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Purpose: To describe the clinical features of a conjunctival apocrine hidrocystoma that developed 6 decades after a strabismus surgery and review existing literature on apocrine hidrocystomas of the conjunctiva and caruncle., Methods: Case report and review of literature on conjunctival apocrine hidrocystomas., Results: A 71-year-old man with a history of strabismus surgery as a child presented with a cystic lesion on the nasal conjunctiva and caruncle for 1 year. Excision of the lesion showed a unilocular cavity lined by a double layer of cells with the hallmark finding of apical decapitations, confirming a diagnosis of apocrine hidrocystoma. Seven additional cases of conjunctival and caruncular apocrine hidrocystomas were reviewed. All cases presented after 50 year of age. Most cases presented nasally or within the caruncle and had a pigmented appearance. No other reported cases had a history of trauma or surgery. All cases were treated with surgical excision without recurrence., Conclusions: History of strabismus surgery or conjunctival trauma may lead to ectopic deposition of apocrine glands that may contribute to the formation of an apocrine hidrocystoma., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: The aim of this study was to evaluate the clinical and therapeutic outcomes of the cases where we used conjunctival autografts with and without the Tenon fascia for ocular surface reconstruction after conjunctival nevus excision., Methods: This study included 63 eyes of 63 patients who underwent conjunctival nevus excision between January 2013 and December 2020. Although a Tenon-free conjunctival autograft was used in 32 eyes of 32 patients in group 1, a Tenon-containing conjunctival autograft was used in 31 eyes of 31 patients in group 2. The clinical and histopathological characteristics of the nevus, complete graft epithelization, cosmetic outcomes, and postoperative complications were evaluated., Results: Conjunctival autografts were harvested from the contralateral eye in 3 eyes (9.3%) in group 1 and 2 eyes (6.4%) in group 2 ( P = 0.66). Postoperatively, the mean defect size at the harvest site was 5.3 ± 1.4 mm in group 1 and 5.5 ± 1.5 mm in group 2 ( P = 0.47). Graft edema was observed in only 1 case (3.1%) in group 1 and 6 cases (19.3%) in group 2 ( P = 0.04). Although a complete graft epithelization was observed in all eyes in group 1, fluorescein staining was present in 2 eyes (6.4%) in group 2 ( P = 0.14). Cosmetically, retracting and shrinking grafts were absent in group 1, whereas group 2 had in 4 eyes (12.9%) ( P = 0.03). Neither group had conjunctival scarring, symblepharon, eyelid cicatrization, dysmotility, or pannus at the donor site., Conclusions: Ocular surface reconstruction with a Tenon-free conjunctival autograft after conjunctival nevus excision provides excellent cosmetic and functional results without significant complications., Competing Interests: The authors has no funding or conflicts of interest to disclose., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To investigate the clinical features and outcomes for conjunctival melanoma based on patient age., Methods: A retrospective review of patients with conjunctival melanoma managed at a single tertiary referral center from April 18, 1974, to September 9, 2019. Clinical features and outcomes were compared by patient age category at presentation (young ≤45 years, middle-aged 46-69 years, and older ≥70 years), with Kaplan-Meier and Cox proportional hazard analysis [hazard ratio (95% confidence interval)]., Results: There were 629 patients categorized as young in 130 (21%), middle-aged in 278 (44%), and older in 221 (35%). A comparison by age category (young vs. middle-aged vs. older) revealed that older patients had melanoma with greater number of affected quadrants (1.7 vs. 1.8 vs. 2.0, P = 0.001) and clock hours (3.9 vs. 4.2 vs. 5.2, P = 0.001). All patients were treated with surgical excision, with no difference in requirement for additional medical or radiation therapy. By 10-year Kaplan-Meier outcomes, older patients had more frequent visual acuity loss ≥3 lines (11% vs. 28% vs. 64%, P < 0.001) and local tumor recurrence (38% vs. 46% vs. 70%, P < 0.001). Hazard ratio for the oldest age group (age ≥70) revealed a 7.76-fold (3.33-18.09) increased risk for visual acuity loss (P < 0.001), and a 2.08-fold (1.32-3.28) increased risk of local tumor recurrence (P = 0.002). There was no difference by age in risk for enucleation, exenteration, locoregional lymph node involvement, distant systemic metastasis, or death., Conclusions: Older patients with conjunctival melanoma present with more extensive disease and have increased risk for visual acuity loss and local tumor recurrence., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To report a single case of donor-derived conjunctival-limbal melanoma that occurred after a keratolimbal allograft (KLAL)., Methods: Case report and literature review., Results: A 56-year-old white woman with a history of bilateral limbal stem cell deficiency developed a donor-related melanoma after a KLAL. Three months after undergoing an uncomplicated KLAL, the patient presented with hemorrhagic nodules within her conjunctiva and transplanted tissue. Excisional biopsy was performed, and the pathology results revealed melanoma cells. Although the donor of the KLAL had a history of metastatic melanoma, the ocular tissue was in compliance with all eye bank requirements for donation. After discovery of the tumor, the patient's systemic immunosuppression was stopped. Within 1 week, the patient demonstrated a dramatic improvement in the size of the lesion. One month after the initial biopsy, the KLAL tissue was excised, and a pathology report revealed that there were no viable tumor cells on the ocular surface. As the limbal stem cell deficiency recurred, the eye underwent placement of a Boston type 1 keratoprosthesis., Conclusions: We present a case of conjunctival-limbal melanoma after a KLAL from a donor who had a history of metastatic melanoma. In response to this case, the US eye banking guidelines were amended to include stricter parameters for vascularized ocular tissue transplantation.

