Tumors of the conjunctiva and cornea

Emerging Techniques in the Treatment of Conjunctival Melanoma

Purpose of review

In this article, we summarize the pathogenesis, diagnostic challenges, current management, and emerging therapeutic strategies for conjunctival melanoma (CM).

Recent findings

CM is a deadly disease with rising global incidence. Key mutations, including BRAF, NF1, and TERT, play crucial roles in CM pathogenesis and may serve as targets for therapy. Advanced imaging and histopathological analysis have improved early detection and prognostic assessment. Treatment depends on tumor stage and includes surgical excision with adjuvant chemotherapy, radiotherapy, or orbital exenteration in advanced cases. Systemic workup is always indicated. Immune checkpoint inhibitors, successful in cutaneous melanoma, show promise in CM based off early studies, although more research is needed to confirm their benefit.

Summary

CM remains a significant clinical challenge and requires a multidisciplinary approach to diagnosis and treatment. Incorporating genetic profiling and targeted therapies is crucial to improving patient outcomes.

A Domain-Specific Pretrained Model for Detecting Malignant and Premalignant Ocular Surface Tumors: A Multicenter Model Development and Evaluation Study

Malignant and premalignant ocular surface tumors (OSTs) can be sight-threatening or even life-threatening if not diagnosed and treated promptly. Artificial intelligence holds great promise for the early detection of these diseases. However, training traditional convolutional neural networks (CNNs) for this task presents challenges due to the lack of large, well-annotated datasets containing OST images labeled according to histopathological results. Here, we introduce the ocular surface pretrained model (OSPM), a domain-specific pretrained model designed to address the scarcity of labeled data. OSPM is constructed utilizing self-supervised learning on approximately 0.76 million unlabeled ocular surface images from 10 clinical centers across China and can be readily adapted to the OST classification task. We then develop and evaluate an OSPM-enhanced classification model (OECM) using 1,455 OST images labeled with histopathological diagnoses to differentiate between malignant, premalignant, and benign OSTs. OECM achieves excellent performance with AUROCs ranging from 0.891 to 0.993 on internal, external, and prospective test datasets, significantly outperforming the traditional CNN models. OECM demonstrated performance comparable to that of senior ophthalmologists and increased the diagnostic accuracy of junior ophthalmologists. Greater label efficiency was observed in OECM compared to CNN models. Our proposed model has high potential to enhance the early detection and treatment of malignant and premalignant OSTs, thereby reducing cancer-related mortality and optimizing functional outcomes.

Role of miRNA in adult ocular tumorigenesis

In recent years, cancer research has made huge advances also thanks to the discovery of the role of non-coding RNAs in the control of tumorigenesis, tumor proliferation, migration and metastasis and therefore also in the diagnosis and therapy of tumors. This work aims to review the most recent literature involving the study of miRNAs in ocular tumors affecting adult patients. We will introduce the role of miRNAs in tumorigenesis, and we will focus on summarizing the studies on uveal intraocular melanomas in which a role of microRNAs has been demonstrated. Similarly, we will also cover observations on miRNAs and eyelid cancers, especially sebaceous gland carcinoma, and cancers of the conjunctiva and the retina, excluding retinoblastoma which is typically a pediatric-onset tumor. We will summarize specific miRNAs that could be considered as diagnostic molecules or as therapeutic targets against some ocular cancer diseases, indicating their potentialities and limitations, considering also their administration as nanomedicine for the eye.

Ocular surface squamous cell neoplasia: risk factors for aggressive growth behaviour and the role of Ki-67

OBJECTIVE

Analyzing characteristics of ocular surface squamous cell neoplasia (OSSN) at first diagnosis and potential risk factors for aggressive growth behaviour.

DESIGN

Retrospective.

METHODS

Including patients with first diagnosis of OSSN at a tertiary center from 2013 until 2022. Cases were analyzed regarding demographics, clinical findings, and histopathological findings, including Ki-67 expression.

RESULTS

A total of 153 patients with first diagnosis of histopathological confirmed OSSN were included. Mean age was 72 years (36-98), with a slight male predominance (66%; n = 101). Most patients had invasive squamous cell carcinoma (SCC; 45.8%, 70), followed by carcinoma in situ (CIS; 37.9%, 58) and epithelial dysplasia (ED; 16.3%, 25). Duration of symptoms varied significantly: ED 6 months (0-36), CIS 1.5 (0-48), SCC 3 (0-36) (p = 0.048). 44.3% (51/115) of cases were previously misdiagnosed, and, therefore, inadequately treated. Orbital involvement was observed in 8.5% (13), intraocular in 1.3% (2), metastasis in 2.7% (4) at initial diagnosis. Ki-67 labeling index (LI) varied significantly across subtypes: ED 35% (2-87%), CIS 45% (11-85%), SCC 50% (18-93%) (p = 0.007) and was higher with involvement of the caruncle, lower fornix, lower eyelid margin, or tarsus (p = 0.023). Patients with globe or orbit invasion had significantly longer median symptom duration (6 months (0-48) vs 2 (0-48); p = 0.01). Patients with metastasis exhibited significantly higher Ki-67 LI (p = 0.027).

CONCLUSIONS

Our study found extended time intervals from first symptoms to first correct diagnosis correlate with higher risk for advanced SCC. Further, elevated Ki-67 LI correlated with more invasive tumor entities, such as SCC and CIS, and indicate an increased risk of metastasis.

Ocular surface squamous neoplasia: Growth, diagnosis, and treatment

BackgroundOcular surface squamous neoplasia (OSSN) is the most common malignancy of the ocular surface, often presenting as a non-pigmented lesion with atypical squamous epithelialization. It is usually asymptomatic and can be confused with benign conditions such as pterygium or conjunctival cysts. If untreated, OSSN may progress to invasive squamous cell carcinoma, causing vision loss or metastasis. The gold standard for diagnosing OSSN is histopathological examination after tumor resection. However, there are still unresolved issues in the clinical management of treatment.Main textIn this review, we have discussed the clinical characteristics, diagnostic techniques, and treatment options for OSSN. OSSN occurs due to changes in the living environment and ocular surface state. It starts as a benign squamous epithelial tumor, which can progress to atypical intraepithelial neoplasia and eventually turn into invasive squamous cell carcinoma. The postoperative pathological histology also shows a corresponding degree of differentiation. Various diagnostic techniques, such as diagnostic imaging, cell biology, and molecular biology, are emerging as valuable tools for distinguishing OSSN. Although surgical resection is the primary treatment for OSSN, drug therapy can also be applied for better management of OSSN treatment.ConclusionAccurately diagnosing OSSN requires advanced examination techniques before and after operation. This is crucial for healthcare professionals to evaluate and treat the condition effectively. Based on our clinical expertise, administering drug treatment before or after surgical resection may serve as a comprehensive and effective management approach for OSSN. This research holds immense potential for the future of personalized and precise medical care.

Can high-resolution optical coherence tomography provide an optical biopsy for ocular surface lesions?

