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| REVIEW ARTICLE |
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| Year : 1980 | Volume
: 28
| Issue : 4 | Page : 171-178 |
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Primary conjunctival tumours
N Zaidi, K Nath, R Gogi
A.M. U. Institute of Ophthalmology, Aligarh, India
Correspondence Address:
K Nath
A.M.U. Institute of Ophthalmology Aligarh U.P.
India
 Source of Support: None, Conflict of Interest: None  | Check |
PMID: 7287109 
How to cite this article:
Zaidi N, Nath K, Gogi R. Primary conjunctival tumours. Indian J Ophthalmol 1980;28:171-8 |
In most of the cases of conjunctival neoformations, the diagnosis by far and large is very evident. Most of the cases present with some sort of swelling in the eyelids, conjunctiva of lids, fornices or as epibulbar growth. Even though, the diagnosis is almost always written on the lesion, some confusion may arise in differentiating a chronic granuloma from a papilloma or an epithelioma, and a dermoid from a conjunctival cyst etc. The aim of this present work is to study clinical and histopathological features of primary conjunctival tumors and an attempt shall also be made to draw a clinicopathological correlation.
| Materials and methods | |  |
This study comprises of 5 1 cases attending the out-patient and in-patient departments of A.M.U. Institute of Ophthalmology. The conjunctival growths were subjected to a detailed clinical examination. After the provisional diagnosis was made the growth was excised and subjected to histopathological examination with routine staining with haematoxyline, eosin, von Gieson's, Periodic Acid Schiff and crystal violet. Other laboratory investigations included conjunctival smears and culture for fungus and bacteria.
| Observations and discussion | | |
Age-The distribution is what might be expected from the nature of the lesion. The benign lesions are more common in the younger age groups, the maximum number of cases being in the second decade. The incidence of benign and malignant lesions is shown in [Table - 1][Table - 2].
Sex : The sex distribution showed a higher incidence of all types of tumors amongst the males (64.74%) as compared to females (37.26%) [Table - 3]. This higher incidence in males may be an indication of the importance of chronic irritation as a possible aetiologic factor amongst them[1],[2].
Nature of lesions : There were 38 benign (74.5%) tumors, and 13 malignant (25.5%) tumors, [Table - 3]
Benign Lesions Commonest amongst them were vascular new growths (19.6%), next common were dermoids & chronic granuloma (13.73%), followed in. order of frequency by conjunctival cysts (11.77%), pigment tumors and amyloidosis (5.88%) and nerve tumors (3.91%), [Table - 4].
Malignant Lesions consisted of 13 cases (25.5%), 11 cases were of squamous ell carcinoma and 3 cases of basal cell carcinoma [Table - 4].
| Cysts | | |
In the present series, the incidence of conjunctival cysts was 11.77%, a similar incidence was reported earlier.[3] Clinically the cysts were more common in the lower fornix (33.34%) in the present study. Norn[3] suggests that the cysts of the caruncle or plica semilunaris are mostly congenital in origin but in this series there was one case of a cyst at the caruncle with a history of trauma and seven days duration in a 55 years old patient. The cysts at the limbus were fixed to the deeper structures which could be due to the papillary nature of the limbal conjunctiva. However it is believed that these cysts are due to epithelial bridges extending from the cornea to the conjunctiva..
The swelling in all cases were oval or circular with a smooth translucent surface, greyish to bluish white in colour with a cystic feel, which was so typical that there was no difficulty in the diagnosis [Figure - 1]. The diagnosis was confirmed by histopathology which revealed that all cysts were epithetial inclusion cysts lined with a double layer of epithelium [Figure - 2].
The cysts in all cases were treated by simple excision.
| Dermoids | | |
The dermoids showed an incidence of 13.73%. They were more common in females than males. The dermoids were most common in the second decade in this series, however their highest incidence has been reported in the first decade[3]. One third presented as dermoids on the bulbar conjunctiva near the lateral canthus as a manifestation of Goldenhar's syndrome.
Conjunctival demoids are congenital misplacements and represent inclusion of epithermal and associated mesodermal tissues during closure of various foetal clefts[4].
