Vascular Tumors of the Conjunctiva in 140 Cases

Isolated conjunctival cavernous hemangioma: a rare case report

Vascular conjunctival tumors are uncommon, usually benign lesions. Here, we report a 65-year-old male who presented with a nasal interpalpebral bulbar firm, oval, and dark-brown and non-mobile conjunctival mass. The systemic and ocular examinations including fundoscopy and gonioscopy were within normal limits. With a diagnosis of conjunctival malignant melanoma (CMM), the patient underwent excisional biopsy, partial sclerectomy, and cryotherapy. Microscopic examination revealed dilated vascular channels filled by red blood cells, separated by fibrous interstitium and no sign of malignancy. Therefore, a diagnosis of conjunctival cavernous hemangioma was made. Our case demonstrates that the conjunctival cavernous hemangioma can mimic malignant conjunctival lesions as well as extrascleral extension of uveal melanoma or uveal prolapse due to scleral necrosis.

Vascular Conjunctival Lesion in a Patient With a Recent Diagnosis of HIV Infection

This case report describes a diagnosis of conjunctival Kaposi sarcoma in a patient recently diagnosed with HIV infection and taking highly active antiretroviral therapy.

Decades of stability of conjunctival vascular malformations in two patients

Key Clinical Message

Conjunctival hemangioma and lymphangioma are rare and their long-term follow-up description has been scarce. In our two patients, conjunctival vascular and lymphatic malformations remained stable in decades and could be observed without treatment.

Abstract

A 65-year-old woman with diabetic retinopathy underwent glaucoma surgery to construct a filtering bleb adjacent to conjunctival hemangioma, and showed bleb function and stable hemangioma for a decade. A 1.5-year-old girl with right eye lid and cheek swelling by orbital to facial lymphangioma was followed for visual acuity development. Conjunctival lymphangioma was stable in 20 years.

How Traumatic is Intravitreal Ozurdex Injection?

BACKGROUND

This study intended to illustrate a rare case of pyogenic granuloma (PG) in retinal vein occlusion (RVO) patient after dexamethasone (DEX) implant therapy.

CASE DESCRIPTION

A 58-year-old female who underwent DEX implant therapy a month ago due to RVO presented with a mass in her right eye. Anterior segment analysis revealed a slowly enlarging, round, fleshy vascular mass indicating PG located at the injection site. Although surgical excision was planned, because of the Covid-19 pandemic, a patient could not come for surgery. Ocular examination revealed a spontaneous PG disappearance three months later. A small mass could, however, be detected using an anterior segment optical coherence tomography.

CONCLUSION

While superficial PG regression can only be observed by slit-lamp biomicroscopy, extensive root ingrowth can be clearly differentiated by anterior segment optical coherence tomography. Besides, depending on the nature, size, location, and associated symptoms, some PG may be left to regress but with close monitoring.

Bindehautdegenerationen und -neoplasien

Erhabenheiten der Bindehaut entstehen durch Gewebevermehrung, die entweder degenerativ oder neoplastisch, aber auch entzündlich sein können. In diesem Artikel werden degenerative (Pterygium und Pinguecula) sowie benigne und maligne neoplastische Bindehautveränderungen (epitheliale, melanozytäre und vaskuläre Tumoren, Choristome sowie Metastasen) bezüglich der Pathogenese, Symptome, Diagnostik und aktuellem Stand der Behandlung dargestellt.

[Conjunctival Degeneration and Neoplasia]

Conjunctival tumors result from gain of tissue, which can be either degenerative or neoplastic, but also inflammatory. In this article, degenerative (pterygium and pinguecula) as well as benign and malignant neoplastic conjunctival changes (epithelial, melanocytic and vascular tumors, choristomas as well as metastases) are discussed with regard to pathogenesis, symptoms, diagnostics and current status of treatment.

Indocyanine Green Angiographic Assessment of Conjunctival Melanocytic Disorders

PURPOSE

To investigate whether transvascular indocyanine green (ICG) dye leakage is associated with conjunctival malignancy.

