Conjunctival tumors in children

Conjunctival amelanotic melanoma presenting as a multifocal pink lesion

Conjunctival amelanotic malignant melanoma is a rare form of melanoma, which lacks visible pigment and is commonly located underneath the eyelids in the bulbar conjunctiva. In this report, we described a case of a Caucasian women in her 70s who presented with unilateral irritation and tenderness following cataract surgery. On eversion of the eyelid, two elevated pink lesions were noted. Tumour - Node - Metastasis staging with the American Joint Committee on Cancer staging system eighth edition was T3C and required multiple excisions and reconstruction procedures. This case exemplified the diagnostic pitfall of conjunctival amelanotic malignant melanoma, which is a potentially life-threatening disease and the importance of histopathology in the diagnostic process.

Epibulbar osseous choristoma with dermolipoma: A case report and review of literature

BACKGROUND

A choristoma is defined as a growth of histologically normal tissue in an abnormal location. Epibulbar osseous choristoma is the rarest type among all ocular choristoma with less than 100 cases reported. Here, we report a case of epibulbar osseous choristoma combined with dermolipoma and a literature review.

METHODS

A 15-year-old female patient presented with an accidentally found subconjunctival mass in her left eye. Slit lamp examination revealed a 10 × 10 mm elevated, sigmoid-shaped mass in the supratemporal quadrant of the bulbar conjunctiva. We performed a debulking excisional biopsy of the mass.

RESULTS

The pathology confirmed osseous tissue surrounded by mature adipose tissue. At 1 week after the operation, the wound was clear and the patient was satisfied with the treatment. A systematic literature review of 14 previously published cases taken from PubMed dating back to 1987 along with ours was undertaken. The average age at presentation was 11.6 years and there was a female preponderance with 10 cases being female and the other 5 cases being male. Supratemporal conjunctiva was the most common site of presentation. There was no systemic disease associated with any of the cases. Since it is a benign tumor, it can be managed by observation, but if necessary, it can be treated by surgical removal.

CONCLUSION

In pediatric subconjunctival mass, particularly located in supratemporal quadrant of bulbar conjunctiva, osseous choristoma should be considered in the differential diagnosis. Pre-operative CT scans will helpful to not also reduce complication with surgical excision but also helpful in prediction of diagnosis and prognosis.

Amelanotic conjunctival melanoma in a child

Purpose

Malignant melanomas of the conjunctiva are extremely rare in children. In this case report we present a conjunctival melanoma of a child.

Observations

We report a case of a 7 years old boy who presented with a rapidly growing reddish lesion measuring 8mm in base × 2.5 mm in thickness on the nasal conjunctiva in his right eye. The patient underwent resection of the lesion (with 4 mm margins of the surrounding clinically normal conjunctiva) and cryotherapy to the adjacent conjunctival margins. Histopathology confirmed the diagnosis of conjunctival melanoma. Pathology also can be challenging; a review of pathology is advisable as happened in this case. Systemic workup was negative for metastatic disease. On 73 months of follow up, the patient was stable without local recurrence or secondary systemic disease.

Conclusions and Importance

Malignant melanoma can present de novo as an amelanotic rapidly growing conjunctival lesion in children. This case should raise the awareness of the variable clinical presentations, the challenging diagnosis, treatment and follow up of pediatric conjunctival melanoma.

Epidemiology and clinical characteristics of congenital choristomas in the ocular adnexa of pediatric patients

PURPOSE

To investigate the epidemiology and clinical characteristics of infants presenting with conjunctival, palpebral, or orbital congenital choristomas (dermolipomas, epidermoids, and dermoid cysts) and children undergoing surgery for congenital choristomas in the ocular adnexa.

METHODS

We reviewed the medical files of congenital choristomas in children seen in The Capital Region of Denmark during a 5-year period (2014-2018). Children (< 18 years) were divided into two groups: those referred < 1 year of age (Group I) and those undergoing surgery to remove the lesion (Group II). Group I was used to calculate a population-based incidence of congenital choristomas by comparing our data to birth statistics from the Danish Medical Birth Registry.