These tumors presented as localised pinkish or yellowish white, rounded raised swelling present since birth. In three cases hair was seen projecting from the surface. The presence of such lesions since birth along with the above clinical picture lead to the diagnosis of conjunctival dermoids [Figure - 3]. Histopathological findings were typical. The cysts were lined stratified squamous epithelium with an evidence of epidermal appendages [Figure - 4].
| Epithelial tumors | | |
Conjunctival epitheliomas (25.5%) were the commonest epithelial tumors. There were ten cases of squamous cell carcinomas and three of basal cell carcinomas. The tumors occurred between 37 years to 75 years and affected 9 males and 4 females. A similar age range has been described by many workers[1],[5],[6]. However this lesion has been reported at 23 and 16 years of age['8].
In this series there were 7 cases of limbal epithelioma, all of which were on the nasal side. Limbal epithelium, in the interpalpebral zone is the favourite site of these tumors, as this is the junction of two epithelium. However, Duke-Elder[6] considered temporal limbus as the commoner site. Its primary occurrence on the palpebral conjunctiva is relatively rare.[2],[5] In the present study 3 cases arose from palpebral conjunctiva, two of which were so extensive, to cover the entire cornea.
Basal cell carcinomas are rare and are said to involve the bulbar conjunctiva but palpebral conjunctiva is also affected[1],[9],[10]. In the 3 cases in this study all were from the palpebral conjunctiva.
It is now accepted that epitheliomas of the conjunctiva are Grade I carcinomas. Malignancy of the epibulbar squamous cell carcinoma decreases with the proximity to the cornea.
Most of the patients presented with the complaints of a gradually increasing irregular mass either on the palpebral conjunctiva or bulbar conjunctiva. One patient gave the history of repeated operations for pterygium. In four cases there was history of recurrent nodule on the upper lid, which was excised repeatedly. Most of the growths were on the nasal side or in the upper palpebral conjunctiva. The size of these growths varied from a pea to 3.0 cm x 1.5 cm. All cases had irregular cauliflower like surface with reddish yellow or pinkish color and well defined margins [Figure - 5]. Histopathology of these growths revealed them to be conjunctival epithelioma [Figure - 6][Figure - 7] In one case however the diagnosis of a papilloma was made on account of its clinical picture but histopathology showed that it was a squamous cell carcinoma.
As regards treatment, simple excision was done in 8 cases and enucleation followed by radiotherapy in four cases, as the growth were too extensive in these cases for local excision Radiotherapy alone was used in one case. No recurrence has been reported. So we feel convinced that local excision should be the procedure of choice and enucleation should be performed only if the recurrence occurs or when there is an intraocular invasion.
| Vascular tumors | | |
Of the benign growths, vascular tumors were the commonest (19.6%). These included six cases of cavernous haemangioma and four cases of granuloma pyogenicum. The incidence reported by other workers differs greatly from the present series. Earlier reports give an incidence of 1 % to 2% for haemangiomas[3],[9]
In four cases haemangioma was present since birth while in two cases it was noticed by the patient only when the size of the growth increased following injury.
The bulbar conjunctiva was the commonest site and in 2 cases the lesion was in the upper palpebral conjunctiva. The haemangiomas were dark red in color with smooth surface, in one case the surface was irregular and friable and the patient gave history of recurrent bleeding i.e. occasional blood tears. The clinical appearance of these patients was so typical that the diagnosis was not difficult, which was further confirmed by histopathology.
The four cases of granuloma pyogenicum had small flat pea sized swellings with smooth surface and well defined margins. The conjunctival smear of these patients showed staphylococcus albus. Histopathology showed chronic inflammatory cells and multiple capillaries filled with R.B.C.
All the cases of haemangiomas were treated by simple excision and diathermy coagulation and the results were good. Granuloma pyogenicum was treated by simple excision.
| Mesenchymal tumors | | |
This group included only inflammatory granulomas (13.73%). There were 5 cases of foreign body granuloma and 2 cases of tubercular granulomas.
These foreign body granulomas may arise from any part of the conjunctiva as a result of inflammatory reaction caused by a retained foreign body. At other times no cause may be found.
In the present study there was history of irritation caused by cosmetic shell, and foreign body in one case each, in the remaining three cases there was history of chronic infection associated with trachomatous scaring.
These neoformations presented as small reddish yellow and granulars masses with well defined margins. Microscopically the lesions showed typical granulomatous inflammatory reaction and Langhan's type of giant cell in the tubercular lesion.
Foreign body granulomas were treated with simple excision, while antitubercular treatment along with subconjunctival streptomycin ¼ gm resulted in complete cure of tubercular granuloma.
| Pigmented tumors | | |
These showed an incidence of 5.88% and included 2 cases of conjunctival naevi and one of oculo-dermal melanosis.
