Reconstruction of Conjunctiva with Amniotic Membrane after Excision of Large Conjunctival Melanoma: A Long-Term Study

Melanocytic Nevus of the Superior Conjunctival Fornix: A Case Report

Introduction

Conjunctival nevi are benign tumors that are commonly located at the nasal or temporal limbus and rarely in the fornix or tarsus. We report a case of a patient presenting with a solitary compound cystic nevus of the conjunctival fornix in the background of bilateral complexion-associated melanosis.

Case Presentation

A 71-year-old African-American female was referred for evaluation of an incidentally noted melanocytic lesion of the right conjunctival fornix. The patient underwent an excisional biopsy, revealing histological features consistent with a compound cystic nevus.

Conclusion

This finding is noteworthy due to the rarity of conjunctival nevi originating in the fornix. The case underscores the importance of excisional biopsy in evaluating conjunctival forniceal melanocytic lesions to exclude malignant melanoma, a critical consideration for prognosis.

Conjunctival Autografts for Ocular Surface Reconstruction after Conjunctival Nevus Excision

PURPOSE

The aim of this study was to evaluate the clinical and therapeutic outcomes of the cases where we used conjunctival autografts with and without the Tenon fascia for ocular surface reconstruction after conjunctival nevus excision.

METHODS

This study included 63 eyes of 63 patients who underwent conjunctival nevus excision between January 2013 and December 2020. Although a Tenon-free conjunctival autograft was used in 32 eyes of 32 patients in group 1, a Tenon-containing conjunctival autograft was used in 31 eyes of 31 patients in group 2. The clinical and histopathological characteristics of the nevus, complete graft epithelization, cosmetic outcomes, and postoperative complications were evaluated.

RESULTS

Conjunctival autografts were harvested from the contralateral eye in 3 eyes (9.3%) in group 1 and 2 eyes (6.4%) in group 2 ( P = 0.66). Postoperatively, the mean defect size at the harvest site was 5.3 ± 1.4 mm in group 1 and 5.5 ± 1.5 mm in group 2 ( P = 0.47). Graft edema was observed in only 1 case (3.1%) in group 1 and 6 cases (19.3%) in group 2 ( P = 0.04). Although a complete graft epithelization was observed in all eyes in group 1, fluorescein staining was present in 2 eyes (6.4%) in group 2 ( P = 0.14). Cosmetically, retracting and shrinking grafts were absent in group 1, whereas group 2 had in 4 eyes (12.9%) ( P = 0.03). Neither group had conjunctival scarring, symblepharon, eyelid cicatrization, dysmotility, or pannus at the donor site.

CONCLUSIONS

Ocular surface reconstruction with a Tenon-free conjunctival autograft after conjunctival nevus excision provides excellent cosmetic and functional results without significant complications.

Amniotic membrane application in surgical treatment of conjunctival tumors

The amniotic membrane (AM) has special properties, making it ideal for clinical applications in various surgical fields like ophthalmology. It is used more frequently to cover conjunctival and corneal defects. In our retrospective study we have been combined 68 patients with epibulbar conjunctival tumors they have been surgically treated in the period of 2011-2021. Seven (10.3%) patients have been treated with AM application after surgical removal of the tumor. 54 (79%) cases were malignant, and 14 (21%) were benign. In the analyzed dataset the males had just slightly higher chance of malignancy than females, 80% versus 78.3%. For the significancy calculation the Fisher exact test was used and the result proved no significancy (p = 0.99). Six patients with AM application were malignant. The observed difference in the number of quadrants of the bulbar conjunctiva infiltrated versus significant malignancy with p = 0.050 calculated by Fisher Exact test and with p = 0.023 calculated by Likelihood-ratio test. The results of our study indicate that AM grafts are an effective alternative to cover defects after removal of epibulbar lesions due to their anti-inflammatory properties because the conjunctiva must be preserved, and especially the most important application is in malignant epibulbar conjunctival tumors.

Amniotic Membrane Transplantation in Surgical Treatment of Conjunctival Melanoma: Long-term Results

Objectives

To investigate the long-term efficacy and results of surgical management of conjunctival melanoma reconstructed with amniotic membrane transplantation.

Materials and Methods

Conjunctival melanoma in 10 patients (5 female, 5 male) was totally excised with adjunctive cryotherapy to the surgical margins, corneal epitheliectomy with absolute alcohol in cases of corneal involvement, lamellar sclerectomy in cases with episcleral involvement, and ocular surface grafting with cryopreserved amniotic membrane. Complications and tumor control rates were evaluated.

