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Title: Conjunctival Melanoma
Author: Xavier Mortensen, MS4
Photographer: Slit Lamp Photo: Glen Jenkins, CRA, OCTC. Ultrasound Image: Roger Harrie, MD
Date: 6/28/18 (images taken 6/20/18)
Image or video:
Image 1: Slit lamp of left eye showing a 9×9 mm large, vascular, pigmented mass which is non-adherent to the sclera in temporal conjunctiva. Biopsy was consistent with a conjunctival malignant melanoma arising from a preexisting primary acquired melanosis (PAM) with atypia.
Image 2: An immersion scan using a high-frequency 40 MHz probe. The lesion measured 2.7 mm in thickness by 10.3 mm in basal dimension. It appears to only involve the outer 25% of the sclera and with no intraocular extension. The ciliary body also appeared normal without evidence of melanoma.
Keywords/Main Subjects: melanoma, neoplasm, ocular, conjunctiva, sclera, ultrasound, b-scan
Diagnosis: Conjunctival Melanoma
Description of Images: see above
Conjunctival melanomas typically present as a nodular brown mass that are often well vascularized. In fact, due to the substantial vascular supply the tumors are more susceptible to bleeding. They occur most commonly on the bulbar conjunctiva or limbus, but may also be found on palpebral conjunctiva. Histologically, isolated or confluent nests of atypical melanocytes are often seen composed of large abnormal cells with high nuclear-cytoplasmic ratio, mitotic figures, and prominent nucleoli. Conjunctival malignant melanomas display invasion into subepithelial layers.
They are more common in patients of European descent and rare in black and Asian populations. Prognosis is poor with an overall mortality rate of 25-45%. Conjunctival melanomas can arise from PAM (70%), nevi (20%), or de novo (10%)[3,4]. Intraocular and orbital extension can occur. It is important to check for an underlying ciliary body melanoma, which can imitate a conjunctival melanoma.
Treatment is time-sensitive and includes excisional biopsy with cryotherapy and/or alcohol corneal epitheliectomy. Depending on how invasive the malignancy is, exenteration may be required. Ultrasound biomicroscopy (UBM) should be done to rule out extrascleral extension of a ciliary body melanoma of a conjunctival melanoma. The recurrence rate is greater than 50% in treated patients, so patients should be followed-up closely by their ophthalmologist.
- Bagheri, Nika, et al. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease. 7th Edition. Philidelphia: Wolters Klewer, 2017.
- Herwig, Martina C. Conjunctival Melanocytic Tumors. 7 November 2017. American Academy of Ophthalmology. 29 June 2018. <http://eyewiki.aao.org/Conjunctival_Melanocytic_Tumors>.
- Kaiser, Peter K, Neil J Friedman and Roberto Pineda. The Massachusetts Eye and Ear Infirmary Illustrated Manual of Ophthalmology. 4th Edition. Elsevier Inc., 2014.
- Skuta, Gregory L, Louis B Cantor and George A Cioffi. “Basic and Clinical Sciences Course.” Section 8: External Disease and Cornea. 2013-2014. American Academy of Ophthalmology, 2013. 227-228.
Faculty Approval by: Roger Harrie, MD; Griffin Jardine, MD
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Disclosure (Financial or other): None