High-resolution optical coherence tomography (HR-OCT) has transformed the diagnosis and management of ocular surface lesions. Providing a detailed cross-sectional view of the cornea and conjunctiva, HR-OCT can be used to identify characteristic features of various benign and malignant ocular surface lesions, aiding in their diagnosis and guiding treatment. When incorporated into an ophthalmology clinic, HR-OCT provides morphological images of lesions in a noninvasive means, akin to an "optical biopsy". The characteristic HR-OCT features of several lesions have been well described in the literature, including for ocular surface squamous neoplasia, papilloma, melanoma, primary acquired melanosis, complexion associated melanosis, nevus, pterygium, pinguecula, lymphoma, and amyloidosis. HR-OCT can be used to differentiate between lesions with similar clinical features, lesions that co-exist on the same ocular surface, and atypically presenting lesions, such as pigmented ocular surface squamous neoplasia or amelanotic melanoma. The management of ocular surface lesions has been transformed by the implementation of HR-OCT, providing clinicians with the ability to monitor tumor response to topical chemotherapies, follow previously excised lesions for recurrence, and map out tumor borders intraoperatively. While there are some limitations to HR-OCT, including imaging of thick or deep lesions, it has become an essential tool for ocular oncologists in the management of ocular surface lesions.

OSSN in South India: Clinical presentation, treatment outcomes, and histopathologic correlations

PURPOSE

This study aimed to analyze the clinical presentation, treatment outcomes, and histopathology features of ocular surface squamous neoplasia (OSSN) in a South Indian population and correlate the area of lesions to the histopathological grade/severity of carcinoma in situ (CIN) and squamous cell carcinoma (SqCC) invasive and noninvasive tumors.

METHODS

The study was a retrospective cross-sectional study. The study reviewed electronic medical records (EMRs) of 99 eyes of 99 South Indian patients who underwent en bloc excision and biopsy for tumors in the corneal and conjunctival epithelium with suspicion of OSSN over 1 year from January 2019 to December 2019. Postoperatively, patients were treated with three cycles of topical 0.04% mitomycin C eye drops. Sixty-three had requisite EMR data with a follow-up period of 1 year.

RESULTS

Patients had equal gender distribution with an age range of 28-83 years. The most common clinical variant was leukoplakic lesion, and the area of the lesion was the only predicting factor for SqCC and CIN.

CONCLUSION

Bigger (T2) lesions should be strongly suspected for OSSN and promptly excised. Histopathologic analysis should be performed, and post-op topical mitomycin C or interferon alpha 2b is administered to avoid recurrence. In this study, by correlating the area of the lesion, we introduce a new variable that may aid in clinical prognostication alongside the AJCC classification.

Incidence, clinical features, and survival outcomes of primary malignant conjunctival tumor: a US population-based retrospective cohort analysis based on the SEER database (1975-2018)

Background

Primary malignant conjunctival tumors (PMCT) are rare. Their clinicopathological characteristics and survival outcomes are not well understood. The Surveillance, Epidemiology, and End Results (SEER) database includes approximately 30% of the total US. In this study, we aimed to investigate the epidemiology, clinical characteristics, and prognosis of PMCT via SEER.

Methods

Data on microscopically confirmed PMCT patients from 1975 to 2018 were retrieved. Patients who were lost to active follow-up, those for whom PMCT was not the primary malignant tumor, and those with unknown death information, laterality, race, or those who survived for less than 1 month after diagnosis were excluded. Disease-specific survival (DSS) and overall survival (OS) were the primary endpoints, calculated through the Kaplan-Meier analysis and log-rank tests. Univariate and multivariate Cox regression analyses were conducted to recognize independent predictive factors for DSS and OS.

Results

In total, we identified 2,853 eligible patients diagnosed with PMCT, with an average age of 61.25 years, among which 1,678 (58.82%) were males, 2,464 (86.37%) were whites, 1,567 (54.92%) were married, and 2,125 (74.48%) were in localized SEER stage. The three major types were lymphoma (39.64%), squamous cell carcinoma (SCC) (34.88%), and melanoma (21.98%). The overall incidence of PMCT was 0.136/100,000 between 1975 and 2020, with an annual incidence rate of 0.929 [95% confidence interval (CI): 0.289-1.573, P<0.05]. Multivariate Cox regression analysis discovered age, sex, marital status, histological type, SEER stage, and surgery as independent prognostic variables. Age ≥75 years [≥75 vs. <60 years, hazard ratio (HR) =3.211, 95% CI: 2.309-4.466, P<0.001], melanoma (melanoma vs. SCC, HR =4.637, 95% CI: 3.235-6.649, P<0.001), distant SEER stage (distant vs. localized, HR =4.318, 95% CI: 2.675-6.968, P<0.001), and no/unknown surgery status (performed vs. no/unknown, HR =1.565, 95% CI: 1.187-2.062, P=0.001) were related to worse DSS. Meanwhile, age ≥75 years (≥75 vs. <60 years, HR =9.399, 95% CI: 7.876-11.216, P<0.001), male (female vs. male, HR =0.701, 95% CI: 0.612-0.803, P<0.001), unmarried status (unmarried vs. married, HR =1.342, 95% CI: 1.17-1.538, P<0.001), distant SEER stage (distant vs. localized, HR =2.077, 95% CI: 1.498-2.881, P<0.001), and no/unknown surgery status (performed vs. no/unknown, HR =1.16, 95% CI: 1.018-1.322, P=0.03) were related to worse OS. Lymphoma (lymphoma vs. SCC, HR =0.628, 95% CI: 0.533-0.74, P<0.001) was associated with better OS.

Conclusions

PMCT incidence increased after 1975 and decreased after 1997. Age, histological type, SEER stage, and surgery were all significantly associated with DSS and OS. Age ≥75 years, melanoma, and distant SEER stage were associated with worse DSS, while age ≥75 years, male, unmarried status, distant SEER stage were related to worse OS and lymphoma was related to better OS. Surgery may improve the prognosis of patient with PMCT.

Update in the Diagnosis and Management of Ocular Surface Squamous Neoplasia (OSSN)

Ocular surface squamous neoplasia (OSSN) includes a variety of ocular surface tumors ranging from mild epithelial dysplasia to invasive squamous cell carcinoma. OSSN is one of the most frequent non-pigmented malignancies of the ocular surface. Debate persists between surgical excision and medical management concerning the optimal regimen for OSSN treatment, with surgical excision continuing to be the recognized standard of care in contemporary medicine. Medical and conservative therapy techniques have advanced significantly in recent years, leading to widespread use in everyday ophthalmology practice. This study aims to look into the efficacy of current treatment options for conjunctival squamous cell carcinoma and to evaluate the available evidence for the most up-to-date approach for the management of the disease.

Clinical profile and outcomes of ocular surface squamous neoplasia at the Philippine General Hospital: a retrospective study

AIM

To evaluate the demographics, clinical characteristics, treatments, and outcomes of patients with ocular surface squamous neoplasia (OSSN) at the Philippine General Hospital.

