University of Gondar

CMHS
Department of Optometry
Advanced clinical practice I seminar presentation
Ocular Surface Tumours.
Prepared by:Abebizuhan.Z (Msc in clinical optometry 1 st year student)

Moderaters:1.Dr Wossen Mulugeta (MD, Assistant Prof of

ophthalmology, Cataract ,cornea and external eye disease specialist )
2. Getasew Alemu (BSc,Msc in clinical optometrist)

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 Objectives
At the end of this presentation, we students able to:
 Differentiate ocular surface tumours
 List the classification of ocular surface tumours
 Identify the clinical feature of ocular surface tumours
 Describe diagnostic and investigational tools of ocular
surface tumours
 Identify and manage different ocular surface tumours

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 Tumours of conjunctiva and cornea
 Congenital
 Acquired

 Origin of Tumours
 Epithelial Tumours
 Stromal Tumours
 Caruncular Tumours
 Secondary Tumours

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 classification
 Epithelial Tumours
 Non-melanocytic
 Melanocytic Tumors
 VASCULAR TUMORS
 METASTATIC TUMORS
 SECONDARY CONJUNCTIVAL INVOLVEMENT
FROM ADJACENT TUMORS
 CARUNCULAR TUMORS AND CYSTS

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 Epithelial Tumours (Non-melanocytic)

Congenital tumors
Choristomas:
 Dermoid and
 Lipodermoid.
BENIGN TUMORS
Papilloma
 Epithelial Inclusion Cyst
Keratotic Plaque
Actinic Keratosis
Malignant Tumours
 Ocular surface squamus neoplasia(OSSN)
Conjunctival Intraepithelial Neoplasia (CIN)
Invasive Squamous Cell Carcinoma

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 CONGENITAL TUMORS
Dermoid
 Conjunctiva dermoids is a congenital well-circumscribed
yellow-white ,smooth, elevated, solid mass.
 It involves the bulbar conjunctiva or the corneoscleral limbus.
 It characteristically occurs near the limbus inferotemporally.
 Mostly it has fine white hairs.

Limbal dermoid Large central corneal dermoid

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 Management
simple observation
 Small lesion
 visually asymptomatic
Lamellar keratoplasty
 Larger lesion or
 Visulal symptomatic dermoids can produce visual loss
from astigmatism
 Lamellar keratoplasty or penetrating keratoplasty
 When lesion involves the central cornea

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 Lipodermoid
 It is believed to be congenital and present at birth.
 A dermolipoma is a pale yellow dermoid containing adipose
tissue that should be distinguished from herniation of orbital fat
 It typically remains asymptomatic for years.
 It typically occurs superotemporally.
 lipodermoid is softer and yellower than a dermoid bcs of its
adipose tissue component.

Dermolipoma in superotemporal
conjunctival fornix direct temporal fornix

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 Managment
Most Lipodermoid mass require no treatment.
Larger symptomatic ones or those that are
cosmetically unappealing can be managed by
excision.

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 Papilloma

  Papilloma is a histopathological term describing tumors with

specific morphology.
 The histopathology shows a vascularized papillary fronds

lined by acanthotic epithelium with almost no keratinization

 Papillomas can be benign or malignant and can be found in

numerous anatomical locations .

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 Conti……….
 Conjunctival papillomas are benign squamous epithelial

tumors with minimal malignancy.

 Papillomatous lesions often are lobulated with a central

vascular core.
 Tumor can occur in both children and adults.

 Papilloma appears as a pink fibrovascular frond of tissue

arranged in a sessile or pedunculated configuration

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 Conti……..
 Pedunculated or Squamous cell papillomas are composed
of multiple branching fronds emanating from a narrow
pedunculated base.It is a fleshy, exophytic growth with a
fibrovascular core

A.Pedunculated.
 Sessile or Limbal papillomas are sessile lesions arising
from a broad base with a gelatinous appearance.
Corkscrew vascular loops and feeder vessels are seen.

