadrants of the bulbar conjunctiva, a total resection can be difficult. In this report, we present a case of a huge nevus treated by surgical excision and amniotic membrane transplantation for reconstruction of the bulbar conjunctiva.Methods A 54-year-old Japanese man was referred to our clinic with suspected malignant tumor of the bulbar conjunctiva in his right eye. A large and diffuse pigmented tumor with numerous small cysts was present mainly on the upper bulbar conjunctiva. Resection of the conjunctival tumor and amniotic membrane transplantation for reconstruction of the bulbar conjunctiva were performed.Results The histopathological diagnosis was conjunctival nevus. Epithelialization of the bulbar conjunctiva over the amniotic membrane sheet was completed 4 weeks after resection. At 44-month follow-up, there was no recurrence or any postoperative complication.Conclusion Surgical resection combined with reconstruction by amniotic membrane transplantation is effective for the treatment of large conjunctival nevus.     

Intraepithelial sebaceous carcinoma of the conjunctiva and skin of the eyelid.

The authors report a 65-year-old woman with a 10-year history of conjunctivitis and progressive loss of lashes due to widespread intraepithelial sebaceous carcinoma of the conjunctiva and skin of the eyelid. After surgery, serial sections of the entire conjunctiva and eyelids showed a single focus of invasive carcinoma in the bulbar conjunctiva, which probably arose from the epithelium. The absence of cilia on the affected lower lid was associated with neoplastic obliteration of the cilial orifices and low-grade, smoldering lipogranulomatous inflammation. This type of tumor-related alopecia is likely to masquerade as blepharitis because there is no identifiable tumefaction or clinical evidence of recurrent chalazia to suggest an underlying sebaceous carcinoma. The 10-year history of "conjunctivitis" before diagnosis indicates that intraepithelial sebaceous carcinoma may have a prolonged clinical course.     

Total lid replacement by an autologous and homologous combination graft in emergencies

Report on 3 cases with total loss of a lid which required an "emergency lid" in order to protect the cornea. In all cases the tarsus was replaced by a strip of dura mater, the eye-lid skin by a free retroauricular graft. In all 3 cases the attempt was made to mobilize the levator and other adjacent tissue and fix them to the tarsus replacement. In one case the upper palpebral and bulbar conjunctiva was also replaced by 2 flaps of lip mucosa. In this case the lower half of the tarsal zone was rejected; however, the situation was mastered by tarsoconjunctival shifting of the lower lid with a free lid skin graft from the other eye. All "emergency lids" resulted in lid closure which protected the cornea sufficiently. The 2 patients in whom the upper lid was replaced had active lid movement of 3 to 4 mm.     

Sebaceous carcinoma of the eyelids. The role of adjunctive cryotherapy in the management of conjunctival pagetoid spread

The extension of sebaceous carcinoma of the eyelid within the epithelium of the palpebral, forniceal, and bulbar conjunctiva (pagetoid spread) is a frequent indication for exenteration, but this recommendation is controversial. Six patients with upper eyelid tumors and variable degrees of epibulbar pagetoid extension were treated without exenteration. All underwent wide local resections of their upper eyelids (repaired by Cutler-Beard procedures), with adjunctive cryotherapy to the involved epibulbar surfaces after preoperative map biopsies of the conjunctiva had been done. Cryotherapy was applied during the second-stage Cutler-Beard procedure after initial resection of the tumor bulk. Follow-ups ranging from 12 to 50 months, with conjunctival biopsies at 6-month intervals, showed no recurrence of pagetoid tumor. Although exenteration was avoided, dry-eye symptoms, symblepharon, corneal erosion, and vascularization were side effects, which the patients were willing to tolerate to avoid radical surgery. The complications were most severe in the two patients who were either elderly or had more than two quadrants of epibulbar pagetoid disease.     

