An experienced clinician often has an opinion about the nature of a conjunctival or corneal lesion after completing the history and physical examination. Many lesions are not worrisome for malignancy (eg, inclusion cysts); others will be indeterminate based on the history and results of the clinical examination. For these cases, observation may be a reasonable option. If observation is elected, regular ophthalmic examinations are essential. If growth or worrisome changes in the characteristics of the lesion are documented, surgery or topical chemotherapy is usually indicated. Tissue for histologic evaluation may be required for definitive diagnosis. Lesions that cause concern for possible malignancy
The next 2 sections, Surgical Treatment and Topical Chemotherapy, provide a paradigm for/general approach to the management of suspicious conjunctival and corneal neoplasms. Following these sections, the various types of ocular surface neoplastic disorders are discussed and additional comments on management are provided for specific lesions as appropriate.
The standard surgical treatment of a suspicious conjunctival lesion is complete removal of the tumor, including a 2-mm margin of uninvolved tissue surrounding the lesion, when possible. The surgeon attempts to avoid touching the tumor during removal (“no touch” technique) in order to prevent inadvertent seeding of the remaining conjunctiva with tumor cells. Incisional biopsies should be avoided for the same reason, especially in pigmented lesions of the conjunctiva. Involvement of the corneal epithelium is managed with absolute alcohol–assisted epithelial curettage with a surgical blade or blunt-edged instrument such as a Kimura spatula; the surgeon takes care to avoid violating the Bowman layer, which is a natural barrier to tumor extension into the corneal stroma. Some lesions may require lamellar sclerectomy for complete removal. Cryotherapy at the time of ocular surface surgery has been shown to improve the prognosis.
Once the tumor is removed, additional manipulations should be performed with clean surgical instruments to reduce the risk of tumor seeding. Primary conjunctival closure or a conjunctival autograft may be considered if the conjunctival defect is small. Ocular surface reconstruction with amniotic membrane transplantation is useful in the management of conjunctival lesions and allows for wider tumor margins with less risk of postoperative scarring. Amniotic membrane also facilitates reepithelialization and reduces postoperative inflammation. The graft should be cut slightly larger than the defect and may be attached with fibrin tissue adhesive. If tissue adhesive is not available, either absorbable (9-0 or 10-0 polyglactin) or nonabsorbable (10-0 nylon) suture may be used to fixate the graft. If more than two-thirds of the limbal epithelium is removed, chronic epitheliopathy may result. Stem cell transplantation using tissue harvested from the fellow eye of the patient or an allograft may eventually be required.
Once removed from the ocular surface, the lesion can be placed on filter paper and the edges labeled with ink or suture to indicate the orientation of the lesion and facilitate histologic diagnosis. The surgeon should take care to avoid damage to the specimen during removal, as any damage could make the lesion more difficult to interpret. The clinical history is relevant to the pathologist’s interpretation of the lesion; thus, the label should include the following information: the age and race or ethnicity of the patient, the duration of the lesion, and whether the lesion has changed clinically. Diagnosis of conjunctival tumors can be challenging, especially for general pathologists. If possible, a conjunctival tumor should be evaluated by an ophthalmic pathologist. Immunostaining can help in distinguishing benign from malignant lesions. See BCSC Section 4, Ophthalmic Pathology and Intraocular Tumors, for further discussion of specimen handling and histologic examination of various ocular surface tumors.
Shields JA, Shields CL, De Potter P. Surgical management of conjunctival tumors. The 1994 Lynn B. McMahan Lecture. Arch Ophthalmol. 1997;115(6):808–815.
Sivaraman KR, Karp CL. Medical and surgical management of ocular surface squamous neoplasia. In: Mannis MJ, Holland EJ, eds. Cornea. Vol 1. 4th ed. Philadelphia: Elsevier; 2017:427–433.
Excerpted from BCSC 2020-2021 series: Section 10 - Glaucoma. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.