Results

The mean age of the patients was 57.4±15.2 (range, 37-84) years. The mean diameter of the tumors was 15.5±4.9 (range, 10-25) mm and histopathologically confirmed complete excision was performed in all cases. Mild limbal stem cell deficiency (2 eyes) and subclinical symblepharon (3 eyes) were observed as long-term complications. In a mean follow-up of 56.7±40.4 (range, 30-132) months, only one local tumor recurrence was detected. Despite retreatment, exenteration was performed in this patient due to re-recurrence. One patient died due to disseminated metastasis despite the absence of local recurrence.

Conclusion

In large conjunctival melanomas, reconstruction of the ocular surface is usually very challenging. The use of cryopreserved amniotic membrane for conjunctival defect repair is safe and effective with mild complications, and allows the excision of wider margins around the tumor.

Fresh frozen amniotic membrane for conjunctival reconstruction after excision of neoplastic and presumed neoplastic conjunctival lesions

PurposeSuspicious neoplastic conjunctival lesions often require wide excision with tumour-free margins, leaving significant conjunctival defects requiring reconstruction. In this study we report the results of using fresh frozen amniotic membrane grafts (AMG) after wide excision of potentially malignant lesions.MethodsRetrospective review of 53 patients; between January 2011 and April 2014. Conjunctival lesions were excised with a non-touch technique (2 mm margin) and sent for histopathological analysis. The surgical margins were treated with cryotherapy and a fresh frozen AMG was used to cover the defect. The main features examined were for any signs of recurrence, the conjunctivalisation of the AMG, complications and cosmetic appearance.ResultsFifty-three patients; 35 males and 18 females. Mean age was 54.9 (range 19-88). The mean follow up to January 2015 for all lesions was 21.4 months (range 8-48 months). The most common lesions were invasive malignant melanoma. There were no local surgical complications in 77.3% of patients; minimal scarring (11.3%), symblepharon (11.3%), and granuloma (7.5%). Five patients with conjunctival melanoma developed in-transit metastasis and orbital extension, none of it was at the site of the AMG.ConclusionOur case series is the largest reported to date, with the largest number of melanomas. The use of fresh frozen AMG has improved the local surgical outcomes by improving healing and reducing scarring as well as allowing for a wider surgical margin.

Advances in the management of conjunctival melanoma

Malignant melanoma of the conjunctiva is a rare but serious condition. Over the last several years, there have been important advances in the classification, diagnosis, and treatment of this condition. Recent cytogenetic and immunohistochemical studies are increasing understanding of its tumorigenesis. Diagnosis, although still made via histopathology, has been aided with imaging techniques such as ultrasound biomicroscopy and anterior segment optical coherence tomography. Primary treatment consists of surgical excision. But adjuvant treatments with cryotherapy, topical chemotherapy, and radiation therapy have shown increased success. Sentinel lymph node biopsy has shown early promise of detecting micro-metastasis. Long term follow-up of patients with conjunctival melanoma with systemic surveillance is necessary to detect recurrences and metastases.

Malignant melanoma of the conjunctiva – successful surgical excision of the primary tumor and reconstruction by conjunctival auto transplantation from the contralateral eye

Malignant melanoma of the conjunctiva is a rare tumor with incidence of 0.5 cases/year per million population. It may also occur as de novo, as on the basis of preexisting melanocytic lesions (nevus or freckle) or most often from the so-called primary acquired melanosis of the conjuctiva (PAM). It metastasizes mainly lymphogenic and hematogenous. The size of the primary tumor lesion, histopathological findings and absolute tumor thickness are essential for unfavorable prognosis. Conjunctival auto transplantation from the other eye is modern and innovative, but also a seldomly feasible method of reconstruction after conjunctival excision of tumors in this area. We present a rare case of a 75-year-old patient with epithelioid cell malignant melanoma of the bulbar conjunctiva of the right eye, which de novo occurred, successfully treated by excision of the primary tumor and subsequent reconstruction by conjunctival auto transplant from the other eye. A very good therapeutic and aesthetic result was achieved.