METHODS

This was a single-center, 11-year retrospective, cross sectional case series on 18 cases of OSSN seen between January 2012 to June 2023. The patient's demographics, presenting symptoms, tumor characteristics, histopathologic diagnosis, treatment, outcomes, and duration of follow-up were reviewed.

RESULTS

Out of 33 identified cases of OSSN, only 18 were eligible for inclusion in the study. Mean age was 60.78y (range 31 to 80), with male predominance (66.67%). The left eye was most commonly affected (61.11%) with most presenting with fleshy mass (83.33%). Most tumors were located nasally (66.67%) and were predominantly papilliform (44.44%) in morphology with associated hyperpigmentation (38.89%). Squamous cell carcinoma (SCCA) was the most common histopathologic diagnosis (72.22%). The main primary treatment was surgical excision (94.44%) with or without adjunctive therapy, with only 1 patient undergoing first-line topical chemotherapy. Only 3 recurrences (16.67%) were noted with a median follow-up of 7.5mo. A statistically significant recurrence-free odds leaning towards the utilization of cryotherapy was noted.

CONCLUSION

OSSN seen at the Philippine General Hospital is presented as a limbal papilliform mass, most commonly affecting elderly males. Surgical excision with adjuvant cryotherapy and/or chemotherapy is the preferred mode of treatment.

A review of the application of in-vivo confocal microscopy on conjunctival diseases

Over the past few decades, the expanded applications of in-vivo confocal microscopy (IVCM) have greatly enhanced the knowledge of a variety of conjunctival diseases. IVCM allows non-invasively detailed observation of tarsal, palpebral and bulbar conjunctiva, from the superficial to the substantia propria at the cellular level. IVCM has been shown as a powerful tool for the assessment of morphological changes in both physiological and pathological conditions. High-resolution images of different cellular phenotypes, together with quantifiable results, open new insights into understanding the mechanisms of conjunctival diseases, as well as provide valuable and longitudinal information for the diagnosis and therapeutic evaluation. This review aims to provide an overview of the current knowledge on the applications of IVCM on conjunctival disorders, including aging changes, dry eye-related morphological changes, glaucoma and glaucoma surgery-related morphological changes, conjunctival neoplasm, pterygium, allergic conjunctivitis, trachomatous scarring, and the conjunctiva-associated lymphoid tissue (CALT) changes. In this review, we highlight the key findings of previous studies and discusses the current limitations and challenges of IVCM in assessing the structural characteristics of the conjunctiva. Furthermore, we consider possible future directions for unlocking the full potential of IVCM applications. The insights presented here will contribute to a more comprehensive understanding of the applications of IVCM in conjunctival diseases.

Orbital Oncocytic Carcinoma: A Comprehensive Case Series and Literature Review

PURPOSE

This case series and literature review evaluated the baseline variables, clinical symptoms, pathological characteristics, and prognosis of patients with orbital oncocytic carcinoma.

METHODS

This retrospective case series collected the medical histories and other related data from 13 patients pathologically diagnosed with oncocytic carcinoma.

RESULTS

The average age of patients with orbital oncocytic carcinoma was 64.8 years, with a significantly higher rate of males than females. Furthermore, unilateral disease was more common than bilateral disease. All patients had surrounding tissue invasion, most commonly to extraocular muscles (69.2%) and bones (53.8%). The clinical manifestations were proptosis (30.8%), swelling of the lesion area (23.1%), vision loss (23.1%), diplopia (23.1%), periocular mass (23.1%), tears (15.4%), eye pain (7.7%), ptosis (7.7%), and visual field loss (7.7%). Microscopic examination revealed many large eosinophilic cells. There were obvious nuclei and abundant mitotic figures. The cancer cells expressed cytokeratin, but not P63 or S-100. The follow-up duration was 2-53 months, and the metastasis rate was 16.7%. The patients exhibited a good prognosis. The main treatment methods included surgical resection, surgery combined with radiotherapy, and the enucleation of ocular contents.

CONCLUSIONS

Orbital oncocytic carcinoma has the immunohistochemical characteristics of eosinophilic tumor cells, with expression of cytokeratin but not P63 or S-100. The prognosis is favorable. Surgical resection, surgery combined with radiotherapy, and enucleation of intraocular material are effective treatment options. Nevertheless, long-term follow-up and close observation for metastases are required.

Two Decades of Insights: Comprehensive Histopathological and Epidemiological Analysis of Conjunctival Tumors

This study analyzed 2102 conjunctival lesions excised between 1981 and 2003 at a single tertiary center in Serbia, with the aim of evaluating their histopathological characteristics, anatomical localization, and demographic distribution. Of the total cases recorded, 55.1% were male, indicating a slight male predominance. The bulbar conjunctiva was the most commonly affected site (34.5%), with 39.3% of tumors extended to multiple regions of the conjunctiva, including areas such as the plica and caruncula. The most common benign lesion was compound conjunctival nevus (16.7%), while squamous cell carcinoma (SCC) (11.4%) and melanoma (11.3%) were the most prevalent malignant tumors. Tumor incidence peaked in the 61-70 and 51-60 year age groups, with malignant tumors such as SCC being more frequent in males. Comparisons with similar global studies reveal that our findings align with worldwide trends, such as the predominance of SCC, which has been linked to UV exposure, and the frequency of melanoma in fair-skinned populations. However, the lower prevalence of fibrodegenerative lesions like pterygia and pinguecula in our cohort likely reflects Serbia's cooler climate compared to regions with higher UV exposure. These findings underscore the diverse nature of conjunctival tumors, the critical role of histopathological examination for diagnosis, and the influence of environmental factors. This study provides valuable insights into the epidemiology of conjunctival tumors, contributing to global understanding and guiding future diagnostic and therapeutic approaches.

Epidemiology and tumor microenvironment of ocular surface and orbital tumors on growth and malignant transformation

The ocular surface and orbit constitute unique microenvironments in the human body. Current advances in molecular research have deepened our understanding of tumor development in these regions. Tumors exhibit greater heterogeneity compared to normal tissues, as revealed by pathological and histological examinations. The tumor microenvironment (TME) plays a crucial role in the proliferation and progression of cancer cells. Factors from the external environment or the body's own inflammation and microcirculation interact within the TME, maintaining a delicate balance. Disruption of this balance, through uncontrolled signal pathway activation, can transform normal or benign tissues into malignant ones. In recent years, various systemic immunotherapies have been developed for cancer treatment. This study reviews the epidemiology of ocular surface and orbital tumors include squamous cell carcinoma, basal cell carcinoma, sebaceous carcinoma and lymphoma in conjunction with their occurrence, growth, and underlying mechanisms. We propose that by examining clinical histopathological images, we can identify specific and shared microscopic features of tumors. By collecting, classifying, and analyzing data from these clinical histopathological images, we can pinpoint independent diagnostic factors characteristic of tumors. We hope this study provides a basis for future exploration of the mechanisms underlying different ocular diseases.