Purpose: We report a 75-year-old woman with a history of multiple myeloma immunoglobulin D (IgD) variant, who presented with an epibulbar plasmacytoma masquerading as a subconjunctival hemorrhage., Methods: Magnetic resonance imaging of the brain and orbits with and without contrast was obtained and surgical biopsy of the subconjunctival lesion was performed; histopathology confirmed the diagnosis of plasmacytoma., Results: Subconjunctival biopsy revealed a plasma cell neoplasm infiltrate in the episcleral layer. The subconjunctival biopsy stained positive for CD138 and lambda-immunohistochemistry in the majority of plasma cells. Histologic findings were consistent with involvement by known IgD plasma cell myeloma where previous bone marrow biopsy demonstrated myeloma cells which stained monoclonally for IgD-lambda light chains., Conclusions: Although plasma cell neoplasms seldom present with ocular manifestations, it is crucial to recognize that these tumors may be associated with multiple myeloma. In patients with known multiple myeloma who present with subconjunctival hemorrhage, close follow-up is highly recommended, as this may be the initial presentation of an ocular plasmacytoma. Although a plasmacytoma is a rare subconjunctival lesion, it should not be immediately excluded from the differential diagnosis of such lesions.

Purpose: To compare treatment strategies for ocular surface squamous neoplasia (OSSN), ranging from surgical excision to empiric topical interferon alpha-2b (IFN-α2b)., Methods: A decision model was constructed to determine which of 4 treatment strategies minimized expected persistence/recurrence of disease in patients with OSSN: excision followed by repeat excision for positive surgical margins, excision followed by IFN-α2b for positive margins, incisional biopsy followed by IFN-α2b for positive biopsies, and empiric treatment with IFN-α2b. Probabilities were estimated from literature published between 1983 and 2015. Expected values for the probability of recurrence could range from 0 (no persistence/recurrence) to 1 (persistence/recurrence). Sensitivity analyses were performed for each variable., Results: Excision followed by IFN-α2b for positive margins was estimated to minimize persistence/recurrence of OSSN (expected value 0.13 versus 0.17 for empiric IFN-α2b, 0.22 for excision-only, and 0.30 for incisional biopsy-directed IFN-α2b). The optimal strategy was sensitive to 3 variables: efficacy of IFN-α2b, recurrence after negative surgical margins, and accuracy of excisional biopsy., Conclusions: In our decision analysis using studies published between 1983 and 2015, surgical excision followed by IFN-α2b for positive margins is the favored strategy for minimizing persistence/recurrence of OSSN. Future prospective studies would add to the certainty of these conclusions.

Purpose: Cryopreserved ultra-thick human amniotic membrane (AM) is used for glaucoma surgery. We evaluated the use of cryopreserved ultra-thick human AM for conjunctival surface reconstruction after excision of a conjunctival tumor., Methods: We retrospectively reviewed the medical records of 28 patients who underwent conjunctival surface reconstruction with cryopreserved ultra-thick human AM after excision of the tumor. The AM was secured to the surrounding conjunctiva and underlying sclera with interrupted 8-0 Vicryl sutures. Clinical data regarding demographics, diagnosis, size and location of conjunctival tumors, patient outcome, and complications were gathered., Results: Of 28 patients, 6 (21.4%) had malignant melanoma, 4 (14.3%) had squamous cell carcinoma, 6 (21.4%) had conjunctival intraepithelial neoplasia, 1 (3.6%) had sebaceous carcinoma, 1 (3.6%) had mucoepidermoid carcinoma, 1 (3.6%) had conjunctival intraepithelial dysplasia, 5 (17.9%) had pterygium, 2 (7.1%) had compound nevus, 1 (3.6%) had a large epithelial inclusion cyst, and 1 (3.6%) patient had a granuloma. The mean area of graft size was 156 ± 120 mm2. Postoperatively, the graft was well tolerated with no failure, discomfort, or dehiscence. During the 17-month mean follow-up, symblepharon, which was clinically nonsignificant, developed in 3 (11%) patients and partial stem cell deficiency was noted in 5 (18%) patients., Conclusions: Cryopreserved ultra-thick human AM is a well-tolerated, effective graft material that is easy to handle. It is a viable alternative for conjunctival surface reconstruction after excision of a conjunctival tumor.