B.Sessile
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 Clinical signs associated with squamous cell
papilloma
 This lesion is benign and self-limiting.

 It is seen commonly in children and young adults.

 Most lesions are asymptomatic without associated

conjunctivitis or folliculitis.
 Anatomically, it commonly is located in the inferior fornix

 The lesion may be bilateral and multiple.

 Grossly, squamous cell papilloma appears as a grayish red,

fleshy, soft, pedunculated mass with an irregular surface

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 Clinical signs associated with limbal papilloma 

This lesion is typically benign.

It is seen commonly in older adults.
Anatomically, the lesion commonly occurs at the
limbus or the bulbar conjunctiva.
These lesions may spread centrally toward the cornea.
Visual acuity may be affected if the lesion grows
centrally.
These lesions almost always are unilateral and single.
They tend to have variable proliferation potential with
a tendency to slowly enlarge in size.

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 Conjunctiva papilloma types

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 DDX OF PAPILLOMA
Sebaceous Gland Carcinoma
Conjunctival Squamous Cell Carcinoma.
Management of papilloma
Surgical excision with supplementary cryotherapy(Adults)
Cryotherapy:
Alternative therapy:
 Alpha-interferon
 Topical mitomycin chemotherapy 0.02% and
 Dinitrochlorobenzene immunotherapy
 Co2 Laser treatment
 oral cimetidine

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 Epithelial Inclusion Cyst

 Conjunctival inclusion cysts typically appear clear and most

commonly occur in either the bulbar conjunctiva or the
conjunctival fornix
 Conjunctival cysts can occur spontaneously or following
inflammation, surgery, or nonsurgical trauma results in
conjunctival overgrowth onto the surface of the cornea.
 cysts of conjunctival epithelium can be
 Congenital
 Acquired.

Clear epibulbar inclusion cyst

 Epithelial Inclusion cysts can be simply observed or they can
be excised completely with primary closure of the conjunctiva

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 Malignant Lesions of Surface Epithelium
Ocular surface squamous neoplasia(OSSN)
 Ocular surface squamous neoplasia (OSSN) is the most
common non-pigmented malignancy of the cornea and
conjunctiva.
 It represents a group of disease including :
 Dysplasia
 Corneal and conjunctival intraepithelial neoplasia and
 Squamous cell carcinoma.

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 Risk factors for OSSN
 Ultraviolet light (UV) exposure

 Human papilloma virus infection(HPV 16 and 18)

 HIV infection

 Hereditary deficiency of DNA repair

 Immunosuppression

 Older age and smoking.

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 Clinical feature of OSSN

 Epithelial thickening
 Lesion may extend onto the peripheral cornea
 ‘Corkscrew" vascular pattern may be a prominent.
 Surface may appear gelatinous or leukoplakic, indicative of
surface keratinization.
 Surface keratinization is not pathognomonic for OSSN.
Ocular surface squamous
neoplasia (aSSN)

Clinical appearance: note the

"corkscrew" vascular pattern of the
conjunctival portion and
leukoplakia of the corneal portion.
Also note feeder vessels
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 Conti……..
Histology of OSSN
 Epithelium exhibits hyperplasia
 Loss of goblet cells
 Loss of normal cell polarity
 Nuclear hyperchromasia and pleomorphism.
 Mitotic figures
 Dyskeratosis may be seen
 A chronic inflammatory response is often present in the substantia
propria.

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 Differential Diagnosis of OSSN
 Actinic keratosis
 Bitot spots (xerophthalmia)
 Pterygium
 Pinguecula
 Pyogenic granuloma
Conjucntival/ limbal cyst
Conjunctival Hemagioma
• Malignant melanoma

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 Diagnostic tests for OSSN
Rose Bengal staining
Exfoliative and Impression Cytology.
Histopathology-Gold standard diagnostic test
Anterior Segment -Optical Coherence
Tomography (AS-OCT)
Ultrasonic biomicroscopy and Confocal
Microscopy