Unilateral amelanotic conjunctival malignant melanoma: a case report

INTRODUCTION

Cutaneous malignant melanomas rarely occur in the eye, usually in the eyelids or the conjunctiva. Conjunctival malignant melanomas are even rarer. Most melanomas are dark in color as they are pigmented. However, amelanotic conjunctival malignant melanomas, a scarce variant of the cancer, can be challenging to diagnose accurately.

CASE PRESENTATION

We present two cases of white Caucasian Swedish-born women who were diagnosed with unilateral amelanotic malignant melanoma in the conjunctiva of the eye. In the first case, the patient was an 81-year-old woman who was suffering from redness and foreign body sensation in the left eye. The initial diagnosis was blepharitis. Three biopsies were taken, which showed malignant melanoma in the eyelid and the conjunctiva. Unfortunately, the eye and the rest of the orbit could not be saved, and the patient had to undergo an orbital exenteration. In the second case, the patient was a 50-year-old woman, and the tumor was localized in the temporal conjunctiva of the left eye. The initial diagnosis was pinguecula, but at the time of surgery, the physician suspected conjunctival intraepithelial neoplasia. The tumor was not completely removed, so adjuvant brachytherapy and local chemotherapy were used. The eye was preserved. No neck and/or lung metastasis was detected in either case at the time of diagnosis.

CONCLUSIONS

Conjunctival amelanotic malignant melanomas should be suspected when tumors are present in the eye and/or the eyelids. By suspecting amelanotic malignant melanoma, the delay in treatment can be shortened. Treating them as soon as possible is essential to minimize the risk of metastasis.

Complete Response to Immunotherapy Using Pembrolizumab in a Patient With Conjunctival Squamous Cell Carcinoma With Nodal Metastasis

A 92-year-old woman presented with a large bulbar conjunctival mass in the OD. She also had a palpable parotid mass which on fine needle aspiration biopsy confirmed to be metastatic squamous cell carcinoma. The conjunctival mass was biopsied to confirm the diagnosis of squamous cell carcinoma with positive programmed cell death ligand 1 expression and a high tumor mutation burden. She was treated with pembrolizumab and had complete resolution of the conjunctival mass and the associated parotid metastasis after just 2 cycles of treatment. This case underscores the promising role of immune checkpoint inhibitors in the treatment of conjunctival squamous cell carcinoma, especially when surgery is associated with significant ocular morbidity, in patients who may not be good surgical candidates, or in patients with metastasis.

A Case Report and an Overview of the Differential Diagnosis of Pigmented Lesions of the Conjunctiva: Just a Freckle or Something to Heckle?

A 42-year-old darkly pigmented woman presented at our emergency department with complaints of pruritus, foreign body sensation, and blurry vision. Besides findings compatible with mild dry eye disease, anterior segment examination revealed dark pigmented, ill-defined areas of the conjunctiva surrounding the temporal limbus and temporal bulbar conjunctiva in the left eye and involving the superior and inferior tarsal conjunctiva in both eyes. The patient reported no recent changes in these lesions. A diagnosis of complexion-associated melanosis in the palpebral conjunctiva of both eyes and primary acquired melanosis in the bulbar conjunctiva of the left eye was assumed, and the patient was placed under regular follow-up. Preservative-free tears were also recommended for her dry eye condition. Conjunctival pigmented lesions are a common finding during ophthalmologic evaluations. They pose a significant diagnostic challenge due to the wide array of differential diagnoses and the concern of misdiagnosing melanoma. A comprehensive clinical history and multidisciplinary evaluation are crucial in managing these cases.

Biological characteristics and clinical management of uveal and conjunctival melanoma

Uveal and conjunctival melanomas are relatively rare tumors; nonetheless, they pose a significant risk of mortality for a large number of affected individuals. The pathogenesis of melanoma at different sites is very similar, however, the prognosis for patients with ocular melanoma remains unfavourable, primarily due to its distinctive genetic profile and tumor microenvironment. Regardless of considerable advances in understanding the genetic characteristics and biological behaviour, the treatment of uveal and conjunctival melanoma remains a formidable challenge. To enhance the prospect of success, collaborative efforts involving medical professionals and researchers in the fields of ocular biology and oncology are essential. Current data show a lack of well-designed randomized clinical trials and limited benefits in current forms of treatment for these tumors. Despite advancements in the development of effective melanoma therapeutic strategies, all current treatments for uveal melanoma (UM) and conjunctival melanoma (CoM) remain unsatisfactory, resulting in a poor long-term prognosis. Ongoing trials offer hope for positive outcomes in advanced and metastatic tumors. A more comprehensive understanding of the genetic and molecular abnormalities involved in the development and progression of ocular melanomas opens the way for the development of personalized therapy, with various potential therapeutic targets currently under consideration. Increased comprehension of the molecular pathogenesis of UM and CoM and their specificities may aid in the development of new and more effective systemic therapeutic agents, with the hope of improving the prognosis for patients with metastatic disease.

Intraocular Invasion by Conjunctival Squamous Cell Carcinoma: Clinical Presentation, Histopathological Findings, and Outcome

Introduction

Intraocular localization of conjunctival squamous cell carcinoma (SCC) is due to scleral or corneal invasion. Herein, we describe the clinical and histopathological findings in four cases of SCC complicated by intraocular invasion, and we review cases reported in the literature and their management. We retrospectively collected and analyzed clinical characteristics, histopathology, management, and follow-up data from 4 patients with conjunctival SCC complicated by intraocular invasion. We reviewed the literature and summarized cases of intraocular invasion by conjunctival SCC reported over the last 30 years.

Case Presentations

Two patients presented with intraocular invasion by conjunctival SCC at diagnosis. The two others developed intraocular invasion as recurrence of conjunctival SCC, previously treated with excisional biopsy and adjuvant radiotherapy. All 4 cases had a previous history of conjunctival surgery, but no history of intraocular surgery. Three patients were managed with modified enucleation, including one that required adjuvant orbital radiotherapy. One patient required orbital exenteration. Histopathology analysis showed a well-differentiated conjunctival SCC in all cases. None developed distant localization after at least 2.5-year follow-up.

Discussion/Conclusion

Intraocular invasion is a rare complication of conjunctival SCC. Appropriate treatment in a tertiary center and long-term follow-up are highly recommended.

Pigmented pyogenic granuloma of the cornea and conjunctiva: a rare bilateral presentation

Pyogenic granuloma, also known as lobular capillary hemangioma, is a benign vascular lesion that primarily affects the skin and mucous membranes. It is not pyogenic; nor is it granulomatous. It typically arises in response to local trauma or surgery, irritation, hormonal changes, or chronic inflammation, and it sometimes occurs spontaneously. The occurrence of pigmented pyogenic granuloma in the conjunctiva and cornea without any history of trauma or surgery is extremely rare, particularly in children. We report the clinical presentation, diagnostic evaluation, and successful management of bilateral biopsy-proven conjunctival and corneal pigmented isolated pyogenic granuloma in an 11-year-old girl. No signs of recurrence were seen at the 3-months follow-up.