Primary orbital melanoma associated with oculodermal melanocytosis

A 29-year-old, otherwise healthy man presented with an approximately 5-months' history of left-sided exophthalmos. The patient had a bluish-black pigmentation on his left upper lid, and black pigmentation on the left conjunctiva and sclera, since birth. CT examination revealed a retrobulbar tumor in the left orbit, and the left medial rectus muscle was wider than the right one. The left orbital cavity and the superior orbital fissure were enlarged. All of the examinations were negative in respect of another primary tumor outside the orbit or of tumor dissemination. At surgery, a pigmented tumor was found and removed. The orbital tissues were darkly pigmented. Histological examination of the excised tumor showed it to be an encapsulated, circumscribed mass. The tumor was built up of fusiform and spindle-shaped cells containing black pigmentation, with very few mitoses and without necrosis. There has been no recurrence or metastasis in 3 years of follow-up. The consequences of the tumorous transformation of oculodermal melanocytosis as reflected in the published literature and the special clinical and histopathological characteristics of our case are discussed.     

An embedded contact lens in the upper lid masquerading as a mass.

A patient who "lost" his right contact lens three years prior to our examination was found to have a mass in the right upper lid which contained the hard contact lens. A careful search of the superior fornix and the upper lid, with double eversion of the lids, is indicated in instances where a patient presents reporting loss of a lens he was wearing or inserting.     

Modified full-lid transplants ("tarsomarginal transplants") in reconstructive eyelid surgery

The author first used modified full-thickness lid grafts (tarsomarginal grafts) in lid reconstruction in 1972. They consist of only conjunctiva, tarsus, and lid margin. The anterior lid lamella is rebuilt by a myocutaneous flap from the adjacent tissue. As compared to conventional full-thickness lid grafts, this reduces the risk of necrosis. No cosmetic or functional disturbance of donor eyelids was observed. In cases of total lid loss up to three tarsomarginal grafts can be inserted simultaneously. The use of modified full-thickness grafts is superior to other well-known techniques, especially in cases with defects of the medial half of the lower lid and upper lid defects, up to and including total upper lid loss, even if the tarsus in the grafts is subject to regressive changes and the lashes are usually lost.     

Primary orbital melanoma associated with oculodermal melanocytosis

A 29-year-old, otherwise healthy man presented with an approximately 5-months' history of left-sided exophthalmos. The patient had a bluish-black pigmentation on his left upper lid, and black pigmentation on the left conjunctiva and sclera, since birth. CT examination revealed a retrobulbar tumor in the left orbit, and the left medial rectus muscle was wider than the right one. The left orbital cavity and the superior orbital fissure were enlarged. All of the examinations were negative in respect of another primary tumor outside the orbit or of tumor dissemination. At surgery, a pigmented tumor was found and removed. The orbital tissues were darkly pigmented. Histological examination of the excised tumor showed it to be an encapsulated, circumscribed mass. The tumor was built up of fusiform and spindle-shaped cells containing black pigmentation, with very few mitoses and without necrosis. There has been no recurrence or metastasis in 3 years of follow-up. The consequences of the tumorous transformation of oculodermal melanocytosis as reflected in the published literature and the special clinical and histopathological characteristics of our case are discussed.     

眼睑重叠综合征的诊断和治疗

目的探讨眼睑重叠综合征的诊断和治疗。方法收集了2001年1月至2004年12月在我院就诊的18例患者,详细询问病史,进行裂隙灯显微镜检查、SchirmerI试验、泪膜破裂时间(BUT)检查、虎红眼表染色,并统计分析患者的临床资料。结果所有患者上睑缘附近的睑结膜均有不同程度的染色,13例患者角膜和球结膜不同程度的虎红染色,SchirmerI试验(7.3±1.5)mm,BUT为(1.3±2.0)s,2例患者发生持续性角膜上皮缺损。所有患者均给予人工泪液和凝胶,分泌物多者加用抗生素眼膏,两例患者进行了上睑水平缩短术。结论EIS是一种少见的上睑重叠于下睑表面的位置异常,虎红着染上睑缘周围的睑结膜有助于其诊断,常伴有干眼,主要给予人工泪液治疗,无效时手术缩短上睑。     

Exuberant epibulbar tumor penetrating into the orbit in xeroderma pigmentosum

The clinical and histopathological findings are described in a 10-year-old girl with xeroderma pigmentosum and multiple ophthalmic complications, including the eyelids, conjunctiva, orbit, cornea and iris; some of these complications took an unusual form. Histological examination following right orbital exenteration revealed an epibulbar squamous cell carcinoma penetrating the orbit and building a noose all around the ocular globe with subsequent strangulation. Moreover, a palpebral squamous cell carcinoma developed independently from the right lower lid and, unconnected with the epibulbar tumor, penetrated to the orbit.     

