- Email: [email protected]
October consultation #6
CONSULTATION SECTION: CORNEA
8. Chang S-W, Huang Z-L. Oral cimetidine adjuvant therapy for recalcitrant, diffuse conjunctival papillomatosis. Cornea 2006; 25:687–690 9. Yuen HKL, Yeung EFY, Chan NR, Chi SCC, Lam DSC. The use of postoperative topical mitomycin C in the treatment of recurrent conjunctival papilloma. Cornea 2002; 21:838–839
2.
3.
- The pinkish, pedunculated grape-like lesion is consistent with conjunctival papilloma. Other considerations include conjunctival intraepithelial neoplasia (CIN) and squamous cell carcinoma. Among these, the lesion is most likely to be papilloma because of its appearance and lack of leukoplakia and because papilloma is one of the most common lesions of the caruncle.1,2 However, this patient's lesion is rapidly growing and gelatinous; therefore, neoplasia should be ruled out. These lesions can be caused by HPV.3 A definitive diagnosis could be made with excisional biopsy or, alternatively, impression cytology. I suggest excisional biopsy with a couple millimeters of margins around the lesion. Subsequently, I would excise slivers from each margin and send them for histopathology examination independently to determine whether they are negative. I would also perform cryotherapy at each margin. Extra care should be taken during excision to preserve the caruncle and its adjacent structures because the lesion is close to the caruncle. I typically do not suggest postoperative medical treatment unless the margin is positive. If so, I suggest further excision or IFNa2b. Topical IFNa2b has been used successfully in the treatment of recalcitrant cases.4,5 I would consider HIV testing in young adult patients with these kinds of lesions. If the margins are clear, the prognosis is quite good; however, I would continue to frequently observe this patient for possible recurrence. This is because up to 25% of conjunctival papillomas can recur after excision.6 Similarly, CIN lesions excised with negative surgical margins might recur. Natalie Afshari, MD San Diego, California, USA
4.
5.
6.
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Eye 2009; 23:1004–1018. Available at: http://www.nature.com/ eye/journal/v23/n5/pdf/eye2008316a.pdf. Accessed August 19, 2016 Shields CL, Shields JA, White D, Augsburger JJ. Types and frequency of lesions of the caruncle. Am J Ophthalmol 1986; 102:771–778 € NC, Heergaard S, Prause JU, von Buchwald C, Lindeberg H. Sjo Human papillomavirus in conjunctival papilloma. Br J Ophthalmol 2001; 85:785–787. Available at: http://www.ncbi.nlm.nih. gov/pmc/articles/PMC1724043/pdf/v085p00785.pdf. Accessed August 19, 2016 Vann RR, Karp CL. Perilesional and topical interferon alfa-2b for conjunctival and corneal neoplasia. Ophthalmology 1999; 106:91–97 de Keizer RJW, de Wolff-Rouendaal D. Topical a-interferon in recurrent conjunctival papilloma. Acta Ophthalmol Scand 2003; 81:193–196. Available at: http://onlinelibrary.wiley.com/ doi/10.1034/j.1600-0420.2003.00043.x/pdf. Accessed August 19, 2016 € NC, Heegaard S, Prause JU. Conjunctival papilloma; a hisSjo topathologically based retrospective study. Acta Ophthalmol Scand 2000; 78:663–666. Available at: http://onlinelibrary.wi ley.com/doi/10.1034/j.1600-0420.2000.078006663.x/pdf. Accessed August 16, 2016
EDITOR’S COMMENT The patient had a surgical excision of the caruncular lesion with double freeze–thaw cryotherapy of the base of the lesion with the adjacent 2.0 mm conjunctiva. The pathologic examination confirmed the diagnosis of squamous caruncular papilloma. Because of the high risk for recurrence, the patient was treated with IFNa2b (1 million IU/mL) 3 times per day for 3 months postoperatively. The blood work was negative for HIV. Six months after the excision, the patient remains asymptomatic without recurrence of the lesion. Dermatologic consultation did not find any other papillomatous lesion involving the patient's face or extremities. The results of a nasopharyngeal examination by otolaryngologist were also completely normal. The patient is scheduled for a follow-up visit at our institution in 6 months. Majid Moshirfar, MD Salt Lake City, Utah, USA
REFERENCES 1. Levy J, Ilsar M, Deckel Y, Maly A, Pe’er J. Lesions of the caruncle: a description of 42 cases and a review of the literature.