METHODS

This is a prospective interventional study. Patients presenting with circumscribed conjunctival melanocytic disorders (CMDs) were included and examined using color photography, anterior segment optical coherence tomography to measure lesion size, and fluorescein and ICG angiography to measure vascular pattern and leakage. Time to vascular leakage was measured by 2 independent observers. Lesions were characterized as benign or malignant based on histopathological features.

RESULTS

Thirty patients with CMD were included: 22 lesions were benign (conjunctival nevus, n = 20; conjunctival melanocytic intraepithelial neoplasia without atypia, n = 2) and 8 were malignant (in situ conjunctival melanoma n = 2; invasive conjunctival melanoma, n = 6). Malignant lesions had larger mean maximal diameters (11.0 ± 4.5 vs. 4.2 ± 2.5 mm, P = 0.003) and more frequently showed intrinsic tumor vasculature (8 of 8 vs. 10 of 22, P = 0.007). The mean time to ICG leakage was 350.9 ± 165.9 seconds in benign and 59.6 ± 22.1 seconds (P = 0.002) in malignant lesions and was inversely correlated with lesion size and thickness.

CONCLUSIONS

Time to angiographic ICG dye leakage is significantly shorter in malignant versus benign CMD.

Silk Suture Granuloma 37 Years After Scleral Buckle Surgery: A Case Report

PURPOSE

To present a rare presentation of pyogenic granuloma arising almost 4 decades after a scleral buckle for retinal detachment.

METHOD

We describe the clinical presentation, diagnostic workup, and management of a suspicious conjunctival lesion in an immunocompromised patient. We report the histopathological findings and the postoperative outcome.

RESULTS

A 58-year-old man with human immunodeficiency virus presented for evaluation of a possible malignant conjunctival lesion in the left eye. The patient reported that the lesion had appeared 1.5 months before presentation with significant growth over the past month. The patient denied any trauma to the eye other than an ocular history of retinal detachment repair with scleral buckle 37 years earlier. Clinical examination revealed a pink, fleshy, mobile, and lobulated conjunctival lesion measuring 7 mm by 10 mm, emanating from the superior-nasal bulbar quadrant. A high-resolution optical coherence tomography revealed highly cellular infiltrate and hyperreflective mass with significant posterior shadowing. Further exploration of the lesion revealed a white, stringy, cauliflower-like material on the underside of the lesion. Surgical excision and pathology subsequently confirmed a diagnosis of pyogenic granuloma with remnants of silk suture.

CONCLUSIONS

A diagnosis of pyogenic granuloma secondary to retained silk sutures should be considered in patients with a history of intraocular surgery irrespective of other risk factors and length of time since procedure.

Topical timolol 0.5% as the primary treatment of ophthalmic pyogenic granuloma: A prospective, single-arm study

Purpose:

To study topical timolol (0.5%) as a first-line treatment in ophthalmic pyogenic granuloma (PG) in terms of safety and efficacy.

Methods:

This was a prospective, interventional, single-arm study conducted at a tertiary eye care hospital in central India. Only new cases of PG were counseled to get enrolled in the study. A total of 40 patients were analyzed in the study. Topical timolol eye drop (0.5%) was started in each patient twice daily for 4–6 weeks duration. The patients were divided into five categories according to the percentage reduction in the size of PG as follows: i) 80–100% reduction - excellent responders, ii) 60–80% – good, iii) 40–60% – satisfactory, iv) 20–40% – poor, and v) <20% – very poor/nonresponder. After 6 months of starting treatment final evaluation was done.

Results:

The mean age of the patients was 23.5 ± 13.3 years. Etiology of the disease included chalazion (n = 11, 27.5%), trauma (n = 2, 5%), surgery (n = 7, 17.5%), foreign body (n = 2, 5%), and idiopathic (n = 18, 45%). An excellent response was achieved in 31 (77.5%) patients. Twenty-seven (67.5%) patients had complete resolution of lesions within 6 weeks. Recurrence of the lesion was not noticed in any patients.