A case of conjunctival malignant melanoma treated with subconjunctival injection of interferon beta--efficacy and side effects

BACKGROUND: The management of conjunctival malignant melanoma remains controversial. Interferon-beta (IFN-beta) is a well-known antineoplastic agent against cutaneous malignant melanoma. CASE: A 44-year-old man was referred to Kobe University, Hospital for treatment of pigmented lesions in the corneal limbus of his right eye, first recognized in 2000 and growing gradually. FINDINGS: There were two pigmentary neoplastic lesions in the conjunctiva of his right eye, one at 9 o'clock in the limbus and the other at the inferior bulbar conjunctiva close to the fornix. Primary acquired melanosis (PAM) extended widely over the bulbar conjunctiva and the corneal surface. These findings led to the clinical diagnosis of conjunctival malignant melanoma. Systemic work-up did not detect any other neoplastic lesion. COURSE: The melanotic lesions were resected and histopathologically malignant melanoma was diagnosed. Microscopically, the tumor cells were present at the surgical margin. Melanoma recurred a half-year later at 3 o'clock in the limbus of the right eye. IFN-beta (3 million units/) was injected subconjunctivally 22 times. Side effects observed were as follows: corneal epithelial erosion, increase of the corneal thickness, lid swelling, conjunctival congestion, subconjunctival hemorrhage, and liver dysfunction. These findings were transient. Melanotic lesions, including PAM, diminished 6 months after the end of treatment. CONCLUSION: This therapeutic trial of local therapy using the subconjunctival administration of IFN-beta demonstrated excellent efficacy for the treatment of conjunctival malignant melanoma. Local and systemic side effects were seen, though transient, suggesting the necessity of long-term follow-up study.     

Hughes technique, amniotic membrane allograft, and topical chemotherapy in conjunctival melanoma with eyelid involvement

A 59-year-old woman presented with a pigmented mass in the inferior tarsal conjunctiva of the left eye with an associated diffuse, multifocal pigmentation involving largely the inferior half of the bulbar conjunctiva, fornix, and eyelid skin. Histopathologic examination of map biopsies disclosed conjunctival melanoma from primary acquired melanosis. Surgical excision of the inferior bulbar conjunctiva, fornix, and lower eyelid with histopathologic free margins was performed. Adjuvant cryotherapy was applied. The bulbar conjunctiva and lower fornix were reconstructed with an amniotic membrane allograft. Lower eyelid reconstruction was accomplished by use of the Hughes technique. Topical mitomycin C (0.04%) was applied after surgery. After 2 years of follow-up, no tumor recurrence has been detected and the eyelid and conjunctival defect have been satisfactorily corrected. This combined surgical procedure using amniotic membrane allograft and a composite tarsoconjunctival flap is shown to be useful in the treatment of an advanced conjunctival neoplasia with extensive eyelid involvement.     

Our Experience with the Masquerade Procedure for Total Eyelid Loss

Purpose: To describe our experience of the Masquerade Procedure, a historical procedure that is poorly described in the modern literature.

Methods: We performed a masquerade procedure in two complex surgical cases where traditional methods of eyelid reconstruction or closure were not possible. The first case suffered a partial de-gloving injury with a right sided anterior exenteration and loss of the upper and lower eyelids. On the left side, he lost the lower forehead and brow as well as the entire left upper eyelid leaving superior bulbar conjunctiva only. The cornea of the left eye was completely exposed and required urgent coverage. The second case was involved in a light aircraft crash and suffered extensive facial burns with periocular involvement bilaterally. On the left side, there was complete loss of the upper and lower eyelids and fornices extending to the bulbar conjunctiva. The cornea was keratinized and vascularised due to chronic exposure.

