A case of limbal Malignant Melanoma: Abstract



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A Case of limbal Malignant Melanoma:

Abstract:

Conjunctival malignant melanoma is a rare pigmented tumor occurring during fifth and sixth decade typically involving limbus with high recurrence rate. A 65 yr male presented with complaints of slowly growing dark colored swelling in his left eye since 2 months. No systemic complaints. A black mass was seen on limbus with lobulated appearance. On USG ocular coats were normal. UBM shows 8 * 5 mm mass. Excision of mass was done and biopsy confirmed diagnosis. Mass excision was supplemented with cryotherapy. Now patient is cosmetically and visually satisfied.



History

A 65-years old male residing at Rajasthan was referred to the Maneklal and Jagjivan Western Regional Institute of Ophthalmology, Ahmedabad with chief complains of swelling, pain and diminution of vision in left eye since two months. He had initially presented to her established local ophthalmologist 10 days before. Examination by the outside ophthalmologist had revealed black conjunctival pigmentation, most dense temporally in the left eye. The patient was subsequently referred to our center for evaluation and management of suspected primary acquired melanosis (PAM). The patient’s past medical history was significant for rheumatoid arthritis, coronary artery disease, and heart failure. Her past ocular history was significant for bilateral cataract extraction with intraocular lens placement.

Examination:

On examination, visual acuity was 20/30 in the right eye and 20/40 in the left eye. Intraocular pressure was 16 mm Hg in the right eye and 6 mm Hg in the left eye. Pupils were noted to be round regular reacting to light. There was no relative afferent pupillary defect. Extra ocular motility was full and visual fields were full to confrontation bilaterally.

Ocular adnexal examination was unremarkable. Slit-lamp examination revealed: globular black colored lobulated mass about 8mm at 3 o’clock limbus with superficial hemorrhages, conjunctiva shows prominent vessels with 2 to 5 o’clock peripheral corneal involvement. [Figures 1] Lids, lashes, and anterior chambers intraocular lens were unremarkable bilaterally.

Fundus examination revealed unremarkable maculae, vessels, and periphery in both eyes. No palpable lymph nodes presented.

Routine blood investigations were normal. In Ultrasonography of eye ocular coats were normal.

On Ultrasound biomicroscopy: 8*5 mm limbal mass involving 2 to 5 o’clock cornea. Ultrasonography of chest and abdomen were normal.[figure 2]

Treatment:

Excision of the mass was done followed by cryotherapy and sent for Histopathological examination.

Differential Diagnosis:

The differential diagnosis of conjunctival pigmentation includes

conjunctival nevus, racial melanosis, primary acquired melanosis, secondary acquired melanosis, and conjunctival melanoma. Secondary acquired melanosis may be due to previous irradiation, hormonal changes, metabolic disorders, chemical exposure, topical glaucoma medications, or chronic inflammatory disorders of the eye.[1] Several cases of secondary acquired melanosis of the conjunctiva with findings similar to our patient’s findings attributable to perforating injury or iris trauma have been reported.[2-6]






Diagnosis and Discussion:

Ocular examinations, general examinations and Histopathological report diagnosed the patient having left eye conjunctival malignant melanoma.

Conjunctival melanomas is a rare (2%) but potentially fatal ocular malignancy and typically present as focal areas of raised macules, plaques, or masses in an asymptomatic patient, most commonly in the sixth decade. [7,8] Clinical features that may suggest conjunctival melanoma include large size, lack of mobility, limbal location, variegation, and presence of feeder vessels.[8] Conjunctival melanoma may arise from areas of primary acquired melanosis, de novo, or from a conjunctival nevus. Usually melanoma arising from a prior nevus or de novo appears as black or grey vascularized nodule, whereas lesions arising from PAM with atypia have areas of nodularity and thickening. Conjunctival melanoma can also present as an amelanotic lesion with a pink, smooth “fish-flesh” appearance. [9]

Patient is kept on follow up for any recurrence of tumor or any signs suggestive of metastasis.

Ultrasound bio microscopy is very useful to know the extent and depth. It can be managed satisfactorily if treated in time.

References:

1. Damato B, Coupland SE. Conjunctival melanoma and melanosis: a reappraisal of terminology, classification and staging. Clin Experiment Ophthalmol 2008;36:786-95.
2. Wanichwecharungruang B, Narumitchai W. Intra-bleb pigmentation after trabeculectomy. J Med Assoc Thai 2003;86:183-90.
3. Rebolleda G, Muñoz-Negrete FJ. Intra-bleb pigmentation after phacoemulsification [in Spanish]. Arch Soc Esp Oftalmol 2001;76:571-4.
4. Smiddy WE, Yeo JH, Michels RG, Green WR. Conjunctival pigmentation following pars plana vitrectomy. Retina 1987 Spring;7:38-40.
5. Campinchi R, Coscas G, Hamard H. A case of pseudo-melanosis of the conjunctiva caused by a surgical clamp [in French]. Bull Soc Ophtalmol Fr 1965;65:298-9.
6. Benson MT, Rennie I, Talbot J. External ocular pigmentation secondary to perforating eye injury. Br J Ophthalmol 1990;74:251-3.
7. Kanski JJ, Bowling B. Clinical Ophthalmology: A Systematic Approach. 7th ed. Philadelphia: Elsevier/Saunders; 2011:482-3.
8. Zembowicz A, Mandal R, Choopong P. Melanocytic lesions of the conjunctiva. Arch Pathol Lab Med 2010;134:1785-92.
9. Skuta GL, Cantor LB, Weiss JS. Ophthalmic Pathology and Intraocular Tumor, Basic and Clinical Science Course. San Francisco: The American Academy of Ophthalmology; 2009:70-1.

[figure 1]



Limbal malignant melanoma on temporal side of left eye.



[figure 2]



Limbal mass not involving deeper structures.


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