RESULTS

A total of 97 children were included, 43 in Group I and 70 in Group II (including 16 patients from Group I). The total incidence of congenital choristomas was 1 in 2537 live born children. Most lesions were palpebral choristomas (27/43, 63%) located in the superotemporal region (17/27, 63%), followed by the superonasal region (7/27, 26%). The main reasons for surgical removal of a congenital choristoma were growth (28/70, 40%) or cosmesis (25/70, 36%).

CONCLUSION

The total incidence of congenital choristomas in the ocular adnexa of infants < 1 year of age, including both conjunctival and palpebral congenital choristomas, is about 1 in 2537 live born children in The Capital Region of Denmark. Hence, congenital choristomas are common masses found in the ocular adnexa.

Paediatric ocular adnexal lymphoma: a population-based analysis

Objective

To investigate the incidence, clinicopathological characteristics and survival of ocular adnexal lymphoma (OAL) in the paediatric population.

Methods and analysis

In this retrospective case series, the Surveillance, Epidemiology and End Results database was accessed to identify individuals with OAL ≤18 years of age, diagnosed between 1973 and 2015. OAL located in the eyelid, conjunctiva, lacrimal apparatus and orbit were included. Main outcome measures were the age-adjusted incidence rates (IRs) per 1 000 000 population at risk (calculated for the period 2000–2015) and descriptive statistics of demographic and clinicopathological features.

Results

The IR of paediatric OAL was 0.12 (95% CI 0.08 to 0.16) per 1 000 000. Males (0.15; 95% CI 0.10 to 0.22) and blacks (0.24; 95% CI 0.13 to 0.42) had a higher tendency for OAL development. A total of 55 tumours in 54 children were identified. The majority were localised (78.4%), conjunctival (49.1%) lymphomas. Extranodal marginal zone lymphoma (EMZL, 45.5%, n=25) was the most frequent subtype, followed by diffuse large B-cell lymphoma (DLBCL, 9.1%, n=5), B lymphoblastic lymphoma (7.3%, n=4), follicular lymphoma (5.5%, n=3), Burkitt lymphoma (5.5%, n=3), anaplastic large cell lymphoma (ALCL, 3.6%, n=2), small lymphocytic lymphoma (1.8%, n=1), diffuse large B-cell lymphoma, immunoblastic (1.8%, n=1) and panniculitis-like T-cell lymphoma (1.8%, n=1). Localised, low-grade, conjunctival lymphomas were frequently treated with complete excision with or without radiation, while high-grade and distant tumours usually received chemotherapy. Only 29.1% of paediatric OAL cases were treated with radiation. Three out of five (60%) patients with DLBCL died of lymphoma at a median follow-up of 21 (range 10–86) months, and 1 out of 2 (50%) patients with ALCL died of lymphoma at 23 months from diagnosis.

Conclusion

OAL in the paediatric population is rare. The majority of OAL are EMZL and are characterised by excellent prognosis. The histological subtype was found to be the main predictor of outcome with cancer-specific deaths observed in patients with DLBCL and ALCL.

Survey of 138 Conjunctival Tumors in the Dominican Republic

PURPOSE

To report the frequency of conjunctival tumors in the Dominican Republic.

METHODS

Retrospective noninterventional case series. One hundred thirty-eight consecutive patients with a conjunctival mass evaluated at two tertiary referral centers from 2010 to 2018. Main outcome measures were frequency of tumors by diagnosis and distribution of tumors relative to patients' age and gender.