Conclusion:

Timolol 0.5% in topical form is a good treatment option for ophthalmic PG in all age groups. The treatment has no adverse effects when given to suitable individuals for a limited period.

Imaging of vascular abnormalities in ocular surface disease

The vascular system of the ocular surface plays a central role in infectious, autoimmune, inflammatory, traumatic and neoplastic diseases. The development, application, and monitoring of treatments for vascular abnormalities depends on the in vivo analysis of the ocular surface vasculature. Until recently, ocular surface vascular imaging was confined to biomicroscopic and color photographic assessment, both limited by poor reproducibility and the inability to image lymphatic vasculature in vivo. The evolvement and clinical implementation of innovative imaging modalities including confocal microscopy, intravenous, and optical coherence tomography-based angiography now allows standardized quantitative and functional vascular assessment with potential applicability to automated analysis algorithms and diagnostics.

Adult Primary Capillary Hemangioma of the Sclera: A Previously Undescribed Entity With a Review of Epibulbar Vascular Lesions

PURPOSE

The objective of this article is to document a unique case of a primary hemangioma and review epibulbar vascular tumors of the conjunctiva and episclera.

METHODS

A case report with detailed histopathologic, histochemical, and immunohistochemical studies coupled with a comprehensive review of the relevant literature with a tabulation of previously reported epibulbar vascular lesions was performed.

RESULTS

A vascular tumor developed in a 46-year-old woman over 2-3 months that histopathologically was located in the superficial third of the normally avascular sclera and was composed of capillary caliber vessels. CD31 and CD34 positivity established the vascular nature of the lesion. Despite its adult onset, the tumor was also glut-1 positive, a vascular characteristic of childhood capillary hemangiomas that will ultimately involute. Smooth muscle actin was positive in the endothelial cells and associated pericytes. An ectatic muscular vessel identified in the midst of the lesion was interpreted as an anomalous intrascleral branch of an epibulbar anterior ciliary artery, where it perforated the sclera in the vicinity of the insertion of an extraocular rectus muscle. It was deduced to be the source of the capillary proliferation. A literature review failed to identify any previously reported epibulbar vascular tumor that originated primarily in the sclera or secondarily infiltrated this ocular tunic.

CONCLUSION

An adult primary capillary intrascleral neoplasm is described as the rarest of all epibulbar vascular tumors and in keeping with the exceptional status of the ocular endothelium was glut-1 positive. This lesion must be distinguished from an array of other common and esoteric epibulbar vascular conditions.

Case Report: Crying Blood

SIGNIFICANCE

Hemolacria (bloody tears) is a rare clinical presentation with varied underlying etiologies. Thorough clinical evaluation is essential to diagnosis and management.

PURPOSE

This study aimed to report unilateral hemolacria in a known contact lens wearer with an occult, palpebral, conjunctival pyogenic granuloma and review the literature.

CASE REPORT

A 21-year-old female contact lens wearer presented to the clinic after three episodes of sudden painless bloody tears from the right eye. She was referred to the oculoplastic clinic for evaluation. On everting her right upper lid, a fleshy, nontender, ovoid, pedunculated mass was found attached to the palpebral conjunctiva of the right, nasal, upper tarsus. Surgical excision was performed in the office, and pathological examination of the lesion was consistent with pyogenic granuloma.

CONCLUSIONS

Unilateral hemolacria should raise clinical suspicion for a hidden conjunctival lesion such as pyogenic granuloma, although other more sinister causes of hemolacria must also be considered. Thorough evaluation including eyelid eversion is critical in identifying and managing occult conjunctival lesions.

Rare presentation of capillary haemangioma

Conjunctival capillary haemangiomas are very rare above 40 years of age group, with few cases reported in the literature. Adding to the scanty literature of this uncommon vascular tumour, we present the case of a 45-year-old man who presented with a nodular growth in the conjunctiva without any associated systemic diseases or cutaneous lesion. Excisional biopsy of the mass was done. Histopathological examination showed lobulated capillary haemangioma which is very rare in this age group.

