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| CASE REPORT |
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| Year : 2023 | Volume
: 3
| Issue : 1 | Page : 6-8 |
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Mendacious conjunctival lesions – A tale of two cases
Deepak K Sharma1, Gaurav Sharma2, Rajeev Tuli2
1 Department of Ophthalmology, Shri Lal Bahadur Shastri Govt. Medical College, Ner Chowk, Himachal Pradesh, India
2 Department of Ophthalmology, Dr. Rajendra Prasad Govt. Medical College, Tanda, Himachal Pradesh, India
| Date of Submission | 03-Aug-2022 |
| Date of Acceptance | 11-Oct-2022 |
| Date of Web Publication | 20-Jan-2023 |
Correspondence Address:
Deepak K Sharma
Department of Ophthalmology, Shri Lal Bahadur Shastri Govt. Medical College, Mandi, Ner Chowk - 175 021, Himachal Pradesh
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/ijo.IJO_1848_22
Presentation of conjunctival tumors ranges from benign lesions like pinguecula and pterygium to highly malignant tumors of melanocytic, lymphoid, and stratified squamous epithelium origin. A 30-year-old female presented with two brown-colored conjunctival lesions in her left eye extending from medial canthus to limbus. Lesions were excised and subjected to histopathologic examination (HPE), which came out to be pigmented squamous cell papilloma, a rare conjunctival lesion having potential to convert to malignancy. Another 50-year-old female presented with pinguicula-like lesions in both her eyes along with maculopapular rash on her forehead. Conjunctival lesions were completely excised HPE, revealed Spiegler–Fendt sarcoid, also known as lymphocytoma cutis, along with conjunctival tumor of lymphocytic origin. Spiegler–Fendt sarcoid is usually a benign lesion with potential for systemic involvement requiring holistic approach for the management of such patients.
Keywords: Dysplasia, lymphocytoma cutis, lymphoid hyperplasia, squamous cell papilloma
How to cite this article:
Sharma DK, Sharma G, Tuli R. Mendacious conjunctival lesions – A tale of two cases. Indian J Ophthalmol Case Rep 2023;3:6-8 |
Conjunctival lesions range from benign non-neoplastic tumors like pinguecula and pterygium to very aggressive malignant neoplasms. Mainly, these lesions have been categorized as tumors of stratified squamous epithelium, melanocytic tumors, lymphoid tumors, and Kaposi's sarcoma.[1] All these lesions require excision and histopathologic examination (HPE) for proper management.[1] Meticulous history and clinical and HPE, along with regular follow-up are mandatory for such patients. Here, we present two cases of conjunctival lesions with varied presentation.
| Case Reports | |  |
Case 1
A 30-year-old female patient reported with the history of two brown-colored lesions in her left eye for last 2 years [Figure 1]a and [Figure 1]b. These lesions were painless and gradually increasing in size. Visual acuity was 6/6 in both eyes. Slit-lamp examination revealed brown pigmented lesion extending from medial canthus to the nasal margin of the cornea with a pigmented infiltration of cornea for about 1 mm from 7 o' clock to 10 o' clock position. The margins were ill defined and firm in consistency with tortuous vessels. Another lesion, measuring 5.4 × 4 mm, circular in shape, and brown in color with irregular margins was present on the superonasal aspect of bulbar conjunctiva. The inferolateral margins of the lesion encroached up to 1mm on the cornea from 10 o' clock to 12 o' clock position. It had few corkscrew-shaped blood vessels, and the feeder vessels were engorged. Systemic examination was essentially normal. The lesions were excised fully and could be scraped off easily from the superficial layers of the cornea. Specimens obtained were sent for HPE. The histopathologic sections showed superficial fragments of hyperplasic stratified squamous epithelium with severe dysplasia at places [Figure 1]c. Melanin pigment was present extracellularly and desmosomes were still intact, suggesting the diagnosis of squamous cell papilloma [Figure 1]d. | Figure 1: (a) Pigmented lesion in the left eye. (b) Pigmented lesion with engorged feeder vessels. (c) Superficial fragments of hyperplasic stratified squamous epithelium with severe dysplasia at places. (d) Extracellular presence of melanin pigment
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Case 2
A 50-year-old female patient reported with redness, foreign body sensation, and fleshy growth in both her eyes (left eye > right eye) for last 4 years. Ocular examination revealed pink-colored elevation of the nasal conjunctiva, not encroaching upon the cornea and not adherent to the underlying sclera [Figure 2]a. Further examination revealed maculopapular lesions on her forehead [Figure 2]b, and the remaining systemic examination was unremarkable. In the first sitting, excision of conjunctival lesion of the right eye followed by HPE was performed. Once diagnosis was established on HPE, complete excision of conjunctival lesion of the left eye was done. Sections examined showed unremarkable epithelium and well-demarcated patches of lymphocytes separated from each other by fibrous septae in the deeper layers. Sections also showed dense lymphoid cell population with germinal follicles in the subepithelial region, hence