Conjunctiva: Benign Lesions

Question 1

Describe Epithelial Inclusion Cyst & a differential diagnosis for it?

Answer 1

• Not a type of tumour
• Relatively common finding
• Non-pigmented
• Often in lower fornix
• Benign lesion/cyst
• Form in apposition of conjunctival folds
• Happens when different layers of conj that are adjacent to each other – in inferior fornix have tarsal conj & bulbar conj – rubbing together & results in epithelium & associated goblet cells becoming buried underneath surface  goblet cells continue to produce fluid & as a result a cyst forms
• Large cysts following burying of epithelium following trauma/surgery/inflammation
• Clear w/ normal epithelium
• Differential diagnosis: lymphangiectasia – hypertrophy of lymphatic tissue
• Complete excision to prevent recurrence
• If px not aware of it & it’s not causing any problems –> DON’T REFER

Question 2

Describe conjunctival papilloma & how it is referred?

Answer 2

• Human papillomavirus (HPV) 6 or 11 initiates neoplastic growth
• Non-pigmented
• Vascular proliferation
• Pedunculated growth:
  o Fleshy, exophytic growth (growing out of surface of conj like a mushroom) from stalk, multilobulated, clear epithelium (non-pigmented)
  o Underlying tortuous BV
• Sessile growth:
  o Flat, broad-based, glistening appearance w/ numerous red spots
  o May spread onto cornea
  o Rarely represents a carcinomatous lesion – HPV 16 & 18
• Reassure px: Spontaneous regression
  o Months to years
• Observe small pedunculated lesions
• If lesion is ↑ in size then ROUTINE REFERRAL for assessment
• Excision:
  o Risk of recurrence – needs removed completely, to do this usually have to take 1-2mm of normal conj around about it
   Large area removed from conj can cause scarring, pain, sometimes needs reconstructive surgery
  o Incomplete excision: worse appearance
  o Excision w/ cryotherapy +/- adjunctive therapy
   Mitomycin C or Interferon α – can help shrink it

Question 3

Describe Freckle - Congenital Epithelial Melanosis?

Answer 3

• Benign pigmentation of the conjunctival epithelial cells
• Flat brown patch near limbus
• Present from early age
• More common in dark skinned individuals
• Can become more prominent w/ age as px goes through puberty – can make freckle darker

Question 4

Describe Benign Acquired Melanosis?

Answer 4

• Increasing diffuse pigmentation w/ age in dark skinned individuals
• Most apparent interpalpebral bulbar conjunctiva (on globe itself) & perilimbal area (round the limbus)
• Possibly related to UV exposure

Question 5

Describe Ocular Melanocytosis?

Answer 5

• Congenital melanosis of episclera (below epithelium)
• Pigmented
• Focal proliferation of subepithelial melanocytes – more focal than diffuse
• Relatively rare – 1 in 2500 – more common in dark skinned individuals
• Slate grey, non-mobile (as in episclera), unilateral lesions
• May have ipsilateral (same side) naevus of Ota (dermal melanocytosis)
  o Together called oculodermal mealnocytosis

Question 6

Describe conjunctival naevus?

Answer 6

• Conjunctival hamartoma – proliferation of normal tissue in the right place – just a lot more of it
• Junctional, compound or subepithelial
• Flat near limbus
• Elevate elsewhere – if grow in size
• Variable pigmentation
• Small inclusion cysts may be present leading to enlargement
• Rapid enlargement can occur at puberty – due to change of growth hormones
• High junctional activity but rarely become malignant
• Observe
• If increase in size (especially if adult) then refer
• Excision if suspicious
• Rare on palpebral conjunctiva – excise lesions in fornix or over tarsus
• Harder to remove if lesion is in eyelid or caruncle or if the lesion is large