6/14/2012. Palpebral. Conjunctival. Bulbar. Fornix. Limbal Stem Cells

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1 Conjunctival Lesions: Links to Systemic Disease Thomas F. Freddo, O.D., Ph.D., F.A.A.O. Professor and Former Director School of Optometry University of Waterloo Tissues of the Conjunctiva Limbal Stem Cells Blood vessels, Mast cells, Blood-derived derived cells Inflammatory or malignant Epithelium Epithelial cells Goblet cells Melanocytes/Nevus cells Langerhans cells Fibroblasts Nerve cells Lymphatics Goblet Cell Distribution Itinerary for the Tour Bulbar Palpebral Conjunctival Fornix Goblet Cells are more abundant near the fornix and are reduced in numbers as you progress toward either the limbus or the lid margin Things at the limbus Cystic things Salmon-colored things Pigmented things 1

2 Itinerary for the Tour Things at the limbus Cystic things Salmon-colored things Pigmented things Limbal or Epibulbar Dermoid Congenital Choristoma Definition? Distinction from hamartoma? How different from orbital dermoids? Associated syndrome? Goldenhar s Syndrome Goldenhar s Syndrome Oculoauriculo-vertebral syndrome Auricular appendages Vertebral skeletal anomalies may include kypho-scoliosis and defects of the cervical spine. Facial asymmetry is often present. Unilateral facial involvement is more common (70-80%) with hemifacial microsomia (a small jaw on one side). Phlyctenule Associated systemic disease? Ocular sequela with chronic phlyctenulosis? 15 y/o female Seen in August Sharing make- up with girl fi friend who developed red- eye. Make-up cultured staph Bilateral and symmetric 2

3 Salzmann s Nodular Degeneration Bluish-white to grey nodules without inflammation Epithelium intact Can occur as sequela to any chronic ocular surface inflammation Bitot s Spot Squamous metaplastic change with normal tear film Leukoplakia Vitamin-A deficiency Vitamin A levels below normal range of µmol/l). ERG indicated to R/O night blindness. Pterygium vs CIN CIN / Squamous Cell CA Even in this advanced case, notice that the nodular form can refrain from crossing onto the cornea 3

4 CIN / Squamous Cell CA This more gelatinous, polypoid form crosses the limbus and exhibits fine, cork- screw vessels. reminiscent of conjunctival papilloma. CIN / Squamous Cell CA HPV-16 often found but not the cause, despite the papillomatous configuration and appearance of the lesion. These are most common at the limbus, arising from the limbal stem cells that are undergoing constant mitotic division. Itinerary for the Tour Things at the limbus Cystic things Salmon-colored things Pigmented things Spherical Epithelial Inclusion Cyst Over Soft Tissue Is it a cyst? 4

5 EIC Formation A surface epithelial cell is driven below the surface and survives. EIC Formation The cell proliferates and each new cell directs its basal surface and basement membrane toward the surrounding stroma. EIC Formation Hemi-Spherical Epithelial Inclusion Cyst Over Sclera The sphere is closed. The epithelium now has regained its desired state. - a basal surface on a basement membrane, touching stroma and an apical surface abutting a different environment. The cells of the cyst wall now feel the same as if they were again at the surface. They resume making whatever they normally make (e.g. fluid), which fills the cyst cavity. 5

6 Lympangiectasis Lympangiectasis Linear variant Multi-lobular lobular variant Hemorrhage into lymphangiectasis? Slides courtesy Rodney Gutner, O.D. Numerous slightly elevated yellowish, possibly cystic spots on bulbar conjunctiva 55 y/o white female CC: diffuse redness OU x 3-4 weeks POH: PMH: Meds: Allergies: No change after 2 weeks of topical steroids Biopsied Biopsy Non-caseating granuloma* Two days before visit with PCP, parotid swelling developed. Granulomatous inflammation is distinguished by the presence of macrophages that look somewhat epithelial and thus are called epithelioid. These can coalesce to become giant cells. 6

