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
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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
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Saunders Company, 1964, 266.
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Jackobiec FA, Folberg R, Iwamoto
T. Clinicopathologic
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Ophthalmology 1989;96:147-66.
Address for Correspondence
Dr. Nitin Batra, Deptt. of
Ophthalmology,
Christian Medical College, Ludhiana