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 Management of OSSN
 Surgical management of OSSN
 Excisional biopsy with 3-4 mm margins and
 cryotherapy to the edges of excision.
 Medical management of OSSN
Topical chemotherapy includes:
 Interferon (IFN) alfa -2b(topically or subconjunctival injection)
 5-f1uorouracil (5 -FU)
 Mitomycine C (MMC)
 Cidofovir

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 Conjunctival Intraepithelial Neoplasia (CIN)

 The conjunctival intraepithelial neoplasia is a squamous

neoplasia confined to the conjunctival epithelium that

sometimes transgresses the basement membrane.
 The human papilloma virus (HPV) and sunlight are considered

to be the main predisposing factors.

 CIN is more common in elderly and immunosuppressed

patients with fair skin and considerable sunlight exposure.

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 Conti………

CIN appears as a fleshy, sessile.It is minimally elevated

lesion
It is less commonly in the forniceal or palpebral conjunctiva
CIN is usually found at the limbus in the interpalpebral
zone..
Mild CIN: Partial replacement of the surface epithelium by
abnormal epithelial cells that do not have normal maturation.
 Severe CIN: Total replacement of epithelium by abnormal
epithelial cells with no maturation.

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 Conti…….
There are 3 principal clinical variants of CIN
1. papilliform, in which a sessile papilloma
harbors dysplastic cells
 2. gelatinous, as a result of acanthosis and
dysplasia
3. leukoplakic, caused by hyperkeratosis,
parakeratosis, and dyskeratosis

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 Conti……..
.

Conjunctival intraepithelial neoplasia:

A, Papilliform. B, Gelatinous.
C, Leukoplakic.

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 Conjunctival invasive squamous cell carcinoma

It occurs when CIN breaks the basement membrane of the

conjunctival epithelium and invades the stroma and underlying

tissues.
The incidence varies from 0.02 to 3.5 per 100,000.

 Its frequency is 60% of all conjunctival malignant epithelial

tumors and 7% of all the conjunctival neoplasms.

It is more common in men (75%) and elderly patients (75%>60

years old).
 Most commonly it begins at the limbus (75%).
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 Clinical features
 It occurs frequently in the interpalpebral region of Caucasian

elderly or immunosuppresed patients.

 Lesion can be a sessile, gelatinous, circumscribed or

papillomatous mass with leukoplakia.

 The lesion is invasive to the local structures (orbit, cornea and

the globe), but with a low range of metastasis (1-2%).

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 Histopathology of Invasive Squamous Cell Carcinoma
 mitotic activity and
 keratinic production
 Some lesions can be poorly differentiated with pleomorphic
cells, giant cells and a lot of mitotic figures with acanthosis
and dyskeratosis.
Diagnosis of Invasive Squamous Cell Carcinoma
 Excisional biopsy: if the lesion is localized and small.
 Impression cytology: If the lesion is diffuse.
 Ultrasound biomicroscopy: to determinate limbal invasion

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 Surgical Treatment for conjunctival intraepithelial
neoplasia and invasive squamous cell carcinoma

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 Medical Treatment for conjunctival intraepithelial
neoplasia and invasive squamous cell carcinoma

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 Epithelial Tumours -Melanocytic Tumors
 Commonest melanocytic tumours.
 Benign Tumours
• Conjunctival Nevus
• Racial melanosis.
• Primary acquired melanosis.
• Ocular melanocytos
• Conjunctival melanocytic
 Malignant Tumours
• Conjuncival melanoma.

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 Conjunctival Nevus
 It is the most common melanocytic tumor of the conjunctiva
 Clinically apparent in the first or second decade of life.
 It is typically located in the interpalpebral bulbar conjunctiva
near the limbus.
 It is discrete variably pigmented, slightly elevated, sessile
lesion that usually contains fine clear cysts.
 Relatively stationary throughout life with less than 1% risk of
malignancy.