Results: In the first patient, poor eyelid closure led to corneal ulceration and scarring. A repeat procedure involved the use of a cheek rotation flap, and ultimately the fashioning of a small port-hole aperture inferiorly to avoid corneal exposure. The patient maintains navigational vision. The second patient had two attempts at a masquerade procedure, however the poor blood supply led to complete and partial failure of the first and second procedures respectively.

Conclusion: The masquerade procedure may be considered in extreme circumstances, however in our experience, multiple interventions and further reconstructive surgery may subsequently be required.     

Comparative sensitivity of fluorescent antibody staining of conjunctival scrapings and irradiated McCoy cell culture for the diagnosis of hyperendemic trachoma.

The sensitivity of an indirect fluorescent antibody (FA) staining technique for detecting chlamydial inclusions in scrapings from the whole conjunctiva (upper tarsus, upper fornix, and lower lid) was compared with the sensitivity of culture in irradiated McCoy cells for the diagnosis of hyperendemic trachoma. In a group of 211 patients with various grades of active trachoma from the Bandar Abbas area of Southern Iran 42 patients were positive for chlamydiae by either method. There was little difference between the rates of positivity of FA staining of the scrapings from the whole conjunctiva (28 positives) and culture in irradiated McCoy cells (32 positives). In the patients included in this study chlamydial inclusions were detected in 15 eyes by examination of FA stained scrapings taken from the upper tarsal conjunctiva, whereas inclusions were detected in 40 eyes by the additional examination of scrapings taken from the upper fornix and lower lid (P less than 0.001). The examination of FA stained scrapings taken from the whole conjunctiva and spread as a single but larger smear may provide a satisfactory alternative to cell culture methods for the diagnosis of trachoma, particularly for field studies when cell culture facilities are not available.     

Excision with Corneoscleral Lamellar Keratoplasty and Amniotic Membrane Transplantation of a Corneal Displaced Recurrent Conjunctival Melanoma

An 81-year-old woman with a raised pigmented nodule over her left cornea for 7 months duration was examined. Dark conjunctival pigmentation was observed in the upper bulbar fornix conjunctiva. She had previously undergone primary surgical excision of a malignant conjunctival melanoma four years earlier. The tumor separated easily from the corneal surface, but remained slightly attached to the corneoscleral surface. A corneoscleral lamellar dissection of 3 mm in width and 2 mm in depth as well as a corneoscleral lamellar keratoplasty for the reconstruction of the corneoscleral defect were performed. The wide upper bulbar and fornix conjunctiva were excised, and an amniotic membrane transplantation was performed. Biopsy revealed an invasive melanoma with a depth of 1 mm. Left, right, and inferior tumor margins of the corneoscleral lesion and the pigmentary lesion in the conjunctiva were free of the tumor. After surgery, 0.04% mitomycin was administered topically 4 times daily for 4 weeks. There was no recurrence 2 years after surgery, and systemic evaluation revealed no metastasis.     

Primary acquired melanosis of the conjunctiva.

BACKGROUND: Primary acquired melanosis (PAM) presents as a unilateral patchy area of conjunctival pigmentation mostly found in middle-aged or elderly white patients. Because PAM has the potential of becoming malignant, it is important to recognize PAM and to rule out other causes of pigmented lesions. The presence or absence of atypia is helpful in determining the potential for malignancy, because PAM without atypia is usually benign, whereas PAM with atypia may convert into a conjunctival melanoma. If atypia is present, the presence or absence of epithelioid cells and the pattern of intraepithelial growth are the main factors in determining the likelihood of neoplastic transformation. However, atypia can only be determined with histopathologic examination. Therefore, a biopsy is usually recommended. CASE REPORT: A 72-year-old white man presented for his annual examination with no visual complaints. His ocular history was remarkable for early cataracts and for a choroidal nevus. Slit lamp examination found a large dark area of elevated conjunctival pigmentation at the medial canthus that extended onto the superior bulbar conjunctiva and superior palpebral conjunctiva in the left eye. No conjunctival pigmentation had been noted previously. Results of a biopsy indicated primary acquired melanosis with atypia. The lesion was surgically excised, and the conjunctiva was reconstructed with an amniotic membrane graft. The patient was subsequently treated with topical 5-fluorouracil chemotherapy. There have been no signs of recurrence to date after his treatment. CONCLUSION: Because of the potential for malignancy, biopsies of all cases of primary acquired melanosis are indicated. If atypia is present, treatment options include local excision, cryotherapy, and topical chemotherapy.     

