conjunctiva lecture 3:cysts and tumors
TRANSCRIPT
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ConjunctivaLecture 3:Cysts and Tumors
Dr Parul IchhpujaniAssistant Professor, Deptt. Of Ophthalmology,Government Medical College and Hospital, Sector 32, Chandigarh
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Cysts Congenital Cystic lesions:
Congenital corneoscleral cyst Cystic form of epibulbar dermoid
Lymphatic cysts: Lymphangiectasia Lymphangioma
Retention cysts Epithelial Implantation cysts Aqueous cysts: Epithelial cysts due to downgrowth of epithelium Parasitic cysts
Hydatid cyst Cysticercus Filarial cyst
Pigmented Epithelial cysts: Prolonged topical use of cocaine/epinephrine
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Lymphangiectasia
• Appears as irregularly dilated lymphatic channels in bulbar conjunctiva
• May be developmental anomaly• Can follow trauma or inflammation• Anomalous communication with venule can leadto spontaneous filling of lymphatic vessels with blood
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Lymphangioma
• Proliferations of lymphatic channel elements• Usually present at birth and enlarge slowly• Patch of vesicles with edema• Intralesional hemorrhage –“chocolate cyst”
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Subconjunctival cysticercus
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Tumors of Conjunctiva:Non-pigmented tumoursI. Congenital: dermoid and lipodermoid (choristomas).II. Benign: simple granuloma, papilloma, adenoma,fibroma and angiomas.III. Premalignant: intraepithelial epithelioma (Bowen's disease).IV. Malignant: epithelioma or squamous cell carcinoma, basal
cell carcinoma.
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Pigmented tumoursI. Benign: naevi or congenital moles.II. Precancerous melanosis: superficial spreading melanoma
and lentigo maligna (Hutchinson's freckle).III. Malignant: primary melanoma (malignant melanoma).
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Dermoid:Epibulbar Dermoid Tumor• 1 in 10,000 individuals• Pathogenesis
– Displaced embryonic skin tissue– Composed of fibrous tissue, hair with sebaceous glands– Covered by conjunctival epithelium
• Clinical findings– Well-circumscribed, solid, smooth, porcelain white, round tooval elevated lesion embedded in superficial sclera or cornea– Most common in infertemporal limbus– Arcus-like deposit of lipid along anterior corneal border– Corneal astigmatism – anisometropic amblyopia
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Epibulbar Dermoid Tumor Management
– No malignant potential– Lesion often extends deep into underlying tissues– Elevated portion may be excised– Relaxing incision or other corrective measure maybe considered– Lamellar keratoplasty for cosmetic appearance– Amblyopia treatment
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Lipodermoid: Found at the limbus or outer canthus. Appears as soft, yellowish white, movable subconjunctival
mass. Consists of fatty tissue and the surrounding dermis-like
connective tissue, hence the name lipodermoid. Sometimes the epibulbar dermoids or lipodermoidsmay be associated with accessory auricles and othercongenital defects (Goldenhar's syndrome).
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Conjunctival Inclusion Cyst
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Benign Tumors:
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Simple Granuloma: Consists of an extensive polypoid, cauliflower-like growth
of granulation tissue. Simple granulomas are common following squint surgery,
as foreign body granuloma and following inadequately scraped chalazion.
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PapillomaPedunculated– HPV, type 6 or 11– Fleshy, exophytic growth with fibrovascular core– Emanates from a stalk with multilobulated appearance
with smooth, clear epithelium and small corkscrew vessels
– Inferior fornix, tarsal or bulbar conjunctiva– May be multiple – more in HIV pts
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PapillomaSessile– HPV, type 16 or 18– More likely dysplastic or carcinomatous– Limbus– Flat base with glistening surface and numerous red dots– Signs of dysplasia• Keratinization (leukoplakia)• Inflammation• Invasion– Rare variant – Inverted papilloma
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Pyogenic granuloma:Common reactive hemangioma• Misnamed – not suppurative, nogiant cells• May occur
– Over chalazion– Minor trauma– Post op granulation tissue
• Rapidly growing red, pedunculated, smooth lesion• Bleeds easily and stains with fluorescein dye
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Pre-malignant tumours
Bowen's intraepithelial epithelioma (carcinoma in situ): Usually occurring at the limbus as a flat, reddish grey,
vascularised plaque. Histologically, it is confined within the epithelium. It should be treated by complete local excision.
