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American Journal of Ophthalmology Case Reports 10 (2018) 122–123

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Possible dissemination of conjunctival melanoma along tear flow path T

a,∗ b
Toshinobu Kubota , Tomonori Kawasaki
Department of Ophthalmology, National Hospital Organization, Nagoya Medical Center, Japan
Department of Pathology, National Hospital Organization, Nagoya Medical Center, Japan


Tear flow

1. Case report 3. Conclusion

A 60-year-old woman presented with conjunctival melanoma Ophthalmologists should be aware that conjunctival melanoma may
arising from pigmented primary acquired melanosis (PAM) located in have a dissemination pattern along the tear flow path.
the temporal upper bulbar conjunctiva of her right eye. The tumor had
a diameter of 16 mm and height of 11 mm (Fig. 1A and Fig. 2A). Author conflicts of interest
Magnetic resonance imaging did not reveal tumor growth in the la-
crimal sac (Fig. 2B) and pigmented PAM was not detected in other areas None.
of the conjunctiva. Complete tumor resection was performed using the
no-touch technique.1 At 34 months after the initial visit, conjunctival Authorship
melanoma dissemination was observed in the lower bulbar conjunctiva
(Fig. 1B), and was resected in the same manner. At 66 months after the All authors attest that they meet the current ICMJE Criteria for
initial visit, melanoma involvement was observed in the lacrimal sac Authorship.
(Fig. 1C and Fig. 2C), and was treated using proton beam radiotherapy.
Histological examination of the lesions from the conjunctiva lacrimal Funding
sac revealed that both showed the same cytological and im-
munohistochemical features (Fig. 3). None.

2. Discussion Patient consent

Conjunctival melanomas occasionally exhibit recurrences in the Written consent to publish was obtained from the patient.
lacrimal drainage.2 However, typically several conjunctival recurrences
occur first, and nasolacrimal recurrences appear at a median of five or Acknowledgements
six years after initial treatments,2,3 along with recurrences at the nasal
passage terminus.4 Most cancers have hematogenous and lymphatic None.
dissemination patterns, and the lacrimal sac melanoma may have de-
veloped within the PAM. However, melanoma cells have been detected Appendix A. Supplementary data
in tears in patients with conjunctival melanoma,5 and thus it is possible
that conjunctival melanoma may have another dissemination pattern Supplementary data related to this article can be found at http://dx.
along tear flow path.

Corresponding author. Department of Ophthalmology, National Hospital Organization, Nagoya Medical Center, 4-1-1, Sannomaru, Naka-ku, Nagoya-shi, Aichi-ken, 460-0001, Japan.
E-mail address: (T. Kubota).
Received 26 December 2017; Received in revised form 14 February 2018; Accepted 22 February 2018
Available online 23 February 2018
2451-9936/ © 2018 Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (
T. Kubota, T. Kawasaki American Journal of Ophthalmology Case Reports 10 (2018) 122–123

Fig. 1. Conjunctival melanoma was detected at the upper temporal forniceal conjunctiva at the patient's initial visit (A), at the lower temporal epibulbar conjunctiva approximately 3
years after the initial visit (B), and in the lacrimal sac approximately 5 years after the initial visit (C).

Fig. 2. Magnetic resonance images at the patient's initial visit, showing a mass lesion at the upper temporal forniceal conjunctiva (A), but no visible lesion in the lacrimal sac (B).
Computed tomography image showing a mass lesion in the lacrimal sac at approximately 5 years after the initial visit (C).

Fig. 3. Histological examination revealing that the tumor cells comprise epithelioid and plump spindle cells (A, hematoxylin-eosin staining; original magnification, 200 × ).
Immunostaining reveals that tumor cells are positive for HMB-45 (B) and S100 (C). Original magnification 400 × .

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