RESULTS

The mean age at presentation was 41.2 years (median, 42 years; range 10 days - 91 years). There were 83 male patients (60%) and 55 female patients (40%). The three most common specific diagnoses were junctional, compound, and subepithelial naevi (47 [34%]), squamous cell carcinoma (SCC) (26 [19%]) and conjunctival squamous intraepithelial neoplasia (CIN) (17 [12%]). The mean age at detection was 36.5 years for non-malignant tumors and 56.3 years for malignant tumors (p < .001), with a mean difference of 19.8 years at time of diagnosis (95% CI, 10.7-28.8). Benign tumors were more common in children and young adults; malignant and premalignant tumors were more common in mid and older adults (p = .009). Malignant tumors were more common in males (73%) than in females (27%) (p = .04).

CONCLUSION

In the Dominican Republic, conjunctival tumors are benign (63%), premalignant (13%) and malignant (24%). Malignant tumors are more common in older adults and men.

Epibulbar complex choristoma with simultaneous involvement of eyelid: a case report

Background

Epibulbar complex choristoma, a rare congenital epibulbar tumor, has many diverse forms. Reviewing the literature, it can present clinically as either a circumferential or isolated epibulbar mass, limbal tumor, lateral canthal mass, aggregate of ectopic cilia in the upper eyelid, eyelid mass mimicking chalazion, or lacrimal caruncle mass. The management depends on the extent of involvement, the risk of amblyopia, and cosmetic concerns. Here, we report an atypical presentation of epibulbar complex choristoma with simultaneous eyelid involvement.

Case presentation

A 1-month-old full-term boy was brought to our clinic with congenital epibulbar mass of the right eye with simultaneous eyelid involvement. Dilated fundus examination was unremarkable. Survey for linear nevus sebaceous Jadassohn was negative. Due to concerns of possible amblyopia and cosmetics, lamellar keratectomy, sclerotomy, and conjunctivoplasty were performed to remove the epibulbar lesion. The eyelid defect was reconstructed with 6–0 Vicryl sutures. Histopathological examination reported complex choristoma. Upon three-year follow-up, low astigmatism and favorable cosmetics results were achieved.

Conclusions

Congenital complex choristoma can present clinically as an epibulbar mass with eyelid involvement. The management depends on the extent of involvement, the risk of amblyopia, and cosmetic concerns. The method of eyelid reconstruction should be tailored according to the residual eyelid defect.

Odontogenic choristoma presenting as dermolipoma

A 5-year-old otherwise healthy girl presented to the oculoplastic service with a painless superotemporal subconjunctival mass in the left eye. Visual acuity was within normal limits, and there was no evidence of proptosis or orbital enlargement. Excision was performed to remove the anterior portion of the mass for alleviation of symptoms. On histopathological analysis, the mass was comprised of fibroadipose tissue consistent with dermolipoma and contained a hard nodule found to be a calcified tooth. In the periocular region, odontogenic choristoma (tooth) is a rare lesion, and has been reported to occur within teratomas, dermoid cysts, and displaced oral embryonic epithelium. We describe an unusual case of a tooth occurring within a sporadic dermolipoma. The clinical presentation, examination, management, and histopathology are reviewed.

Epibulbar osseous choristoma within a dermolipoma: case report and literature review

A healthy 18-year-old girl presented with a superotemporal epibulbar mass that was present since birth. Computed tomography revealed a cystic mass with fat-like low-density and a central oval-shaped mass that was isodense to the bone in the superotemporal region of the globe. Histopathology of the excised tumour revealed osseous choristoma and dermolipoma. Our review of literature yielded nine reported cases of epibulbar osseous choristoma within a dermolipoma and we reviewed these cases.

An Unusual Presentation of Conjunctival Dermolipoma With a Skin Tag

Dermolipoma is considered the second most common benign conjunctival tumor in children after nevus. Usually, dermolipoma located just deep in the superotemporal bulbar and forniceal conjunctiva. The authors describe an uncommon presentation of dermolipoma that arise in the conjunctiva as well as in the skin of the lateral canthus. A 5-month-old baby with lateral limbal lesion involving the conjunctiva and the skin underwent excision biopsy. The pathological examination found a dermolipoma in the conjunctiva as well as in the dermis. The outcomes of the excision were satisfactorily functional and cosmetic.This is only the second case of dermolipoma in the dermis in normal baby that described those far in the literature. This case should raise the awareness that dermolipoma should be considered in differential diagnosis of lesions of the lateral cantus and the periocular skins near it.