Update on amniotic membrane transplantation

Cryopreserved amniotic membrane modulates adult wound healing by promoting epithelialization while suppressing stromal inflammation, angiogenesis and scarring. Such clinical efficacies of amniotic membrane transplantation have been reported in several hundred publications for a wide spectrum of ophthalmic indications. The success of the aforementioned therapeutic actions prompts investigators to use amniotic membrane as a surrogate niche to achieve ex vivo expansion of ocular surface epithelial progenitor cells. Further investigation into the molecular mechanism whereby amniotic membrane exerts its actions will undoubtedly reveal additional applications in the burgeoning field of regenerative medicine. This article will focus on recent advances in amniotic membrane transplantation and expand to cover its clinical uses beyond the ocular surface.

Excision with corneoscleral lamellar keratoplasty and amniotic membrane transplantation of a corneal displaced recurrent conjunctival melanoma

An 81-year-old woman with a raised pigmented nodule over her left cornea for 7 months duration was examined. Dark conjunctival pigmentation was observed in the upper bulbar fornix conjunctiva. She had previously undergone primary surgical excision of a malignant conjunctival melanoma four years earlier. The tumor separated easily from the corneal surface, but remained slightly attached to the corneoscleral surface. A corneoscleral lamellar dissection of 3 mm in width and 2 mm in depth as well as a corneoscleral lamellar keratoplasty for the reconstruction of the corneoscleral defect were performed. The wide upper bulbar and fornix conjunctiva were excised, and an amniotic membrane transplantation was performed. Biopsy revealed an invasive melanoma with a depth of 1 mm. Left, right, and inferior tumor margins of the corneoscleral lesion and the pigmentary lesion in the conjunctiva were free of the tumor. After surgery, 0.04% mitomycin was administered topically 4 times daily for 4 weeks. There was no recurrence 2 years after surgery, and systemic evaluation revealed no metastasis.

Ocular surface reconstruction using amniotic membrane following excision of conjunctival and limbal tumors

PURPOSE

To report the clinical results of patients treated by preserved human amniotic membrane transplantation (AMT) following the removal of conjunctival and limbal tumors.

METHODS

Retrospective noncomparative interventional case series of 9 patients (9 eyes) who underwent AMT after removal of conjunctival and limbal tumors with lesion-free margins and perilesional cryotherapy.

RESULTS

The excised tumors were histopathologically examined and included 2 squamous cell carcinomas, 2 papillomas, and 5 nevi. Bulbar conjunctiva was involved in all of the eyes, limbus and cornea in 7 and 3 eyes, respectively. The mean extent of the limbal involvement was 4 clock hours (range 2-9, SD 2.4); the average diameter of the base of the tumor was 12.8 mm (range 10-20, SD 4.4). The mean follow-up time was 38 months (range 13-60, SD 15). No surgical or early postoperative complications were observed. In all eyes, complete healing of the tissue defect occurred, resulting in a stable, wet, and noninflamed epithelium. All eyes demonstrated a smooth ocular surface except one with a clinically insignificant symblepharon after the excision of a squamous cell carcinoma. Superficial peripheral corneal vascularization and opacification as a sign of partial limbal stem cell deficiency developed in 2 eyes. In one case, a recurrence of conjunctival papilloma was diagnosed after a 3-year follow-up.

CONCLUSIONS

Amniotic membrane transplantation is an effective method of reconstruction following a conjunctival and limbal tumor excision and cryotherapy of surgical wound margins. In most cases, complete healing of an ocular surface can be achieved without any clinically significant complications.

Amniotic membrane in ophthalmology: indications and limitations

The amniotic membrane remains a useful tool in the treatment of several ophthalmic conditions, especially those related to the ocular surface. However, the 'success' reported in individual case reports and case series is not substantiated in the few published randomised controlled trials. More often than not, it is not as good as existing alternative options and, at best, is as good but with probably an increased cost. The variable outcomes could be related to inter and intra donor variations in the membrane and the depletion or alterations in its constituents subsequent to processing and storage. The membrane thus is a fairly 'non-standardised product' making comparisons of different applications and indications difficult. The potential for 'epidemic' infections, such as HIV, hepatitis B and C, is a serious issue as, in many parts of the world, fresh unquarantined membrane, at times with no tests for the above infectious agents, is being used. The exact mechanism of action of the membrane is not known but the consensus is that it acts as a substrate or scaffold for host cells to populate and thus facilitate healing and repair. The development of a standard 'synthetic membrane' using collagen or polymer matrices impregnated with putative beneficial ingredients, such as growth factors and antimicrobials, is being considered and may prove to be a step in the right direction.