suggestive of diagnosis of lymphocytoma cutis, also known as Spiegler–Fendt sarcoid [Figure 2]c. Skin biopsy of the patient showed features similar to those of conjunctival lesions consistent with lymphocytoma cutis [Figure 2]d. So, lesion looking like pinguecula turned out to be conjunctival tumor of lymphocytic origin. | Figure 2: (a) Conjunctival lesion of the left eye. (b) Maculopapular rash on forehead. (c) Unremarkable epithelium with well-demarcated patches of lymphocytes separated from each other by fibrous septae in the deeper layers. Also showing dense lymphoid cell population with germinal follicles in the subepithelial region. (d) Skin biopsy showing unremarkable epidermis and well-demarcated patches of lymphocytes separated from each other by fibrous septae in the reticular dermis with infiltrate extending to the subcutis
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| Discussion | | |
Papilloma of conjunctiva is a cauliflower-like growth which may have limbal, forniceal, or medial canthal involvement. Different types of papillomas like squamous cell papilloma, viral papilloma, limbal and inverted papillomas have been noticed. Pigmentation of the papilloma is not found usually. Melanin ingestion by the cells of malignant and benign lesions of the lid surface leads to their pigmentary changes. Association of pigmented epithelial tumors with racial melanosis of conjunctiva is usual. Surface ulceration of squamous cell carcinoma may cause hemorrhage, leading to black discoloration of the tumor.[2] Papillomas of conjunctiva on the basis of origin may be either neoplastic or viral. Histologically, both are nonpigmented. Tumor cells containing melanin pigment in papilloma has been a rare finding.[1],[2] Presentation of the pigmented squamous papilloma in our case was in the form of pigmented growth extending from medial canthus to limbus, covering the cornea. Since such lesions are not cosmetically good, they can impair vision if they cover the central cornea and have got the potential to convert to malignancy. Therefore, complete excision along with HPE of the lesion is the treatment of choice, and such patients should be kept on regular follow-up to monitor recurrence.
Lymphocytoma cutis, also called Spiegler–Fendt sarcoid, is a type of pseudolymphoma which is represented by benign reactive hyperplasia of preexisting pleuripotential lymphoid elements to unidentified antigen.[3] It includes various clinical entities showing predominantly lymphocytic infiltrates without malignant potential. Lymphocytoma cutis–favored sites are face, chest, and upper extremities. Exposed areas are more commonly involved in the form of solitary nodules of varied sizes.[3]
Two clinical forms have been noticed, which are localized in 72% of cases and generalized in 28% of cases. Conjunctival tumors of lymphocytic or hematopoietic origin are benign reactive lymphoid hyperplasia, malignant lymphoma, and plasmacytoma.[1]
Lymphoid tumors of the conjunctiva may be benign, malignant, or indeterminate. Many of these lesions have overlapping clinical and pathologic features. About 20% of patients with a conjunctival lymphoid tumor have detectable extraocular lymphoma.[4]
Most of the patients are older than 40 years, although, in rare instances, extranodal lymphoid hyperplasia has occurred in children. This mass presents as a minimally elevated, salmon-colored subepithelial tumor with a pebbly appearance corresponding to follicle formation.[1] It is clinically indistinguishable from conjunctival lymphoma and is often moderately or highly vascularized. Primary localized amyloidosis can have similar appearance.[5] Lymphoid hyperplasia may resolve spontaneously. Local use of corticosteroids,[6] radiotherapy, and excision of the lesion have been tried successfully. Patients with benign polyclonal lymphoid lesion can have systemic manifestation, so medical consultation should be sought.
| Conclusion | | |
Clinical appearance of the conjunctival lesions can be deceptive. A malignant-looking lesion may turn out to be benign and vice versa. Meticulous history along with complete ocular examination and biopsy should always be done to confirm histopathologic diagnosis.
Acknowledgements
Dr. Balchandra, Department of Pathology, Dr. Rajendra Prasad Govt Medical College Kangra at Tanda is acknowledged.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | James JA, Zeila MC. Tumors of conjunctiva and cornea. In: Myron Yanoff, Jay S Duker, editors. Ophthalmology 3 rd ed. Mosby Elsevier Inc; 2009. London,U.K. p. 241-6.  |
| 2. | Kremer I, Sandbank J, Weinberger D, Aryeh R, Shapiro A. Pigmented epithelial tumours of conjunctiva. Br J Ophthalmol 1992;76:294-6. |
| 3. | Gangopadhyay DN, Dey SK, Barbhuiya JN. Lymphocytoma cutis. Ind J Dermatol 1999;44;149-50. |
| 4. | Coupland SE, Krause L, Delecluse HJ, Anagnostopoulos I, Foss HD, Hummel M, et al. Lymphoproliferative lesions of the ocular adenexa. Analysis of 112 cases. Ophthalmology 1998;105:1430-41. |
| 5. | Jason L, Vassilios AD, Lady CD, Clarence WB. Conjunctival papilloma. Cutis 2012;89:38-40. |
| 6. | Moraes BRM, Nascimento MVDD, Neto EDDS, Santo RM. Topical steroids eye drops in conjunctival lymphoid hyperplasia. Medicine 2017;96:e8656. |
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