Pediatric conjunctival melanoma arising from a compound nevus

We present a rare case of conjunctival melanoma in a 9-year-old girl who presented with a conjunctival lesion of the left eye, growth of which was documented by patient photographs. Examination showed a raised pigmented lesion at the temporal limbus, with fine surrounding vessels. Enhanced depth imaging-optical coherence tomography showed no invasion into the sclera. The patient underwent excisional biopsy, and histopathology revealed conjunctival melanoma arising from a nevus with malignant cells that stained positively with markers HMB-45 and Ki-67. Systemic workup was negative for metastatic disease. Conjunctival nevi are the most common melanocytic conjunctival lesions in children and generally demonstrate physiologic growth during adolescence. Thus, there may be a greater risk of misdiagnosis of conjunctival melanoma in a child.

Benign reactive lymphoid hyperplasia of the conjunctiva in childhood

BACKGROUND/AIM

Our aim is to the report the clinical and histopathological features of benign reactive lymphoid hyperplasia (BRLH) of the conjunctiva in children and the outcomes of treatment.

METHODS

A retrospective chart review was performed for children aged 0-18 years, diagnosed with conjunctival BRLH from January 2000 to December 2013 at two large ophthalmology hospitals in the Middle East. Data were collected on patient demographics, features of the lesions, the site of the lesion, location, adnexal involvement, lymph nodes involvement, local spread, histopathology and molecular genetic studies of the cases (if available), outcomes of treatment and recurrence.

RESULTS

There were 24 patients with lymphoid lesions classified as conjunctival BRLH during the 12-year period evaluated in this study. The mean age at diagnosis was 11.6 years. Twenty-three patients were males (96%). Systemic medical history included three patients with bronchial asthma, one patient with Down's syndrome, one patient with generalised skeletal malformation and one patient with gastritis. The initial uncorrected visual acuity was 20/30 or better in 93.5% of the eyes. At presentation, the tumour was unilateral in 12 cases (50%). The conjunctival mass was located on the bulbar conjunctiva in all cases. The mass was present nasally in 96% of lesions. No cases (that were tested) had an infectious aetiology. PCR demonstrated monoclonality suggestive of lymphoma in two cases; however, this did not alter the final diagnosis as BRLH per histopathological criteria and clinical course, CONCLUSIONS: All investigated cases of paediatric conjunctival BRLH had a benign clinical course with no local or systemic dissemination and a male predominance. Recurrence was rare, and in our cohort, it was not associated with malignant transformation.

Epibulbar osseous choristoma: A case report

Purpose

To present the case of a 12-year-old female with an epibulbar osseous choristoma.

Observations

The patient presented with right-sided conjunctival mass, which caused her discomfort. Slit lamp examination revealed a 5×5-mm, firm nodule in the superotemporal quadrant of the bulbar conjunctiva. The nodule had feeder vessels, adhered firmly to the sclera, and lacked signs of malignancy. The patient underwent excisional biopsy under general anesthesia. During this procedure, great care was taken to avoid perforation of the globe. The pathologic sections were significant for well-circumscribed osseous tissue without atypia.

Conclusions and importance

We describe diagnosis and successful surgical management of osseous choristoma the rarest subtype of ocular choristoma. With only 65 cases reported since mid-19th century, the condition remains poorly described. This report provides additional information on diagnosis and treatment of this rare condition.

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.

Spontaneous regression of a conjunctival naevus

Conjunctival naevi are one of the most common lesions affecting the conjunctiva. While benign in the vast majority of cases, the risk of malignant transformation necessitates regular follow-up. They are well known to increase in size; however, we present the first photo-documented case of spontaneous regression of conjunctival naevus. In most cases, surgical excision is performed due to the clinician's concerns over malignancy. However, a substantial proportion of patients request excision. Highlighting the potential for regression of the lesion is important to ensure patients make an informed decision when contemplating such surgery.