Episcleral racemose hemangioma

Racemose hemangioma is a rare, benign vascular malformation. In the episclera, it appears as dilated, tortuous blood vessels that pass from the fornix over the globe surface to the limbal area, without capillary architecture, and then loop backward into the fornix. Fluorescein angiogram reveals the vascular malformation with rapid flow and confirms the episcleral vessels to be large in caliber and with a curvilinear, twisted configuration. We report the case of a 22-year-old man with nonhemorrhagic, coincidental racemose hemangioma of the episclera.

Vegetating erosive cutaneous lesions and pyogenic granuloma in the course of mucous membrane pemphigoid: a case report and review of literature

Mucous membrane pemphigoid (MMP) is a group of chronic autoimmune sub-epithelial blistering disorders, which mostly affect the oral mucosa and the conjunctiva. MMP is very diverse in terms of both the clinical and immunological features (IgG and IgA autoantibodies may react with different antigens). MMP can be induced by infections and medication, including ophthalmologic medication, which may lead to the development of eye lesions. In contrast, a vegetating variant of MMP is extremely rare. Here, we report an MMP case that demonstrated unusual clinical features, that is, pyogenic granulomas on the conjunctivae and extensive vegetating erosions on the skin of intertriginous regions. All these lesions were considered to be induced by unconventional medication containing arsenic.

Medically uncontrolled conjunctival pyogenic granulomas: correlation between clinical characteristics and histological findings

BACKGROUND

Conjunctival pyogenic granulomas are commonly seen after ocular surgeries or at an ocular wound site. The aim of this study is to describe a novel histological classification for medically uncontrolled conjunctival pyogenic granulomas (MUCPG), and to explore whether the diversity in clinical features correlates to different histological subtypes of MUCPG.

METHODS

This is an observational cross-section case series. We reviewed 46 consecutive patients with conjunctival pyogenic granulomas who did not respond to topical corticosteroids and underwent surgical excision from January 1, 2006 through December 31, 2015. Clinical features and histological findings were presented and analyzed.

RESULTS

Ocular surgery, accidental injury, and chalazion were the main predisposing causes of MUCPG. The lesions tended to occur unilaterally on the bulbar conjunctiva. Forty patients (87%) presented an enrichment of inflammatory cells and proliferated capillaries in their pathological sections (inflammatory pattern). Six patients (13%) showed relatively few inflammatory cells and capillaries within fibrous stroma (fibrous pattern). Patients with the inflammatory pattern were older (p = 0.025) and tended to be located in bulbar conjunctiva (p = 0.002). The predisposing causes were also different between two histological subtypes (p = 0.007).

CONCLUSIONS

We found the correlation between clinical presentation and histological subtypes in patients with MUCPG, indicating this disease may need a new classification scheme.

Conjunctival Capillary Hemangioma

Conjunctival hemangioma over the age of 60 is rare, with few cases reported in the literature. We present a unique case of a conjunctival capillary hemangioma, adding to the sparse literature of this uncommon vascular tumor. Here, we present an interesting case of spontaneous development of this tumor at age 68, without associated systemic disease process or cutaneous manifestations.

Infantile hemangiomas with conjunctival involvement: An underreported occurrence

BACKGROUND/OBJECTIVES

Infantile hemangiomas (IHs) involving the conjunctiva are only anecdotally reported in the literature and little is known about their clinical course. In a retrospective case series we aimed to better delineate the clinical presentation, complications, and response to treatment of this uncommon subtype of IH. A classification of conjunctival IH is proposed.

METHODS

Medical charts at three academic pediatric dermatology institutions were retrospectively analyzed. Data were collected on the clinical characteristics, ophthalmologic findings, treatments, and outcomes of 22 individuals with conjunctival IH.

