Conjunctival and lid margin



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CONJUNCTIVAL AND LID MARGIN

LESIONS: LINKS TO SYSTEMIC DISEASE Thomas F. Freddo, O.D., Ph.D., F.A.A.O.

Professor and Director

School of Optometry

University of Waterloo



Structure of Conjunctiva

Tissue and Cell types

Epithelium - goblet cells (density and distribution), melanocytes, Langerhans cells

Stroma- fibroblasts, vessels, lymphatic channels, melanocytes, nerves, lymphocytes, plasma cells, mast cells

Eyelid Margin – mucocutaneous junction, Meibomian orifices, lash follicles and glands of Zeis
Clinical Approach to Conjunctival Lesions by Location

Lesions at the Limbus

Congenital –

Limbal Dermoid (distinguish choristoma from hamartoma)

Systemic association = Goldenhar’s Syndrome

Nevi (see pigmented lesions-below)

Inflammatory –

Pinguecla – elastotic degeneration. Systemic association = none

Phlyctenule - Usually hypersensitivity response when at limbus, Systemic association = TB.

Vernal keratoconjunctivitis – Systemic association = seasonal allergies

Metaplastic and Neoplastic

Bitot's spot: Squamous metaplastic change. Systemic association = avitaminosis A.

Conjunctival Intraepithelial Neoplasia (CIN) and Squamous Cell CA- Systemic association = none unless mets.

Melanoma: (see pigmented lesions-below) Systemic association = none unless mets
Lesions that appear Cystic and Pseudocystic

Epithelial inclusion cysts: Variability of shape and color/content based upon location

Systemic association = None

Retention cysts: Variability in color and content. Systemic association = None



Lympangiectasis: Morphological variants. Systemic association = None

Bulbar conjunctival granulomas: Multiple small, yellow, pseudocystic = Systemic association = Sarcoid


Lesions that appear Salmon-Colored

Pyogenic granuloma: misnomer. Significance of locations and causes. Systemic associations = None

Hemangiomas: congenital hamartomas. Systemic associations – Sturge-Weber

Kaposi's Sarcoma: nodular mass varying in color from purplish-red to brown. Systemic association = AIDS. This is rarely the presenting sign however. Those AIDS patients with HLADR5 phenotype are at increased risk.

HBID = Triracial family from North Carolina. Systemic association = genetically inherited


MALT Lymphoma – Fills inferior or superior fornix. Systemic association = lymphoma

Solid tumor mets – metastasis to conjunctiva (e.g. Systemic association = adenoCA breast)

Conjunctival Papilloma – Viral induced vs malignant (Squamous cell CA). Systemic associations = Some associated with systemic HPV infection.

GUIDELINES FOR DISTINGUISHING BENIGN FROM MALIGNANT PAPILLOMAS

VIRAL NEOPLASTIC


Children/Adolescents Adults

Bilateral Unilateral

Multiple Solitary

Pedunculated in fornix Pedunculated or sessile at limbus

Non-inflamed Inflamed

Spontaneously resolve Continue to grow



Pigmented Lesions of the Conjunctiva:

Guidelines: New pigmentation does NOT always mean malignancy (melanoma). Degree of pigmentation tells you nothing about behavior or malignant potential.


Pigmented masses arise from 3 cell types:

1. melanocytes 2. nevus cells 3. epithelial cells


FEATURE NEVUS CONGEN/MEL ACQUIRED/MELANOSIS


Onset Congenital Congenital Acquired

Structure Discrete Diffuse Diffuse

Color Brown Blue/Black Brown

Cysts 50% of cases None None

Pigment Variable Always Always

Moves Yes No Yes

Growth Stationary Stationary Wax and wane

Uvea


involved No Heterochromia No

Skin


involved No in Nevus of Ota No

Malignant

potential Conjunctiva Uvea or skin Conjunctiva

Melanoma of the Conjunctiva- Arise from 3 sources.
1. 20% from nevi (primarily nevocellular) 2. 40% from acquired melanosis 3. 40% de novo

Occur most often in middle-aged caucasians. Most often near the limbus. Those rarer tumors arising in palpebral conjunctiva generally have a less favorable prognosis. Characterized by slow superficial growth. Other than tumor thickness, few prognostic indicators for 5 yr survival available. Can't be classified according to Callender classification or Clark system used for skin melanomas.




Lesions at the Lid Margin and Muco-cutaneous Junction (Pearl: Disortion of lash line as soft indicator of benign vs malignant.)

Solitary Mollsucum contagiosum – unique morphology and associated viral conjunctivitis Systemic association = HIV or other immunocompromise.

Verruca – unique morphology and associated viral conjunctivitis. Systemic association = None



Sebaceous gland CA – Two clinical masquerades (recurrent chalazion or unilateral moderate blepharitis. Systemic associations = none unless mets

Granulomata along lid margin – Systemic association = Sarcoidosis


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