Conjunctival Nevus

Purpose of Review

To provide an up-to-date review of the epidemiology, presentation, diagnosis, and treatment options for conjunctival nevi (CN).

Recent Findings

Around 17.2%-42% of all conjunctival tumors have been found to be CN, which most frequently present in White individuals between the first to early third decade of life, with equal distribution between males and females. CN commonly occur in the interpalpebral bulbar conjunctiva with pigmentation ranging from amelanotic to dark. Diagnosis is typically made through slit lamp examination, visualized by a well circumscribed, variably elevated, variably pigmented, solitary lesion with clear cysts distributed throughout the pigment. In ambiguous cases, anterior segment optical coherence tomography (AS-OCT) can highlight the presence of sub-clinical cysts, whose presence points to a diagnosis of nevus. However, excisional biopsy with histopathology examination is the gold standard for identifying CN.

Summary

CN are benign, variably pigmented lesions. They are the most common of the conjunctival melanocytic tumors. Due to the extremely low risk of transformation to malignant melanoma (MM), CN are usually managed with routine observation and photo documentation.

Conjunctival Melanoma: A Case Presentation

Conjunctival melanoma is an uncommon tumor that is likely to recur and carries an overall mortality rate of approximately 30%. Melanoma arises from melanocytes, most often in sun-exposed skin. Less commonly, melanoma originates from other tissues such as the uvea, rectum, mouth, respiratory tract, and conjunctiva. Conjunctival melanoma represents only 1.6% of all noncutaneous melanoma. Herein, we reported a case of conjunctival melanoma followed by reviewing the literature to provide an optimal diagnostic approach.

Exogenous Ochronosis With Ocular Involvement From Chronic Use of Teavigo

Exogenous ochronosis refers to accumulation of homogentisic acid metabolites in tissues, manifesting as pigmentation of affected tissues. Phenolic compounds are most commonly implicated, including hydroquinone, quinine, phenol, resorcinol, mercury, and picric acid. The affected connective tissues exhibit brownish discoloration when heavily pigmented and the histopathological appearance is characteristic with "banana-shaped" ochre-colored pigment deposits. Herein, the authors describe a rare case of exogenous ochronosis involving the conjunctiva, sclera and skin, as a result of chronic use of Teavigo (94% epigallocatechin gallate), a polyphenol compound with postulated antioxidant and antiapoptotic activity.

Genetic predisposition to ocular surface disorders and opportunities for gene-based therapies

The ocular surface, comprised of the corneal and conjunctival epithelium, innervation system, immune components, and tear-film apparatus, plays a key role in ocular integrity as well as comfort and vision. Gene defects may result in congenital ocular or systemic disorders with prominent ocular surface involvement. Examples include epithelial corneal dystrophies, aniridia, ectrodactyly-ectodermal dysplasia-clefting (EEC) syndrome, xeroderma pigmentosum (XP), and hereditary sensory and autonomic neuropathy. In addition, genetic factors may interact with environmental risk factors in the development of several multifactorial ocular surface disorders (OSDs) such as autoimmune disorders, allergies, neoplasms, and dry eye disease. Advanced gene-based technologies have already been introduced in disease modelling and proof-of-concept gene therapies for monogenic OSDs. For instance, patient-derived induced pluripotent stem cells have been used for modelling aniridia-associated keratopathy (AAK), XP, and EEC syndrome. Moreover, CRISPR/Cas9 genome editing has been used for disease modelling and/or gene therapy for AAK and Meesmann's epithelial corneal dystrophy. A better understanding of the role of genetic factors in OSDs may be helpful in designing personalized disease models and treatment approaches. Gene-based approaches in monogenic OSDs and genetic predisposition to multifactorial OSDs such as immune-mediated disorders and neoplasms with known or possible genetic risk factors has been seldom reviewed. In this narrative review, we discuss the role of genetic factors in monogenic and multifactorial OSDs and potential opportunities for gene therapy.

Conjunctival Melanoma in Aotearoa-New Zealand: A 21-Year Analysis of Incidence and Survival

PURPOSE

Conjunctival melanoma (CM) is a rare and aggressive malignancy. Global studies demonstrate increased burden of disease in countries with high rates of cutaneous melanoma. There are currently no reports on CM incidence, trends, or survival within Aotearoa-New Zealand (NZ), a country with the highest global rates of cutaneous melanoma, which this study aims to address.

DESIGN

This was a retrospective review using the national cancer registry.

METHODS

Data on histologically confirmed CM diagnosed between January 1, 2000, and December 31, 2020, were obtained from the NZ Cancer Registry. Cases were identified using the International Classification of Disease, 10th edition (ICD-10) codes. Primary outcome measures were age-standardized incidence, trends, and survival.

RESULTS

A total of 68 CM cases were identified. There was a preponderance for females (n=40, 58.8%) and CM predominantly affected European patients (n=63, 92.6%). Median follow-up was 5.0 years [interquartile range (IQR)=2.4-9.9 y] and the median age at diagnosis was 68.5 years (IQR=57.0-79.0 y), with non-Europeans presenting at a significantly younger age [-17.3 y (95% CI: -31.3 to -3.2), P =0.019] than Europeans. The annual age-adjusted incidence(±SD) was 0.6±0.2 cases per million population per year with a stable incidence trend over 21 years. All-cause mortality was found in 28 cases (41.2%) and the median time to death was 3.76 years (IQR=2.1-5.7 y). Five-year all-cause survival and disease-specific survival was 69% and 90%, respectively.

CONCLUSIONS

This is the first report on CM incidence, trends, and mortality in NZ. The CM burden is in line with European and North American data, despite NZ having the highest rate of cutaneous melanoma. The incidence remained stable over 2 decades.

Anterior segment optical coherence tomography in ocular surface tumours and simulating lesions

This study aims to systematically review the reported literature on the use of anterior segment optical coherence tomography (AS-OCT) in ocular surface tumours and simulating lesions. A systematic literature search was done using PubMed, Scopus, and Web of Science databases between January 2002 and December 2021. On AS-OCT, ocular surface squamous neoplasia typically demonstrate epithelial thickening, epithelial hyperreflectivity, and an abrupt transition between normal and abnormal epithelium. Conjunctival nevi usually show mildly hyperreflective epithelium of normal thickness, internal hyperreflectivity, and intralesional cysts which is the hallmark of this tumour. Primary acquired melanosis presents with normal thickness epithelium, basal epithelial hyperreflectivity, and absence of cysts. Conjunctival melanoma demonstrates hyperreflective normal/thickened epithelium, hyperreflective basal epithelium, internal hyperreflectivity, and absence of intralesional cysts. Conjunctival lymphoma shows homogenous, low-medium reflective subepithelial lesions with smooth borders, and dot-like infiltrates. Benign reactive lymphoid hyperplasia findings are similar to lymphoma but the infiltrates are more hyperreflective compared to lymphoma. Pterygium shows thickened conjunctival epithelium, epithelial hyperreflectivity, and subepithelial wedge-shaped hyperreflective tissue separated from the overlying epithelium by a cleavage plane. Pinguecula demonstrates mildly thickened epithelium and similar findings with pterygium but does not extend beyond the corneal limbus. This review shows that AS-OCT, as a noninvasive tool, has potential uses in the differential diagnosis of ocular surface tumours and simulating lesions. Major limitations of AS-OCT include limited visualization of the posterior border of thick, keratinized, and pigmented tumours and lack of assessment of large conjunctival tumours in a single cut.