7 Sarcoidosis This is the more common presentation, occurring on the palpebral conjunctiva and/or at the lid margin. While we are at the lid margin. Molluscum contagiosum Epithelial transition areas are predisposed to development of viral-induced induced lesions. Transitions include lid margin and limbus. Appearance at lids in this form not classical. At the lid margin will produce a chronic follicular conjunctivitis Molluscum contagiosum Molluscum contagiosum Caused by unidentified member of the pox virus family Molluscum Bodies In immunocompromised patients, such as those with AIDS, the lesions are usually far more numerous. The appearance is more classic (i.e. clusters of smooth, pearly lesions with a central umbilication). 7

8 Molluscum Contagiosum in AIDS 10% of HIV-infected individuals may develop hundreds of lesions. Some become "giant" (greater than 1 cm), and display a predilection for the lid margins. The lesions are often pruritic and may become superinfected. Ocular lesions can be sight- threatening. Treatment is unsatisfactory. Antiretroviral therapy, particularly in the early stages, is sometimes effective. Cyrotherapy and pricking lesion with toothpick dipped in phenol may provide transient relief, but recurrences common. Cidofovir, an anti- cytomegalovirus agent, is under investigation for treatment of molluscum contagiosum. 7 y/o HIV+ boy with a CD4 count of 150 cells/microliter Sebaceous Gland Carcinoma masquerades may include seemingly recurrent chalazion or unresponsive unilateral blepharitis Sebaceous Gland Carcinoma Masquerade presentations may include an unusual, unresponsive unilateral blepharitis with red thickened lid margins and madarosis. Pagetoid Spread of Sebaceous Gland Carcinoma Pagetoid spread can significantly complicate the surgical management of this disease. 8

9 Factors in Assessment of Lid Lesions - Alteration of lash-line line Getting back to the tour.. Things at the limbus Cystic things Salmon-colored things Pigmented things Pyogenic Granuloma Pyogenic Granuloma Patient had resection of pterygium 3 weeks ago. Now concerned about pink mass developing at surgical site. Misnomer - neither pyogenic nor granulomatous. No epithelioid cells, merely granulation tissue. May also occur if a chalazion ruptures through the tarsus to the conjunctival surface and spontaneously drains May also occur in response to retained foreign material Did you notice the lymphangiectasis? 9

10 HBID Hereditary Benign Intraepithelial Dyskeratosis Bilateral dyskeratosis with similar lesions of oral mucosa. Autosomal dominant pattern arising from a tri- racial family in Halifax county, N.C. Due to a gene duplication on chromosome #4. Can involve cornea and commonly recurs when removed. Oncocytoma: Eosinophilic cystadenoma Slowly enlarging, non-pigmented mass of the caruncle. Usually benign tumor of accessory lacrimal gland tissue in the caruncle. Pedunculated Papilloma Pedunculated papillomas are most often fornix-based (upper or lower). Almost invariably they are viral. Sessile Papilloma Human Papilloma viruses 6 and 11 have been associated with these lesions. They are members of the papova family of DNA viruses. 10

11 Classification of Conjunctival Papilloma MALT Lymphoma VIRAL Children/Adolescents Often Bilateral l Often Multiple Pedunculated in fornix No inflammation Resolve in 2 yrs NEOPLASTIC Adults Unilateral l Solitary Sessile, at limbus Inflammation Do not resolve Conjunctival lymphoma is commonly differentiated as the less aggressive MALT (mucosa associated lymphoid tissue) or the more malignant-behaving non-malt (Mantle) lymphoma. MALT Lymphoma MALT When biopsied, these lesions contain a uniform population of lymphocytes. 11

12 Metastatic Breast CA Kaposi Sarcoma Lesions can be red, purple or brown in color, and can be flat, raised, or nodular. Uncommon in HIV-infected children in the United States. Frequent in HIV-infected African and Romanian children. KS in adults associated with human herpes virus 8 (HHV-8) This virus is present in greater than 90 percent of all KS lesions in adults with AIDS. Cavernous Hemangiona Itinerary for the Tour In this location rule-out an anterior extension of an orbital caverous hemangioma Note purple-red, lobulated appearance Things at the limbus Cystic things Salmon-colored things Pigmented things 12