Pediatric conjunctival lymphoma associated with oral carbamazepine use

Purpose

To report a case of a pediatric patient diagnosed with conjunctival lymphoma associated with oral carbamazepine use.

Observation

An 11-year-old boy who presented with 5-month history of a small nasal conjunctival mass in the left eye that failed therapy with topical corticosteroids. Upon excision and molecular analysis, diagnosis of Follicular Lymphoma was favored. The patient was healthy and did not have any known risk factors except for a history of epilepsy treated with systemic carbamazepine.

Conclusion and importance

We report a case of a rare childhood conjunctival lymphoma. Conjunctival lymphomas may masquerade as chronic conjunctivitis, or scleritis that fail therapy with topical corticosteroids. Furthermore, our patient did not have any known risk factors such as old age, systemic lymphoma or immunosuppression. The patient did have a history long-term use of systemic carbamazepine. This is to our knowledge the first case conjunctival lymphoma that may be associated to the use of carbamazepine.

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.

Primary conjunctival anaplastic large cell lymphoma in a child

Conjunctival tumors in children are uncommon and behave differently from those in adults. The vast majority of tumors are benign. Of the malignant lesions in this age group, lymphoma and melanoma are most commonly reported. Most lymphoid tumors in children represent lymphoid hyperplasia, not lymphoma. Clinical differentiation of these two entities is not possible and biopsy is required to establish the diagnosis. We present an unusual case of primary anaplastic large cell lymphoma of the conjunctiva in a young boy.

Dermolipoma surgery with rotational conjunctival flaps

PURPOSE

To describe a useful technique of surgical resection of dermolipomas.

METHODS

This is a retrospective, noncomparative and interventional case series. Sixteen eyes of 16 patients with dermolipomas and large areas of conjunctiva strongly adherent to the masses underwent surgical removal of the dermolipomas. The anterior portion of the mass, including closely adherent conjunctiva and pilosebaceous areas, was excised, and the conjunctival defects were covered with rotational conjunctival flaps from the superior or inferior bulbar conjunctiva.

RESULTS

The mean follow-up time was 12.5 months (range, 6-47 months). The cosmetic outcome was satisfactory in all 16 patients. There were no cases of reappearance of the mass, symblepharon or significant scar formation during follow-up. One patient developed blepharoptosis and another showed limitation of medial gaze postoperatively. Both were resolved spontaneously within 3 months. There were no other significant complications.

CONCLUSION

Rotational conjunctival flap is a useful technique of conjunctival reconstruction following removal of large dermolipomas and the overlying epithelium.

Neuro-ophthalmology of orbital disease

In this chapter the presentation and management of common orbital diseases are discussed. An accurate clinical history and assessment are essential, with computed tomography being the imaging of choice. Magnetic resonance imaging provides detail of intrinsic optic nerve disease and orbital apical or intracranial pathology, and ultrasonography is valuable in assessing anterior orbital masses, in particular vascular lesions. Inflammatory lesions require a tissue biopsy before immunosuppression is instituted. Exceptions to this principle are scleritis, myositis, thyroid eye disease, and characteristic orbital apex syndrome, in which delay in immune suppression may jeopardize visual outcome. The term "orbital pseudotumor" is now obsolete. The management of active thyroid eye disease includes immunosuppression and low-dose orbital radiotherapy. Urgent orbital decompression is indicated in the presence of nonresponsive optic neuropathy, and inactive disease is managed by decompression for exophthalmos, and correction of muscle imbalance and lid retraction. Subacute lacrimal gland inflammation, unresponsive to a few weeks of nonsteroidal treatment, may be due to underlying carcinoma and a specialist opinion should be sought without delay. Pleomorphic adenoma, with typical features on imaging, should always be excised intact to avoid subsequent pervasive malignant disease.

