Vol.14
No. 1, Januray, 2004
Malignant Melanoma of the Conjunctiva- An Unusual Presentation
Nitin Batra, SG Jaison,
Sunitha Jacob
Malignant
melanoma of the conjunctiva is a relatively rare malignancy
that accounts for only 2% of all ocular malignancies.
The melanoma arises either from a pre-existing naevus or from
acquired melanosis. Vary rarely it develops as de novo
lesion. We report an unusual case of malignant melanoma
of the conjunctiva developing in the eye of a 70-year old
male, 25 years after evisceration following ocular
trauma. To the best of our knowledge, such a case has
not been reported before.
CASE
REPORT
A 70 year old healthy male patient presented with complaints
of severe discomfort in the left eye along with watering and
discharge for the past 3 months. He also reported one
episode of mild bleeding from the left eye 5 months ago, which
stopped spontaneously. He gave history of a severe
ocular trauma to the left eye 25 years ago, following which it
was eviscerated. he was then fitted with an artificial
eye. All these years he had been regularly using the
artificial eye and prior to this episode of discomfort, the
patient's left eye had been asymptomatic. During the
past 3 months he had also been having difficulty in inserting
the artificial eye and had noticed a discolouration in his
left eye.
Ocular
examination of the right eye showed a small, central nebular
corneal opacity and immature senile cataract. The fundus
examination was normal. The left eye examination
revealed a grayish-black pigmentation of the conunctiva, the
density of which increased towards the periphery. It
covered an area of approximately 24 mm horizontally and 18 mm
vertically, involving the caruncle and the palpebral as well
as forniceal conjunctiva. The margins of the pigmented
area had a feathery appearance. The conjunctiva was
thickened and firmly adherent to the underlying tissue
(Fig.1). The area was not vascularised and there was no
tenderness or bleeding on touch. There was no
discolouration of the skin of the eyelids.
Fig.1:
Clinical photograph showing greyish-black pigmentation of the
conjunctiva in an eviscerated eye.
On
general physical examination, there was no evidence of
pre-auricular and submandibular lymphadenopathy or
organomegaly. The routine blood examination and chest
x-ray were within normal limits. CT-scan of the left
orbit showed a shrunken globe with few specks of calcification
seen in the posterior aspect. There was no bony
involvement.
A
biopsy of the tissue was carried out under local anaesthesia
and subjected to histopathological study. The section
showed fragments covering stratified squamous epithelium with
underlying tumour tissue comprised of groups and sheets of
large pleomorphic epithelioid and spindle-shaped cells,
containing large round or ovoid nuclei with prominent
nucleoli. The cytoplasm contained extensive melanin
pigment. Formation of organised clusters was seen at
places. Mitosis was frequent. Area of necrosis,
haemorrhages and inflammatory cell infiltrate were also
seen. The histopathological diagnosis was consistent
with malignant melanoma of the conjunctiva (Fig. 2.)
Fig.2
: Microphotograph showing Spindle & Epithelioid shaped
cells lying in sheets. Abundant amount of intracelluar
& extracellular melanin pigment is also seen. (H&E, x
400)
DISCUSSION
Malignant melanomas of the conjunctiva are relatively rare.
Approximately 75% cases arise from acquired melanosis.
Upto 20% of patients either have a history of or microscopic
evidence of a benign naevus and the remainder arise de novo.1,2
Melanomas that arise without a pre-existing naevus or acquired
melanosis tend to occur first at the limbus.3 They
are unusual in the caruncle and rare in the palperbaral
conjunctiva.4
Treatment
is necessary in all cases to reduce the opportunity for spread
of the tumour. Conjunctival melanomas disseminate by local
extension and by spread into the regional lymphatics.
The ipsilateral, pre-auricular and submandibular lymph nodes
are the most common sites for metastasis.5 From the
lymphatics great potential exists for hematogeneous
spread. Therefore complete surgical excision of the
tumour is the goal of treatment.
The
overall mortality rate for conjunctival melanomas is
25%. Indications of poor prognosis include involvement
of palperbral conjunctiva, forniceal conjunctiva or caruncle
and invasion into deeper ocular tissues.3
In
this case, the patient's left eye had been eviscerated 25 year
ago, following an ocular trauma. The patient was not
aware of any discolouration or naevus in the eye prior to the
trauma. All these years he had been using an artificial
eye, and sicne he had remained asymptomatic, he had not had an
ophthalmic check up.
It
is quite possible that the mechanical irritation to the
conjunctiva, caused by the artificial eye over the past 25
years, could have led to the development of the pigmented
lesion.
Our
patient was explained about the treatment modalities and the
prognosis. However, he was unwilling to undergo any treatment.
We
wish to emphasise the need of a regular ophthalmic examination
for people using artificial eyes.
REFERENCES
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Folberg
R, Mc Lean IW, Zimmerman LE. Malignant melanomas of the
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Jackobiec
FA, Bronstein S, Albert W. The role of Cryo-therapy
in the management of conjunctival melanoma. Ophthalmology
1982; 89:502-15.
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Conlon
MR, Alfonso EC, Stark I. Tumours of the cornea and
conjunctiva. In: Albert DM, Jackobiec FA, editors.
Principles and practice of ophthalmology Clinical
practice. Philadelphia: WB Saunders Company
1994;276-91.
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Hogan
MJ, Zimmerman LE. Ophthalmic Pathology: An Atlas and
Texbook. 2nd ed. WB Saunders Company, 1964, 266.
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Jackobiec
FA, Folberg R, Iwamoto T. Clinicopathologic
characteristics of premalignant and malignant melanocytic
lesions of the conjunctiva. Ophthalmology 1989;96:147-66.
Address
for Correspondence
Dr. Nitin Batra, Deptt. of Ophthalmology,
Christian Medical College, Ludhiana.