External ocular findings in lupus erythematosus: a clinical and immunopathological study.

A selected group of 18 patients with systemic lupus erythematosus (SLE) and 30 patients with chronic cutaneous lupus erythematosus (CCLE) showed an unexpectedly high incidence of problems involving the globe or eyelids. Five SLE patients had recurrent episcleritis, two CCLE patients had lower tarsal plaques, and two further CCLE patients had erosion of the lower lid margins associated with conjunctival scarring and symblepharon. This association has not previously been reported. There was an unexpectedly high incidence of deposition of immunoreactants in a linear pattern at the basement membrane zone in normal bulbar conjunctiva, which occurred in both SLE (42%) and CCLE (50%). The significance of these findings is discussed. We believe surface ocular problems in lupus erythematosus to be under-reported and that direct immunofluorescence of bulbar conjunctival biopsy might be helpful in diagnosis.     

Case of conjunctival liposarcoma.

A case of primary conjunctival liposarcoma was reported. The patient was a 62-year-old woman who complained of swelling of the left bulbar conjunctiva. As the swelling lesion did not respond to treatment and had gradually enlarged, surgical excision was performed 18 months after her first visit. The tumor was bean-sized and was located subconjunctivally without connecting orbital tissues. Histopathological examination of the specimen revealed numerous neoplastic cells containing stellate and hyperchromatic nucleus. The cytoplasm of these cells contained vacuoles resembling lipid droplets. Signet-ring type cells were also observed. These cells were considered to be lipoblasts. The stroma was myxomatous and thin-walled vessels were observed. The present tumor was confirmed by histopathological study as myxoid liposarcoma and considered to be of bulbar conjunctiva origin. The patient showed no sign of recurrence during 16 months of follow-up.     

Case-controlled clinical and histopathological study of conjunctivochalasis

BACKGROUND/AIMS: Conjunctivochalasis, a secondary cause of the watery eye, is frequently seen in the older age group as an elevation of the bulbar conjunctiva lying along the lateral or central lower lid margin. A prospective, interventional, case-controlled clinical and histopathological study was conducted. The relevant features of 18 patients (29 eyes) who had their conjunctivochalasis resected as part of the surgical management of their watery eye syndrome were examined. In the control group, tissue was obtained from an age matched series of 24 normal subjects undergoing routine cataract surgery. METHODS: 24 controls (24 specimens) and 18 patients (29 specimens) had conjunctival strip biopsies, taken from the usual lid margin level bulbar conjunctiva in line with the inferior limbus (controls), and the clinically apparent conjunctivochalasis (patients). These were submitted for histological study. RESULTS: 23 of 24 control sections demonstrated normal conjunctival variation. Four of 29 patient specimens demonstrated a chronic non-granulomatous conjunctivitis, while three eyes of the patient group (two patients) demonstrated features of elastosis. Of the four patients who had the inflammatory infiltrates, three had functional nasolacrimal duct obstructions (FNLDOs) and one had a primary acquired nasolacrimal duct obstruction (PANDO). Of the two patients who had elastosis, one had an FNLDO and the other had normal lacrimal drainage and was Jones 1 positive. CONCLUSION: Six of 18 patients--that is, seven of 29 specimens of conjunctivochalasis demonstrated signs of elastosis or of chronic non-granulomatous inflammation. Clinically, patients had a spectrum of aetiologies of their watery eye syndrome.     

Congenital total eversion of the upper eyelids.

Eight cases of bilateral and 6 cases of unilateral congenital total eversion of the upper eyelids are reported here. It is suggested that an appreciable overlapping of the lower eyelid margin by the upper eyelid is a predisposing factor in the mechanism of eversion in this condition. Treatment by injection of hyaluronidase into the chemotic conjunctiva followed by placement of a lid suture to revert the eyelid resolves the condition in 1 or 2 days.