Comparative study of descemet stripping automated endothelial keratoplasty donor preparation by Moria CBm microkeratome, horizon microkeratome, and Intralase FS60

PURPOSE

To evaluate the quality of stromal bed and the safety on endothelium in preparation of donor tissue for Descemet stripping automated endothelial keratoplasty in a masked fashion using 2 mechanical microkeratomes and a femtosecond laser.

METHODS

Deep anterior lamellar dissection was performed on 15 donor corneas. Central endothelial cell density was calculated using specular microscopy before and after the dissection. One cornea from each of 5 donor pairs was cut with the Moria ALTK system with the CBm microkeratome using the 300-μm head and the mate cut with the Horizon disposable 300-μm microkeratome. Five additional donor corneas were cut with the Intralase 60-kHz FS laser. The donor corneas were then bisected with half of the cornea used for Live/Dead assay to study central endothelial viability. The other halves were sent for scanning electron microscopy of the stromal bed. Qualitative surface roughness of the scanning electron microscopy images was graded by 2 masked observers, and quantitative surface roughness was assessed using roughness evaluation software.

RESULTS

The Horizon group showed a smoother stromal bed compared with the Moria or Intralase groups by 2 masked observers. However, the Moria group had the smoothest quantitative score of all the groups when assessed by roughness evaluation software. There was no statistically significant difference among the 3 groups in the percentage change in the central endothelial cell density or percentage of viable central endothelium by Live/Dead assay after the dissection.

CONCLUSIONS

Both mechanical microkeratomes created smoother stromal bed dissections than the femtosecond laser. All systems provided good endothelial cell viability.

Subconjunctival fat prolapse and dermolipoma of the orbit: differentiation on CT and MR imaging

BACKGROUND AND PURPOSE

Subconjunctival fat prolapse and dermolipoma of the orbit are unfamiliar to radiologists and yet should be differentiated because their treatments are different. The purpose of this study was to investigate the CT and MR imaging findings that distinguish these 2 conditions.

MATERIALS AND METHODS

Between 1995 and 2009, we found 33 patients (27 men, 6 women; mean age, 63 years) with surgically proved subconjunctival fat prolapse and 27 patients (3 males, 24 females; mean age, 17 years) with dermolipoma in our hospital. Among them, 8 patients with subconjunctival fat prolapse and 6 patients with dermolipoma underwent CT and/or MR imaging examinations. We retrospectively reviewed CT scans and MR images in these patients.

RESULTS

In all of the 8 patients with subconjunctival fat prolapse, CT and MR images demonstrated the herniated fat at the superotemporal epibulbar area, continuous with the intraconal fat, extending forward between the lateral wall of the globe medially and the lateral rectus muscle and the lacrimal gland laterally, either bilaterally (n = 7) or unilaterally (n = 1). In contrast, all 6 patients with dermolipoma had a unilateral, crescent- (n = 5), or triangle-shaped (n = 1) fatty mass at the temporal or superotemporal epibulbar area, which lay on the lateral wall of the globe, anterior to the insertion of the lateral rectus muscle and medial to the lacrimal gland, without connection to the intraconal fat.

CONCLUSIONS

The characteristic CT and MR imaging findings may help easily differentiate subconjunctival fat prolapse and dermolipoma, both of which usually present as an epibulbar fatty mass in the lateral canthal area.

Ocular surface tumors

Tumors of the conjunctiva and cornea comprise a large and varied spectrum of conditions. These tumors are grouped into two major categories of congenital and acquired lesions. The acquired lesions are further subdivided based on origin of the mass into surface epithelial, mucoepidermoid, melanocytic, vascular, fibrous, neural, histiocytic, myxoid, myogenic, lipomatous, lymphoid, leukemic, metastatic and secondary tumors. Ocular surface tumors include a variety of neoplasms originating from squamous epithelium, melanocytic tumors and lymphocytic resident cells of the conjunctival stroma. In this review, we highlight clinical features of these lesions, important diagnostic and investigative tools and standard care of management.