Malignant lesions of the caruncle

Caruncle malignancy is rare, but signs of disease can be easily missed by both patients and clinicians. There is significant potential for significant morbidity and even mortality from delayed diagnosis and treatment. Clinical features of primary malignant cancer include rapid growth, pigment deposition, ulcerated surface and bleeding. Malignant diagnoses include lymphoproliferative disease, basal cell carcinoma, squamous cell carcinoma, sebaceous carcinoma and malignant melanoma. Increased pigmentation is associated with melanoma, yellow coloured deposition with sebaceous carcinoma and a salmon-pink hue with lymphoproliferative disease. Treatment involves excision with margin control which may necessitate exenteration. Metastases to cervical and preauricular lymph nodes has been reported.

Sublimation of Benign Conjunctival Nevi Using Plasma-Assisted Noninvasive Surgery: A Clinical Case Series

Background

Conjunctival nevi (CN) are common benign ocular tumors. Given their low risk of malignancy, surgical removal of nevi is primarily requested by patients. Herein, we introduce Atmospheric Low-temperature Plasma (ALTP) as a novel noninvasive method for the removal of CN.

Methods

A clinical case series was conducted from 2020 to 2021 at the Vision Health Ophthalmic Center in Tehran, Iran. CN in one of the eyes of seven patients was treated. In all patients, the benignity of CN was confirmed by ocular oncologists. The white handpiece of the Plexr device, which generates plasma with the lowest output, was used to apply plasma spots on the nevi. In addition, the Ocular Surface Disease Index (OSDI) questionnaire was completed by all patients before and six months after the treatment.

Results

In all patients, the nevi outside the limbus area completely disappeared. The mean size of pre- and post-operative nevi was 3.89×11.7 and 0.54×1.69 mm, respectively. Results of the OSDI questionnaire showed significantly lower scores after the surgery in all patients.

Conclusion

The ALTP method is a simple, cost-effective, and office-based surgery to remove CN safely and effectively.

Bone metastasis in a case of primary acquired melanosis with atypia resulting from conjunctiva melanoma

A 66-year-old woman presented to a tertiary referral centre with a diagnosis of limbal stem cell deficiency secondary to multiple treatments for primary acquired melanosis (PAM) by her referring ophthalmologists. She was known with primary acquired melanosis with severe atypia of the right eye which had been treated with several excisions, cryotherapy and topical chemotherapy. She had PAM over 360° of alternating intensity. Throughout the follow-up period, she developed a cataract and subsequent a retinal detachment for which she underwent a phacovitrectomy on the right eye. There was no nodule present nor did the routine lymph nodes inspection show any enlargement. No abnormalities were observed on intranasal examination. Seven years after the last excision, a metastasis to the spine (Th3) was diagnosed. A complete systemic work-up and a pathological examination did not show any alternative primary melanoma in the body. The original histological material was reviewed again by an ophthalmopathologist. After a new round of stains and immunohistochemistry, the presence of atypical melanocytes in both the epithelium and stroma were found in a scar region leading to a renewed conclusion that the PAM in question was actually the primary melanoma.

Real-life data of adjuvant IFN-α2b and MMC in conjunctival melanocytic lesions

PURPOSE

We herein compare topical interferon alpha 2b (IFN-α2b) to topical mitomycin C (MMC) in the adjuvant management after excision of primary acquired melanosis with atypia (PAM) and melanoma of the conjunctiva/cornea (CM).

METHODS

We included 25 tumors from 25 patients (six with PAM and 19 with CM). After surgical excision, four patients started with adjuvant IFN-α2b (two in combination with radiotherapy), 19 with MMC, and two with radiotherapy alone. Five patients were switched from initial MMC/radiotherapy to IFN-α2b during follow-up. Efficacy was assessed via time to tumor recurrence and initial therapy response.

RESULTS

With initial IFN-α2b, three patients (3/4, two with additional radiotherapy) showed complete remission (follow-up: 1478-1750 days) and one recurrence (1/4) was noted after 492 days. With initial MMC, no recurrence was recorded in 15 of the 19 patients (follow-up: 99-4732 days). Five patients were switched from MMC or radiotherapy to IFN-α2b: two patients showed complete remission (2/5), while another two (2/5) experienced recurrences and remained without recurrence after repeated courses of IFN-α2b (follow-up: 1798 and 1973 days). Only one patient showed incomplete response. Adverse effects were recorded in five patients, all received MMC.

CONCLUSION

Topical IFN-α2b (arguably together with radiotherapy) may be a viable alternative to MMC in PAM and CM. We observed fewer side effects at similar response rates. However, when response to MMC was poor, IFN-α2b may also be of limited utility.

Blue nevi of the palpebral conjunctiva: report of 2 cases and review of literature

PURPOSE

To describe two patients with blue nevi of the palpebral conjunctiva and to review the existing literature on common and cellular blue nevi of the conjunctiva.

METHODS

Report of two cases and literature review.

RESULTS

We present two cases of blue nevi in the palpebral conjunctiva: an atypical cellular blue nevus of the left upper eyelid and a common blue nevus around the lacrimal punctum of the left lower eyelid. Both patients underwent full thickness eyelid excision with wide margins. There was no tumor recurrence at 11 and 4 months postoperatively.

CONCLUSIONS

Blue nevi are a group of melanocytic tumors that rarely involve the ocular adnexa. They may arise in the palpebral conjunctiva and should be considered in the differential diagnosis of pigmented lesions in this location as they can mimic melanoma.

Insidious ocular surface lesion in an 81-year-old woman

Ocular surface melanoma (OSM) is rare. An 81-year-old Caucasian woman presented with a 4-month history of right eye pain and reduced vision. Histopathological examination of the excisional biopsy identified invasive amelanotic melanoma of the conjunctiva expressing Melan A and SOX10. X-ray of chest, CT of liver and MRI of the brain and orbit did not identify macroscopic metastases. She was given adjuvant topical mitomycin-C 0.04% for four cycles of 2 weeks. Her vision improved and the cornea was clear at 6 months.

Conjunctival melanoma: outcomes based on tumour origin in 629 patients at a single ocular oncology centre

PURPOSE

To investigate clinical features and outcomes of conjunctival melanoma classified by tumour origin.

METHODS

Retrospective review of conjunctival melanoma patients at a single ocular oncology centre between April 18, 1974 and September 9, 2019. Lesions were divided into three tumour origin groups (primary acquired melanosis [PAM], nevus, and de novo) and clinical features and outcomes were compared.