J CATARACT REFRACT SURG - VOL 42, OCTOBER 2016
8. Chang S-W, Huang Z-L. Oral cimetidine adjuvant therapy for recalcitrant, diffuse conjunctival papillomatosis. Cornea 2006; 25:687–690 9. Yuen HKL, Yeung EFY, Chan NR, Chi SCC, Lam DSC. The use of postoperative topical mitomycin C in the treatment of recurrent conjunctival papilloma. Cornea 2002; 21:838–839
2.
3.
- The pinkish, pedunculated grape-like lesion is consistent with conjunctival papilloma. Other considerations include conjunctival intraepithelial neoplasia (CIN) and squamous cell carcinoma. Among these, the lesion is most likely to be papilloma because of its appearance and lack of leukoplakia and because papilloma is one of the most common lesions of the caruncle.1,2 However, this patient's lesion is rapidly growing and gelatinous; therefore, neoplasia should be ruled out. These lesions can be caused by HPV.3 A definitive diagnosis could be made with excisional biopsy or, alternatively, impression cytology. I suggest excisional biopsy with a couple millimeters of margins around the lesion. Subsequently, I would excise slivers from each margin and send them for histopathology examination independently to determine whether they are negative. I would also perform cryotherapy at each margin. Extra care should be taken during excision to preserve the caruncle and its adjacent structures because the lesion is close to the caruncle. I typically do not suggest postoperative medical treatment unless the margin is positive. If so, I suggest further excision or IFNa2b. Topical IFNa2b has been used successfully in the treatment of recalcitrant cases.4,5 I would consider HIV testing in young adult patients with these kinds of lesions. If the margins are clear, the prognosis is quite good; however, I would continue to frequently observe this patient for possible recurrence. This is because up to 25% of conjunctival papillomas can recur after excision.6 Similarly, CIN lesions excised with negative surgical margins might recur. Natalie Afshari, MD San Diego, California, USA
4.
5.
6.
1539
Eye 2009; 23:1004–1018. Available at: http://www.nature.com/ eye/journal/v23/n5/pdf/eye2008316a.pdf. Accessed August 19, 2016 Shields CL, Shields JA, White D, Augsburger JJ. Types and frequency of lesions of the caruncle. Am J Ophthalmol 1986; 102:771–778 € NC, Heergaard S, Prause JU, von Buchwald C, Lindeberg H. Sjo Human papillomavirus in conjunctival papilloma. Br J Ophthalmol 2001; 85:785–787. Available at: http://www.ncbi.nlm.nih. gov/pmc/articles/PMC1724043/pdf/v085p00785.pdf. Accessed August 19, 2016 Vann RR, Karp CL. Perilesional and topical interferon alfa-2b for conjunctival and corneal neoplasia. Ophthalmology 1999; 106:91–97 de Keizer RJW, de Wolff-Rouendaal D. Topical a-interferon in recurrent conjunctival papilloma. Acta Ophthalmol Scand 2003; 81:193–196. Available at: http://onlinelibrary.wiley.com/ doi/10.1034/j.1600-0420.2003.00043.x/pdf. Accessed August 19, 2016 € NC, Heegaard S, Prause JU. Conjunctival papilloma; a hisSjo topathologically based retrospective study. Acta Ophthalmol Scand 2000; 78:663–666. Available at: http://onlinelibrary.wi ley.com/doi/10.1034/j.1600-0420.2000.078006663.x/pdf. Accessed August 16, 2016
EDITOR’S COMMENT The patient had a surgical excision of the caruncular lesion with double freeze–thaw cryotherapy of the base of the lesion with the adjacent 2.0 mm conjunctiva. The pathologic examination confirmed the diagnosis of squamous caruncular papilloma. Because of the high risk for recurrence, the patient was treated with IFNa2b (1 million IU/mL) 3 times per day for 3 months postoperatively. The blood work was negative for HIV. Six months after the excision, the patient remains asymptomatic without recurrence of the lesion. Dermatologic consultation did not find any other papillomatous lesion involving the patient's face or extremities. The results of a nasopharyngeal examination by otolaryngologist were also completely normal. The patient is scheduled for a follow-up visit at our institution in 6 months. Majid Moshirfar, MD Salt Lake City, Utah, USA
REFERENCES 1. Levy J, Ilsar M, Deckel Y, Maly A, Pe’er J. Lesions of the caruncle: a description of 42 cases and a review of the literature.
J CATARACT REFRACT SURG - VOL 42, OCTOBER 2016