Year : 2004 | Volume
: 52 | Issue : 2 | Page : 154--5
Seborrheic Keratosis of the Conjunctiva
Arun K Jain, J Sukhija, B Radotra, V Malhotra
Department of Ophthalmology, Post Graduate Institute of Medical Research and Education, Chandigarh, India
Arun K Jain
Department of Ophthalmology, Post Graduate Institute of Medical Research and Education, Chandigarh
Seborrheic keratosis can simulate a malignant melanoma and should form the differential diagnosis of a malignant melanoma. Histopathology is confirmatory.
|How to cite this article:|
Jain AK, Sukhija J, Radotra B, Malhotra V. Seborrheic Keratosis of the Conjunctiva.Indian J Ophthalmol 2004;52:154-5
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Jain AK, Sukhija J, Radotra B, Malhotra V. Seborrheic Keratosis of the Conjunctiva. Indian J Ophthalmol [serial online] 2004 [cited 2020 Apr 8 ];52:154-5
Available from: http://www.ijo.in/text.asp?2004/52/2/154/14604
Seborrheic keratosis is a common lesion found on the eyelids and face of middle-aged and elderly persons.,  Other favoured locations include the central areas of the body, such as chest, back and abdomen. It is a well circumscribed growth, friable and has a "stuck on" appearance. It is a common observation that the growth and depth of pigmentation are directly related to exposure to sunlight. This report documents a case of conjunctival sebborheic keratosis. The occurrence of this benign lesion on the conjunctiva, to the best of our knowledge, has so far only been reported once in the literature (Medline search).
An otherwise healthy 42-year-old male was referred for evaluation of a conjunctival mass with a clinical diagnosis of malignant melanoma. The patient noticed a brownish mass over his temporal conjunctiva adjacent to the limbus in the left eye for 3 months. Because the lesion enlarged rapidly, he visited his ophthalmologist and was suspected to have malignant melanoma.
The initial examination showed that the visual acuity was 6/9 in his right eye and 6/12 in his left eye. Slitlamp biomicroscopy revealed a markedly elevated, darkly pigmented mass, measuring 4x4mm on the juxtalimbal conjunctiva of the left eye [Figure 1]. The external appearance of the lesion was smooth with several feeder vessels. There was no keratin-like material overlying the lesion and there was no evidence of primary acquired melanosis adjacent to the lesion. The rest of the ocular examination was within normal limits. A complete metastatic work-up revealed no abnormality. The patient had no significant past history, weight loss, or other symptoms suggestive of malignancy. With a provisional diagnosis of malignant melanoma, a wide excision biopsy was done and the tumour mass sent for histopathology.
Pathological findings: Gross examination revealed a deeply pigmented mass that measured 4x4x3mm. Histopathological examination of the specimen showed acanthosis of the uniform basaloid cells extending from the basal layer to the surface of the conjunctival epithelium with a sharply demarcated basement membrane. Mild keratinisation with scattered melanophages was noted [Figure 2]. The underlying substantia propria had actinic degeneration. Several horn cysts were seen in the epithelium [Figure 3]. Pale eosinophilic spinous cells were seen beneath the epidermis, surrounding the infundibular horn tunnels. There was no evidence of malignancy. The surgical margin was clear. These features seemed compatible with the diagnosis of seborrheic keratosis.
Seborrheic keratosis, a benign growth lesion, is a very common cutaneous lesion encountered in white races. in the fourth and fifth decade. Our case is only the second to be reported in the literature (Medline search). Pathologically the essential feature is accumulation of immature keratinocytes between the basal layer and the keratinising surface of the epidermis. Following the pathological diagnosis of the tumour mass, we reviewed the literature. Tseng et al in their report had suggested impression cytology and immunucytochemistry for cytokeratin and HMB-45 to differentiate this epithelium-derived tumour from a melanocyte-derived tumour. A proliferation of melanocytes is admixed among the keratinocytes and accounts for the variable pigmentation of the mass lesion. These features were present in our patient.
The epithelial pearls which arise from abnormal keratinisation of individual cell nests, and are the most distinguishing features of squamous cell carcinoma, were absent. Other features of malignancy like pleomorphism, formation of tumour cells with hyperchromatic nuclei and scanty cytoplasm, and atypical mitotic figures, were absent.
In solar keratosis the surface epithelium often reveals acanthosis, hyperkeratosis, parakeratosis and dyskeratosis. Basophilic degeneration of collagen or solar elastosis results because of sun-induced degeneration of collagen and elastic tissue. The most characteristic structures of seborrheic keratosis are the small keratin-containing cysts entrapped among proliferative cells. These cysts, which are absent in solar keratosis are called pseudohorn cysts . They should not be confused with the epithelial pearls of squamous cell carcinoma.
In view of the clinical history of a rapidly growing, pigmented mass with prominent feeder vessels and a smooth surface, the diagnosis was more in favour of a malignancy, particularly malignant melanoma. Conjunctival melanoma, which is uncommon but potentially lethal, is likely to recur and carries an overall mortality rate of 30-40%., A complete and wide excision of such a lesion is mandatory. Our case highlights the fact that seborrheic keratosis, though rare, can involve the conjunctiva and simulate malignant melanoma. Therefore, such a lesion should be part of the differential diagnosis of malignant melanoma.
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