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Conjunctival Intraepithelial Neoplasia(CIN)Clinical findings– 3 clinical variants:
• Papilliform – sessile papilloma harboring dysplastic cells• Gelatinous – result of acanthosis and dysplasia• Leukoplakic – hyperkeratosis, parakeratosis, and dyskeratosis
– Mild inflammation and abnormal vascularization– Classification: Mild, Moderate, Severe (Carcinoma in situ)– Slow growing tumors– Potential to spread to other ocular surfaces
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Conjunctival Intraepithelial Neoplasia(CIN)
Management– Excisional biopsy with adjunctive cryotherapy• Recurrence rates at 10 years– Negative surgical margins ~ 33%– Positive surgical margins ~ 50%– Topical chemotherapeutic agents• Interferon, MM-C, 5-FU• No long term recurrence studies
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Malignant tumors:
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Squamous cell carcinomaPathogenesis– Risk factors: UV radiation, viral, genetic– More common and aggressive in:
• HIV• Xeroderma pigmentosa
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Clinical findings SCC:
– Broad based lesion at or near limbus in interpalpebralfussure
– Grow outward with sharp borders– Can be leukoplakic– Usually remains superficial rarely penetrating sclera– Pigmentation in dark-skinned pts– Engorged conjunctival vessels feeding tumor– Inflammation– Locally invasive and can metastasize
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Management of SCC:
– Complete local excision• 4 mm beyond clinically apparent margins• Thin lamellar scleral flap beneath tumor
– Absolute alcohol to remaining underlying sclera– Adjunctive cryotherapy to margins– Risk of recurrence related to surgical margins– Extensive external spread
• Orbital exenteration and possible radiation therapy
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Kaposi Sarcoma
• Malignant neoplasm of vascular endothelium involvesskin, mucous membrans and internal organs• Pathogenesis
– Infection with HHV-8– Occurs in setting of AIDS
• Clinical findings– Reddish, highly vascular subconjunctival lesion
• Can be mistaken for subconjunctival hemorrhage– Orbital involvement – lid and conjunctival edema– Inferior fornix most common– Nodular or diffuse
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Management– Treatment may not be curative– Nodular lesions less responsive to therapy– Surgical debulking– Cryotherapy– Radiotherapy– Local or systemic chemotherapy– Intralesional interferon alpha-2a may be effective
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Pigmented Tumors:
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Nevus
• Nevocellular nevi of conjunctiva – hamartia arising duringchildhood and adolescence• Junctional, Compound, Subepithelial• Flat near limbus, Elevated elsewhere• Pigmentation variable• Small epithelial inclusion cysts ~ 50%• Secretion of mucin in inclusion cysts – enlargement• Rapid enlargement at puberty• High prevalence of junctional activity but rarely become malignant• Excision of suspicious lesions• Excise nevi on palpebral conjunctiva
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Primary Acquired Melanosis
• Preinvasive intraepidermal lesion of sun-exposed skin
• Flat, brown noncystic lesions of conjunctival epithelium
• PAM associated with cellular atypia – progress to
melanoma in ~ 46%
• Pathogenesis– Abnormal melanocytes proliferate in basal conjunctivalepithelium of middle-aged, light-skinned individuals
• Malignant transformation – nodularity, enlargement or
increased vascularity
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Management of PAM:
– Excisional biopsy– All palpebral pigmented lesions should be excised– Lesions that show atypia
• Adjunctive cryotherapy• Mitomycin-C
– Check regional lymph nodes
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Melanoma
• Less than 1% of ocular malignancies• Prevalence:
~ 1 per 2 million in population of European ancestry– Rare in blacks and Asians
• Better prognosis than cutaneous melanoma
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Pathogenesis of Melanoma
– Arise from acquired nevi, PAM, or normal conjunctiva– Malignant transformation of congenital conjunctival nevus
very rare– Intralymphatic spread increases risk of metastasis– Underlying ciliary body melanoma can extend through
sclera– Cutaneous melanoma can rarely metastasize to conj
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Clinical findings : Melanoma
– Most common on bulbar conj or at limbus–Variable pigmentation– Highly vascularized – bleed easily– Grow in nodular fashion– Can invade globe or orbit– Outcome
• Bulbar melanomas have better prognosis than those on palpebralconj, fornix, or caruncle• Metastasis in ~ 26%, Mortality ~ 13% 10 yrs after surgical excision
– Cytologic risk factors for metastasis: large size, multicentricity,epithelioid cell type, lymphatic invasion– Can metastasize to LN’s brain, and other sites
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Melanoma
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Management– Excisional biopsy– Excision of conjunctiva 4mm beyond clinically apparent margins– Excision of thin lamellar scleral flap beneath tumor– Treat remaining sclera with absolute alcohol– Cryotherapy to conjunctival margins– Primary closure or conj/amniotic membrane graft– Topical mitomycin-C – can be used for residual disease– Orbital exenteration – advanced disease or palliative tx
• Poor prognostic factors– Melanomas arising de novo– Tumors not involving limbus– Residual involvement at surgical margins