RESULTS

There were 629 patients with conjunctival melanoma that arose from PAM (n = 476, 76%), nevus (n = 59, 9%), or de novo (n = 94, 15%). A comparison (PAM vs. nevus vs. de novo) revealed patients with tumours arising from PAM presented with older mean age (62 vs. 52 vs. 55 years, p < 0.001), worse initial logMAR visual acuity (Snellen equivalent 20/30 vs. 20/25 vs. 20/25, p = 0.03), and greater clock hour involvement (4.8 vs. 4.0 vs. 3.2, p < 0.001). Tumours arising from nevus had lower frequency of fornix (31% vs. 9% vs. 24%, p = 0.02) and tarsal involvement (29% vs. 9% vs. 26%, p = 0.046) and more frequent classification as AJCC category T1 (60% vs. 89% vs. 62%, p = 0.01). After follow-up of (57.2 vs. 68.2 vs. 51.7 months, p = 0.35), tumours arising from PAM had worse mean final visual acuity (20/50 vs. 20/40 vs. 20/40, p = 0.02) and greater frequency of visual acuity loss ≥3 lines (25% vs. 15% vs. 10%, p = 0.02). Kaplan-Meier estimates for 5-year risk showed no difference by tumour origin for visual acuity loss ≥3 lines, local tumour recurrence, exenteration, metastasis, or death.

CONCLUSIONS

Conjunctival melanoma most often arose from PAM, and tumour origin did not affect clinical outcomes.

Modified procedure of anterior orbital exenteration enables eye socket reconstruction: A retrospective cohort study

The conventional procedure of anterior orbital exenteration is unfavorable for eye socket reconstruction, whereas a modified procedure enables socket reconstruction and prosthesis fitting. Our study aims to compare the cosmetic outcomes between these 2 surgical techniques.We retrospectively recruited patients treated with modified or conventional exenteration during January 2015 to May 2021 in our hospital. The conventional approach was performed along with dermis-fat graft transplantation. The modified approach was conducted followed by eye socket reconstruction and eyelid blepharoplasty. The clinical data were collected and analyzed, including demographics, tumor characteristics, postoperative complications, tumor-related events, and cosmetic outcomes.Forty-nine patients were consecutively recruited in this study, including 22 cases of modified exenteration and 27 cases of conventional exenteration. Forty-four subjects (89.8%) were diagnosed with ocular surface malignancies (conjunctival melanoma and squamous cell carcinoma) and 5 subjects (10.2%) were diagnosed with extraocular stage of uveal melanoma. After follow-up for 31.8 ± 17.1 months, the 1-, 2-, 5-year overall survival rate was calculated as 100%, 79.2%, and 59.2% in the Modified group, and 94.2%, 73.8%, and 51.5% in the Conventional group. Comparison of the survival curves showed no significant differences. In the Modified group, all patients received orbital implant placement and eye socket reconstruction. The implant motility was satisfactory in 12 cases (54.5%) with movements in 3 to 4 directions. The eyelid function was acceptable in 17 cases (77.3%) with no entropion, ectropion or lower lid laxity. Ocular prosthesis was delivered in 17 cases (77.3%) with successful fitting in 11 cases (64.7%). The self-rated cosmetic score was statistically (t test, P < .0001) higher in the Modified group (6.7 ± 0.9) than the Conventional group (2.2 ± 0.4).The modified approach to anterior orbital exenteration enables eye socket reconstruction and cosmetic rehabilitation while still preserves the curable chance for the treatment of advanced periocular/intraocular malignancies.

Clinico-pathological correlation of lacrimal caruncle tumors: a retrospective analysis over 22 years at the University Eye Hospital Bonn

Purpose

The lacrimal caruncle is composed of numerous structures including different glands as well as hair follicles. Accordingly, the spectrum of benign and malignant lesions is broad, and the clinical diagnosis is often challenging. Here we systematically analyzed excised caruncular tumors over the past 22 years with special emphasis on the clinico-pathological correlation to provide a guidance for clinicians.

Methods

Retrospective evaluation with clinico-pathologic correlation of surgically removed caruncular tumors between 1998 and 2020 at a tertiary referral center.

Results

Eighty-two caruncular tumors were identified in the respective period. The patients were between 11 and 85 years of age (mean, 46.8 years; median, 49 years). Nevi (n = 35), cystic lesions (n = 14), oncocytoma (n = 9), papilloma (n = 8), sebaceous gland hyperplasia (n = 8), and reactive lymphoid hyperplasia (n = 4) were observed most frequently. Besides, we are the first reporting herniated orbital fat accompanied by a pyogenic granuloma. 2.4% (n = 2) were malignant tumors (sebaceous gland carcinoma, conjunctival intraepithelial neoplasia with pyogenic granuloma).

Conclusion

Caruncular tumors show a broad spectrum of mostly benign tumors. They can occur in patients of any age. However, 8/9 oncocytomas and both malignant lesions were detected in patients older than 60 years. Although the clinical diagnosis was confirmed in only 68.3% by the histopathological analysis, the two malignant lesions were identified as such already clinically. Caruncular lesions with a history of growth or other signs of malignancy should be excised followed by detailed histopathological examination to allow a final diagnosis and exclude rare malignant tumors with lethal potential.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00417-021-05464-x.

Sebaceous adenoma of the conjunctiva and caruncle: a clinicopathological report of three cases and literature review

Sebaceous tumors of the conjunctiva and caruncle are rare conditions, accounting for 1% of caruncle lesions and even lower among conjunctival lesions. Almost 50% of cases are associated with Muir-Torre syndrome, a rare autosomal-dominant condition characterized by at least one sebaceous skin tumor and one visceral malignancy. We report 3 cases of sebaceous adenoma with different presentations that were submitted to excisional biopsy and immunohistochemical study. Diagnosis of these tumors should increase the level of suspicion and lead to clinical investigation to rule out neoplasms, particularly because in up to 41% of cases, these can be the first sign of the disease.

Advanced ocular surface squamous cell carcinoma (OSSC): long-term follow-up

PURPOSE

To analyze the clinical characteristics and long-term follow-up of patients with advanced ocular surface squamous cell carcinoma (OSSC) involving periocular tissues and/or orbit. Primary outcomes were overall survival (OS), disease-free survival (DFS), and overall recurrence rate (RR). Secondary outcomes were a correlation between primary outcomes and tumor location, American Joint Committee on Cancer Classification (AJCC) staging system, histological results, surgical margins, and type of treatment.

STUDY DESIGN

a retrospective case series.

METHODS

The medical records of patients affected by OSSC involving periocular tissues and/or orbit referring, from 01/2011 to 01/2020, to our tertiary referral center were reviewed.

RESULTS

Thirty-six eyes of 36 patients were included. The mean age was 68.2 years; 18 (50%) patients were males. The mean follow-up was 40 months. The RR was 64%. The OS at 12, 24, 36, and 60 months was respectively 97.1%, 92.7%, 92.7%, and 92.7%. The DFS at 12, 24, 36, and 60 months was respectively 62.9%, 50.8%, 41.6%, and 29.7%. Multicentric disease (p = 0.0039), inferior tarsus localization (p = 0.0428), histological diagnosis of high-risk SSCs (p = 0.0264), positive surgical margins (p = 0.0434), and excisional biopsy (EB) alone (p = 0.0005) were associated with an increased risk of recurrence. A shorter OS was observed in patients who underwent EB alone (p = 0.0049).