Nonpigmented conjunctival Cystic conjunctival

Pigmented conjunctival nevus
nevus nevus
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 Racial melanosis
 Racial melanosis is a relatively common.
 bilateral condition.
 Flat conjunctival pigmentation found in darkly pigmented
individuals.
 Pigment is generally present at the limbus, often for 360°
 It is extremely rare for conjunctival melanoma to arise from
racial melanosis.
 The recommended management is periodic observation.
Racial melanosis found
bilaterally at limbus and
on bulbar conjunctiva in
patient with dark skin
complexion

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 Primary acquired melanosis(PAM)
 PAM is a benign conjunctival pigmented condition that can
give rise to conjunctival melanoma.
 It is acquired in middle age,and appears as diffuse, patchy, flat,
and non cystic.
 Located within the conjunctiva, and appears brown, in color.
 PAM generally is found in fair-skinned individuals as a
unilateral patchy condition.

 Mild PAM Advanced PAM

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 Malignant melanoma
 Malignant melanoma of the conjunctiva most commonly arises
from PAM.
 It is generally a pigmented tan, elevated conjunctival lesion.
 Malignant melanoma can be located on the limbal, bulbar,
forniceal, or palpebral conjunctiva

Pigmented melanoma at temporal

limbus

 Conjunctival melanoma can show both local tumor recurrence and

distant metastasis.

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 Conti………
 DDX OF malignant melanoma
 Naevus,
 Ciliary body melanoma with extraocular extension
 Melanocytoma
 Pigmented conjunctival squamous carcinoma
 Metastasis occurs in 20–30% particularly to regional lymph
nodes, lung, brain and liver
 Mortality rate is up to 19% at 5 years and 30% at 10 years

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 Treatment of malignant melanoma
 Surgical excision
 Radiotherapy
 Cryotherapy
 Surgical excision with mitomycin C

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 Differential diagnosis of pigmented epibulbar lesions

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 VASCULAR TUMORS

 Pyogenic Granuloma
 Kaposi Sarcoma
 Capillary Hemangioma

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 Kaposi sarcoma
 Kaposi sarcoma, a malignant neoplasm of vascular
endothelium, involves the skin and mucous membranes.
 Kaposi sarcoma is a slowly growing tumour
 It is typically found in individuals with AIDS.
clinical features
 A vascular bright red or purplish plaque or nodule is seen .
 Eyelid skin involvement:presents as a purplish nodule
 Orbital involvement:it may produce eyelid and conjunctival
edema
 Conjunctival involvement:presents as a reddish, highly
vascular subconjunctival lesion.

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 Conti………
 Lesions are most often found in the inferior fornix and may
be nodular or diffuse.

Kaposi sarcoma of the conjunctiva.

Treatment
 systemic AIDS therapy should be optimized, with local
radiotherapy, excision and
 local or systemic chemotherapy as additional options

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 METASTATIC TUMORS
 Metastatic tumors rarely occur in the conjunctiva.
 conjunctival metastasis can occur
 From breast carcinoma,
 cutaneous melanoma, and
 other primary tumors
 Metastatic carcinoma appears as one or more fleshy pink
vascularized conjunctival stromal tumors.
 Metastatic melanoma to the conjunctiva usually is pigmented.
 Breast Carcinoma is the most common malignancy to
metastasize to the conjunctiva and may be also from
bronchogenic carcinoma

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 Conti……

Metastatic carcinoma of Metastatic carcinoma of conjunctiva—

conjunctiva—primary site breast primary site bronchus

Treatment: Excisional biopsy to confirm, external beam radiotherapy or

chemotherapy

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 Conti…………
Reference
1.BCSC.Section 8:External eye disease and cornea
2.BCSC.Section 4: Ophthalmic Pathology and Intraocular
Tumors
3.JJ ,KANSKI’S Clinical Ophthalmology A Systematic Approach
9th edition
4.Ocular pathology ,Yanoff 7th edition
5. Tasman W, Jaeger E, Duane’s Clinical Ophthalmology.
6. https://eyewiki.aao.org › 

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 THANK YOU

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