Conjunctival Viral Papilloma: Present and Future Management
The human papillomavirus (HPV) currently affects 79 million Americans, and an additional 14 million new infections occur each year, said Carol L. Shields, MD, speaking on Saturday at the Cornea Subspecialty Day. And while HPV infection is best known for its contribution to genital warts and cervical and other cancers, the virus is also implicated in the development of conjunctival papilloma.
Patient history. Conjunctival papilloma can occur across the lifespan, Dr. Shields said, although most cases (90%) affect adults. In evaluating patients, the clinician should ask about cutaneous warts, evaluate the patient’s immune status, and ask about family history of warts.
Most conjunctival papillomas occur in the plica/caruncle area (40%); they can also occur in the fornix (19%) and tarsus (14%). In children and adolescents, these lesions are larger and more multifocal than in adults, and they are also more likely to recur, Dr. Shields said.1
Management strategies. The first line of treatment is surgery with excision and cryotherapy, Dr. Shields said. Immunotherapy is the second line, and she employs interferon and cimetidine. “We pull out the big guns, and we use them,” she commented. (Interferon can be given topically or injected; cimetidine—which is used in dermatology—is given orally.) Chemotherapy should be avoided due to the risk of toxicity.
Photodynamic therapy can be effective, Dr. Shields said. However, laser therapy—which she avoids—should be used with great caution if at all, as it “aerosolizes the HPV and can cause nasopharyngeal papilloma in doctors or health care personnel,” she warned. “If you use laser, be sure to wear a mask and gloves, and ventilate the room.”
Vaccination success. Of the 3 HPV vaccines available, Gardasil 9 provides the broadest coverage, as it is nonavalent, protecting against 9 types of the HPV virus. As HPV vaccination has gained greater acceptance, the incidence of genital warts and cervical cancer has dropped, Dr. Shields noted. She cited a 2015 study conducted in France, in which researchers estimated that vaccination with the nonavalent vaccine could prevent nearly 90% of cases of genital warts, anal cancer, and cervical cancer.2
Given this positive trend in vaccination, “I anticipate a parallel reduction in conjunctival papillomas as well,” she said. And in a nod to the future, she said, “You probably won’t invite me back, because this disease won’t exist.”—Jean Shaw
1 Kaliki S et al. JAMA Ophthalmol. 2013;131(5):585-593.
2 Reithmuller D et al. BMC Public Health. 2015;15:453.
Financial disclosures. None.