RESULTS

Growth characteristics of conjunctival IH closely mirrored those of their cutaneous counterparts. Ophthalmologic abnormalities were associated with the IH in six individuals (27%); in three, they were considered severe. Seventeen subjects (77%) required treatment, most commonly because of risk of ocular compromise. All treated individuals responded favorably to topical timolol or systemic propranolol.

CONCLUSION

Conjunctival IH have clinical characteristics similar to those of cutaneous IH and respond readily to beta-blocker treatment. Ocular complications may occur in a minority of individuals receiving treatment.

Conjunctival granuloma post pulley fixation suture

Pulley fixation sutures to the medial rectus muscles have been used to manage variable-angle esotropia and convergence excess esotropia. Most techniques use a nonabsorbable suture. The posterior location of the sutures usually minimizes complications. We report a case of chronic conjunctival granuloma occurring after pulley fixation suture to the medial rectus muscle.

Conjunctival Tumors in 5002 Cases. Comparative Analysis of Benign Versus Malignant Counterparts. The 2016 James D. Allen Lecture

PURPOSE

To evaluate frequency of conjunctival tumors in all ages and compare benign vs malignant counterparts.

DESIGN

Retrospective series.

METHODS

setting: Tertiary referral center.

STUDY POPULATION

Total of 5002 patients.

OBSERVATION

Clinical features.

MAIN OUTCOME MEASURE

Differentiation of benign from malignant counterparts.

RESULTS

The tumor was benign (52%), premalignant (18%), or malignant (30%). Malignant tumors included melanoma (12%), squamous cell carcinoma (SCC) (9%), lymphoma (7%), and others. Comparison of primary acquired melanosis vs melanoma revealed melanoma with greater median patient age (54 vs 61 years, P < .0001), male sex (35% vs 49%, P < .0001), location in fornix (2% vs 6%, P = .0016) and tarsus (1% vs 4%, P = .0018), larger median basal diameter (6 vs 8 mm, P < .0001) and thickness (<1 vs 1 mm, P < .0001), and intralesional cysts (0% vs 7%, P < .0001), feeder vessels (10% vs 48%, P < .0001), intrinsic vessels (4% vs 33%, P < .0001), and hemorrhage (<1% vs 3%, P = .0001). Comparison of conjunctival intraepithelial neoplasia (CIN) vs SCC revealed SCC with greater diffuse involvement (1% vs 8%, P < .0001) and larger median basal diameter (7 vs 8 mm, P < .0001) and thickness (1 mm vs 2 mm, P < .0001). Comparison of benign reactive lymphoid hyperplasia vs lymphoma revealed lymphoma with greater median patient age (50 vs 61 years, P < .0001), fornix location (32% vs 54%, P < .0001), larger median basal diameter (10 vs 20 mm, P < .0001), and less involvement of nasal region (50% vs 23%, P < .0001).

CONCLUSION

In an ocular oncology practice, conjunctival tumors are benign (52%), premalignant (18%), or malignant (30%). Malignant tumors tend to occur in older patients and demonstrate greater basal diameter and thickness, compared with benign counterparts.

Large benign de novo conjunctival hemangioma in an 11-year-old boy: case report and literature review

Benign hemangiomas are rare vascular tumors of the conjunctiva that typically present clinically in the first few weeks of life and resolve spontaneously. De novo presentation later in childhood has not been well documented. We present the unusual case of an 11-year-old boy with a rapidly growing benign de novo conjunctival hemangioma that was treated with surgical excision.

Hemangiomas and the eye

Infantile hemangiomas are a common vascular birthmark with heterogeneous presentations and unique growth characteristics with early rapid growth and eventual self-involution. Hemangiomas that develop around the eye have the potential for inducing amblyopia by several mechanisms and may eventually result in permanent visual impairment in otherwise healthy infants. Segmental periocular hemangiomas carry the additional risk of associated structural anomalies and PHACE syndrome. In recent years, the treatment of periocular hemangiomas has been revolutionized by the serendipitous discovery of the effectiveness of beta-blockers (systemic and topical), with most experts viewing these as first-line therapies. The management of periocular hemangiomas should involve a close partnership between an ophthalmologist and dermatologist or other relevant specialists familiar with the unique clinical features, differential diagnosis, treatment approaches, and potential complications.