The incidence reported by other workers for conjunctival naevi is very high[6]. Probably because of racial factors. The naevi in both cases were situated near the limbus, which is, its commonest site[15]. These tumors were sharply demarcated and darkly pigmented with no symptoms. Histopathology showed them to be junctional naevi
Simple excision was done for cosmetic reasons.
Oculodermal melanosis is a benign condition usually unilateral. In this series one case involving the conjunctiva, is described, in which pigmented patches were present on the bulbar conjunctiva since birth [Figure - 5].
| Neural tumors | | |
Neurofibroma of bulbar conjunctiva is rare[12]. In this study the incidence is 3.92%.
The lesions-in one case was restricted to the palpebral conjunctiva, in one case it was more extensive and involved the bulbar conjunctiva and lower fornix. The general appearance was that of a gelatinous firm mass with irregular surface and ill defined margins. The provisional diagnosis was doubtful and only confirmed after histopathology, which showed haphazardly arranged nerve fibre bundles traversing through the nerve tissue.
The treatment was simple excision.
| Miscellaneous | | |
This group included 3 cases of amyloid degeneration of the conjunctiva (5.8%). There were 3 cases affecting 2 males and 1 female between the age of thirty and fifty years. Fuchs reported that the disease affected middle aged persons.
The lesion was unilateral in two cases and bilateral in one case. In one unilateral case there was history of trauma and the duration was short. In the other two cases there was associated trachomatous scaring.
Clinically the growths presented as friable, gelatinous masses of reddish white color. This led to the provisional diagnosis of amyloidosis. Special staining of histopathological section with stains like P.A.S., V.G. and crystal violet confirmed the diagnosis in all cases.
The treatment was by piece meal removal of the growth.
| Conclusion and summary | | |
A clinicopathological examination of 51 cases of primary conjunctival tumors has been carried out. The maximum incidence of conjunctival neoformations was observed in the second decade.
Males are predominantly affected. The benign tumors are more frequent (74.50%) than malignant tumors (25.50%). Vascular new growths were the commonest benign tumors closely followed by dermoids and chronic granulomas.
Amongst the malignant tumors, squamous cell carcinomas were the commonest (25.50%).
A note on the management of these cusses has been added.[16]
| References | | |
| 1. | Ash, J.E. 1950, Amer J, Ophthalmol., 33:1203.  |
| 2. | Ash, J.E. and Wilder, W.C., 1942, Amer, J, Ophthalmol , 25:926. |
| 3. | Norn, M.S., 1959, Acta Ophthalmol. Kbh. 37:172. |
| 4. | Kornerup, T., 1949, Acta Ophthalmol., 27:483. |
| 5. | Elsas, F.J. Green, W.R., 1975, Amer. J. Ophthalmol., 79:1001. |
| 6. | Hogan, M.J. and Zimmerman, L.E., 1962. An Atlas and Textbook of Ophthalmic Pathology, 2nd ed., W.B. Saunders Company, Philadelphia, London, Pp. 227. |
| 7. | Gogi, R., Nath, K, & Govil, A.K. : 1977. Ind. J. Ophthalmol., 24 (IV) : 1. |
| 8. | Sheta, A., 1972, Ophtha. Dep. Fac. Univ. Alexandria, Bull. Ophth. soc., Egypt, 65:1972. |
| 9. | Maria, D.L. & Shukla, S. P. 1965, J. All India Ophthalmol. Soc., 131:68. |
| 10. | Maria, D.L., Kale, M.D. & Patel, S.D., 1971, Orient. Arch. Ophthalmol 9:164, |
| 11. | Duke-Elder, Sir Stewart 1965, System of Ophthalmology Vol. 8, Henry Kimpton, London. Pp. 1165, 1210, 1239. |
| 12. | Chandra, P., Ahluwalia, B.K., Parmar, I.P.S., Singh, I., & Yadav, M.S., 1975, East. Arch. Ophthalmol.,3:87. |
| 13. | Aftab, M. & Percival, S.P.B. 1973, Brit, J. Ophthalmol. 57, 836. |
| 14. | Apte, P.V. , Talib, V.H., Patil, S.D. 1975, Ind. J. Ophthalmol. 23 (3), 33. |
| 15. | McGavic, J.S., 1943, Arch. Ophthalmol. (Chic.)., 30:179. |
| 16. | Fuchs, A., 1961, Klin. Mbl. Augenheilk., 138: 566. |
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7]
[Table - 1], [Table - 2], [Table - 3], [Table - 4]
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