|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
Limbal Dermoid (distinguish choristoma from hamartoma)
Systemic association = Goldenhar’s Syndrome
Nevi (see pigmented lesions-below)
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
Pedunculated in fornix Pedunculated or sessile at limbus
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
involved No Heterochromia No
involved No in Nevus of Ota No
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