Resolution of conjunctival sessile hemangioma with topical timolol

PURPOSE

To report a single case of acquired sessile hemangioma of the conjunctiva which resolved after treatment with topical timolol.

METHODS

Case report and literature review.

RESULTS

A 77-year-old African American woman developed an acquired sessile hemangioma of the conjunctiva of the right eye. She was followed for primary open-angle glaucoma, and the lesion was monitored for 12 months without change. Topical timolol-dorzolamide was then added to her glaucoma medication regimen twice daily. On follow-up examination 6 months later, the lesion had completely resolved.

CONCLUSIONS

In this case report, an acquired sessile hemangioma of the conjunctiva resolved with topical timolol therapy.

Beta blocker treatment of infantile conjunctival hemangiomas--observations from 2 cases

Infantile conjunctival hemangiomas are rare lesions in comparison to cutaneous and orbital capillary hemangiomas. They generally present several weeks following birth as a red stromal mass. Recent reports of cutaneous and orbital infantile hemangiomas involuting in response to oral or topical beta blocker treatment suggest that infantile conjunctival hemangiomas could respond similarly. We report 2 cases of presumed infantile hemangiomas of the conjunctiva. One, associated with cutaneous hemangiomas, did not respond to oral propranolol; the other was isolated and resolved with topical timolol.

Conjunctival pyogenic granuloma associated with intravitreal bevacizumab injection

PURPOSE

To report a case of conjunctival pyogenic granuloma after intravitreal injection of anti-vascular endothelial growth factor, bevacizumab.

METHODS

A 52-year-old patient after 3 intravitreal bevacizumab injections was found to have a vascular conjunctival nodule at the injection site. A pathologic analysis of the vascular conjunctival nodule was performed after surgical excision.

RESULTS

The pathologic analysis revealed a conjunctival pyogenic granuloma.

CONCLUSION

Conjunctival pyogenic granuloma can complicate an otherwise uneventful intravitreal anti-vascular endothelial growth factor injection.

Subconjunctival hemorrhage: risk factors and potential indicators

Subconjunctival hemorrhage is a benign disorder that is a common cause of acute ocular redness. The major risk factors include trauma and contact lens usage in younger patients, whereas among the elderly, systemic vascular diseases such as hypertension, diabetes, and arteriosclerosis are more common. In patients in whom subconjunctival hemorrhage is recurrent or persistent, further evaluation, including workup for systemic hypertension, bleeding disorders, systemic and ocular malignancies, and drug side effects, is warranted.

Conjunctival lymphangiectasia presenting as pediatric pseudopterygium

OBJECTIVES

The aim of this study is to report a case of conjunctival lymphangiectasia simulating a pediatric pterygium.

METHODS

A 10-year-old girl with Turner syndrome and familial history of pterygia presented because of a conjunctival growing lesion clinically consistent with pterygium in her left eye. Visual acuity (VA) was 20/20 in the right eye and 20/40 in the left eye. Cycloplegic refraction was +1.50sph -0.50cyl×93° and +9.00sph -9.00cyl×180° in the right and left eyes, respectively.

RESULTS

Resection of the lesion with amniotic membrane implantation and conjunctival autograft was performed. The histologic examination revealed conjunctival lymphangiectasia. Ten months later, the patient did not show any signs of recurrence. Refraction in the left eye was +0.5sph -1.5cyl×70°, and spontaneous VA was 20/20 in both eyes.

CONCLUSIONS

Pediatric pseudopterygium may be the clinical presentation of several ocular surface disorders. Thus, pathologic analysis of this lesion should be considered to determine its exact nature. Surgery lessens the refractive defect and hastens visual recovery.