CONCLUSION

OSCC involving periocular tissues and/or orbit is an aggressive disease with a high recurrence rate. Multicentric disease, positive surgical margins, inferior tarsus localization, and surgery without adjuvant therapies are strong predictors of recurrence and are the main factors affecting prognosis.

Bubble Forming Films for Spatial Selective Cell Killing

Photodynamic and photothermal cell killing at the surface of tissues finds applications in medicine. However, a lack of control over heat dissipation following a treatment with light might damage surrounding tissues. A new strategy to kill cells at the surface of tissues is reported. Polymeric films are designed in which iron oxide nanoparticles are embedded as photosensitizers. Irradiation of the films with pulsed laser light generates water vapor bubbles at the surface of the films. It is found that "bubble-films" can kill cells in close proximity to the films due to mechanical forces which arise when the bubbles collapse. Local irradiation of bubble-films allows for spatial selective single cell killing. As nanosurgery becomes attractive in ophthalmology to remove superficial tumors, bubble-films are applied on the cornea and it is found that irradiation of the bubble-films allows spatial and selective killing of corneal cells. As i) the photosensitizer is embedded in the films, which reduces its uptake by cells and spreading into tissues and ii) the bubble-films can be removed from the tissue after laser treatment, while iii) a low laser fluence is sufficient to generate vapor bubbles, it is foreseen that bubble-films might become promising for safe resection of superficial tumors.

Conjunctival melanoma: New insights in tumour genetics and immunology, leading to new therapeutic options

Recent developments in oncology have led to a better molecular and cellular understanding of cancer, and the introduction of novel therapies. Conjunctival melanoma (CoM) is a rare but potentially devastating disease. A better understanding of CoM, leading to the development of novel therapies, is urgently needed. CoM is characterized by mutations that have also been identified in cutaneous melanoma, e.g. in BRAF, NRAS and TERT. These mutations are distinct from the mutations found in uveal melanoma (UM), affecting genes such as GNAQ, GNA11, and BAP1. Targeted therapies that are successful in cutaneous melanoma may therefore be useful in CoM. A recent breakthrough in the treatment of patients with metastatic cutaneous melanoma was the development of immunotherapy. While immunotherapy is currently sparsely effective in intraocular tumours such as UM, the similarities between CoM and cutaneous melanoma (including in their immunological tumour micro environment) provide hope for the application of immunotherapy in CoM, and preliminary clinical data are indeed emerging to support this use. This review aims to provide a comprehensive overview of the current knowledge regarding CoM, with a focus on the genetic and immunologic understanding. We elaborate on the distinct position of CoM in contrast to other types of melanoma, and explain how new insights in the pathophysiology of this disease guide the development of new, personalized, treatments.

Congenital Smooth Muscle Hamartoma Obscuring the Cornea

Congenital smooth muscle hamartoma is a benign proliferation of smooth muscle that most commonly presents in the lumbosacral area or proximal extremities. Although exceedingly rare, congenital smooth muscle hamartomas have been reported to occur in ocular structures such as the brow, eyelid, and conjunctival fornix. This case describes an atypical congenital bulbar lesion in a newborn male which obscured the cornea. The lesion, which appeared to originate from the bulbar conjunctiva and/or the limbus, was excised at 5 months of age. Pathologic evaluation was consistent with congenital smooth muscle hamartoma. The authors of this report believe it is the first to describe a patient with a congenital smooth muscle hamartoma of the bulbar conjunctiva/limbus.

Iatrogenic Ocular Surface Diseases Occurring during and/or after Different Treatments for Ocular Tumours

Simple Summary

The ocular surface represents a finely regulated system that allows the protection of the eye. It can be affected by therapies used for the treatment of various intraocular tumours, particularly conjunctival cancers and uveal melanoma. In these conditions, treatments are chosen according to the characteristics of the lesion, and include a combination of selective surgery, anticancer eye drops, and/or radiotherapy delivered through different mechanisms. Possible side effects affecting the ocular surface range from transient dry eye or keratitis up to more severe complications such as corneal melting and perforation. These complications deserve careful evaluation for the risk of permanent sight-threatening sequelae. Physicians involved in the management of patients affected by ocular tumours should be aware of this risk in order to reach an early diagnosis and promptly set up an adequate treatment. The present review summarizes acute and chronic complications affecting the ocular surface following different therapies for the treatment of conjunctival cancers and uveal melanoma, and also reports clinical cases of representative patients who experienced these complications.

Abstract

The ocular surface represents a finely regulated system that allows the protection of the eye. It is particularly susceptible to different treatments for intraocular tumours, such as uveal melanoma and conjunctival cancers. Traditionally, the management of ocular tumours depends on the characteristics of the lesion, and is based on a combination of selective surgery, topical chemotherapy, and/or radiotherapy delivered through different mechanisms (e.g., charged-particle radiotherapy or brachytherapy). Possible complications involving the ocular surface range from transient dry eye disease or keratitis up to corneal melting and perforation, which in any case deserve careful evaluation for the risk of permanent sigh-threatening complications. Clinicians involved in the management of these patients must be aware of this risk, in order to reach an early diagnosis and promptly set up an adequate treatment. The present review of the literature will summarize acute and chronic complications affecting the ocular surface following different therapies for the treatment of ocular tumours.

Conjunctival and uveal melanoma: Survival and risk factors following orbital exenteration

PURPOSE

This study aims to analyse disease-free survival, overall survival and risk factors after orbital exenteration in patients with conjunctival and uveal melanoma.

METHODS

Patients who underwent orbital exenteration due to conjunctival and uveal melanoma were included in this retrospective study (March 2000 to March 2018).

RESULTS

A total of 76 patients were enrolled in this study: 60 patients had a conjunctival melanoma and 16 had a uveal melanoma. In conjunctival melanoma, the mean age was 68.4 years. The overall survival rate was 82% after 1 year and 52% after 5 years. Univariate analysis of overall survival found that the following parameters were predictive of a worse prognosis: gender, extent of the primary tumour, lymph node metastases, distant metastases, adjuvant chemotherapy or radiotherapy and relapse. In multivariate analysis, relapse and adjuvant radiotherapy appeared to contribute to a significantly worse prognosis. In uveal melanoma, the mean age was 63.6 years. Eleven patients died during follow-up (mean follow up 30.7 months). The overall survival and disease-free survival rates after 1 year were 62% and 57%, respectively. An analysis of risk factors was not possible due to the small number of cases.

CONCLUSION

Orbital exenterations in conjunctival and uveal melanoma are rarely necessary, but can be performed as an ultima ratio treatment with curative intent. Disease-free survival and overall survival are significantly lower for both groups due to the advanced stage of the disease compared to patients treated without exenteration in the literature. If a recurrence occurs after exenteration, the prognosis is poor in both groups.