13 Epinephrine adrenochrome pigment Conjunctival Nevus? Melanin and thyroid hormones also start from tyrosine Nevus, PAM, Congen melanosis Conjunctival Nevus Congenital Ocular Melanocytosis Primary Acquired Melanosis (PAM) Onset Congenital-may darken Congenital Acquired-middle age Structure Discrete Diffuse Diffuse Color Brown Blue/slate gray Brown Cysts 50% of compound nevi None None Pigmentation Variable Always Always With conj movement Lesion moves Lesion does NOT move Lesion moves Growth Stationary Stationary Waxes and wanes Uvea Not involved Heterochromia Not involved Skin Not involved May be involved (in Nevus of Ota) Malignant Potential Conjunctival melanoma Skin or uveal, rarely conjunctival Not involved Conjunctival melanoma Melanocytic Nevus May not be noticed until darkening occurs with puberty. Congenital, hamartomatous, focal, brown masses that move with the conjunctiva. 13

14 Nevus of Caruncle Same monitoring criteria as in conjunctiva. Best to photograph and monitor for change in size or appearance of sentinel vessel or surrounding inflammation. This is an especially unfavorable location for the development of conjunctival melanoma. Compound Cystic nevus Conjunctival nevi may be: - junctional -stromal - compound 50% of compound nevi will develop intraneval cysts. Photograph to distinguish cyst enlargement from enlargement of nevus. Compound Cystic Nevus of the Conjunctiva Inflamed nevus Note deep redness around and beneath this nevus (arrow). Development of this type of redness, especially in the company of larger feeder vessels, warrants resection. 14

15 Congenital Melanosis Oculi Blue, grey or brown patch of pigmentation does NOT move with the conjunctiva. No skin involvement Nevus of Ota Most frequently in Asian populations, Estimated prevalence of % 0.6% for nevus of Ota in Japanese persons. Other ethnic groups with increased prevalence include Africans, African Americans, and East Indians. Uncommon in Caucasians. Male-to-female ratio is 1:4.8 for nevus of Ota. Age: Peak onset in infancy, 50% of present at birth. A second peak is seen during adolescence. Nevus of Ota Nevus of Ota Distribution of the skin component is invariably within the distributional field of the first (VI) and second (VII) divisions i i of the trigeminal nerve VI VII Patients may also have ipsilateral heterochromia iridis. Patients with Nevus of Ota have NO increased risk for conjunctival melanoma Patients with Nevus of Ota DO have increased risk for choroidal melanoma 15

16 PAM Lesions wax and wane. 35% of those with PAM will develop melanoma Conjunctival Melanoma Sources: 10% arise de-novo 20% from a preexisting nevus 60-70%from the flat spreading pigmentation of primary acquired melanosis with atypia Mortality/Morbidity: Overall 25-26% % 44% if the tumor arose from PAM with an intraepithelial pagetoid growth pattern. Spreads first to the pre-auricular or submandibular nodes. Prognosis: Tumor thickness (>0.8 mm), mixed cell type, and lymphatic invasion on histologic examination were found to increase the death rate (3-4 times). Conjunctival Melanoma Unfavorable locations (caruncle, palpebral conjunctiva, or forniceal conjunctiva. Thickness > 0.8 mm. Age of onset commonly in early 50 s Malignant melanoma of the conjunctiva accounts for only 2% of all ocular malignancies. Race: This condition occurs predominantly in whites and rarely is seen in blacks. Sex: No clear sex predilection has been established. Age: Typically, conjunctival melanoma occurs in patients in their early 50s. It rarely is seen in people younger than 20 years. In 1999, Strempel reported 3 cases of conjunctival malignant melanoma in children. Conjunctival Melanoma Like squamous cell carcinoma of the conjunctiva, melanoma of the conjunctiva tends to have a long period of superficial fiil growth. hth They rarely invade the globe, but it is important to palpate pre-auricular and submandibular nodes The incidence of conjunctival melanoma among white males in the US soared 295% between 1973 and Reason? 16