Purpose: To report a solitary epibulbar neurofibroma in 2 elderly patients without systemic neurofibromatosis., Methods: Case reports and literature review., Results: A 67-year-old man presented with a 2-month history of left epibulbar mass. On slit-lamp examination, an 8- × 8-mm amelanotic, translucent, gelatinous, circumscribed lesion was present deep to the nasal bulbar conjunctiva. A 60-year-old otherwise healthy man presented with a 6-week history of a subconjunctival growth causing pain and photophobia in his right eye. On slit-lamp examination, an 8- × 8-mm amelanotic, translucent, gelatinous, circumscribed subconjunctival lesion, causing a delle was present near the nasal limbus. In each case, excisional biopsy was performed and histopathologic study revealed the diagnosis of neurofibroma. In both cases, after 12 months of follow-up, there was no evidence of recurrence or systemic disease., Conclusions: Solitary epibulbar neurofibroma in older adult patients without systemic neurofibromatosis is rare but should be considered in the differential diagnosis of epibulbar tumors.

Purpose: To assess the efficacy of interferon alpha-2b (IFNα2b) in the management of ocular surface squamous neoplasia (OSSN)., Methods: This is a retrospective, nonrandomized interventional case series study of 80 patients with 81 tumors treated with IFNα2b eye drops and/or injection combined with surgical excision when necessary. The main outcome measure was complete response or partial response based on the American Joint Committee on Cancer classification., Results: The OSSN was classified as Tis (n = 10, 12%), T1 (n = 13, 16%), T2 (n = 6, 7%), T3 (n = 51, 63%), and T4 (n = 1, 1%). IFNα2b was used as immunotherapy alone (n = 22, 27%) or combined with surgery (n = 59, 73%). Overall (n = 81), complete response was achieved in 90% Tis, in 100% T1, in 100% T2, in 94% T3, and in 100% T4. Specifically for immunotherapy (n = 22), IFNα2b alone achieved complete response in 75% (3/4) Tis, in 100% (8/8) T1, and in 70% (7/10) T3. Planned IFNα2b plus surgery (n = 59) achieved control in 100% (6/6) Tis, in 100% (5/5) T1, in 100% (6/6) T2, in 100% (41/41) T3, and in 100% (1/1) T4. Tumor recurrence was noted in 5% (4/81) of cases over a median follow-up of 1 year. Ocular side effects included conjunctival hyperemia (n = 4, 5%), ocular irritation (n = 3, 4%), superficial punctate keratitis (n = 3, 4%), and conjunctival follicles (n = 1, 1%). Systemic side effects included postinjection flu-like syndrome for 1 day (n = 7, 9%)., Conclusions: IFNα2b, when appropriately combined with surgical excision for OSSN, provides complete control in 95% of cases overall, specifically in 90% Tis, in 100% T1, in 100% T2, in 94% T3, and in 100% T4.

Purpose: To evaluate the use of in vivo toluidine blue (TB) dye in the diagnosis of ocular surface squamous neoplasia and to correlate staining intensity with the histopathological diagnosis., Methods: A prospective study was performed at the Federal University of Sao Paulo, Brazil. Patients with conjunctival epithelial lesions were examined by slit-lamp biomicroscopy, with and without 1% TB eye drops, and the results were photo documented. Before the instillation of the dye, 1% proxymetacaine HCl eye drops were used. All patients were submitted to surgery and histopathological analysis to confirm the diagnosis. The patients were grouped according to the histopathological aspects of the lesions into 3 groups: group 1-patients with ocular surface squamous neoplasia; group 2-patients with premalignant lesions; and group 3-patients with pterygium. The digital images were analyzed by 2 masked examiners who had no previous access to the histopathological results. The photographs were classified according to the positivity and intensity of the staining. The statistical analysis method chosen depended on the type of data, with the level of significance set as P < 0.05., Results: Forty-seven patients were included in the study: 10 had benign lesions (pterygium), 10 had premalignant lesions (actinic keratosis), and 27 had malignant lesions (conjunctival intraepithelial neoplasia and conjunctival squamous cell carcinoma). Agreement between observers regarding the analysis of the digital photographs was 100% for positivity and 82.9% for intensity of staining (κ = 0.938). Ninety percent of patients with premalignant lesions and all patients with malignant lesions showed positive staining with 1% TB. One patient had positive staining, but histopathological examination revealed a benign lesion (false positive)., Conclusions: The use of 1% TB eye drops is an efficient method for the clinical diagnosis of ocular surface squamous neoplasia and premalignant lesions. Nevertheless, the intensity of the staining does not correlate with the degree of malignancy of these tumors.

Purpose: To analyze the outcome of excisional biopsy of ocular surface (conjunctival and corneal) squamous cell intraepithelial (in situ) neoplasia with and without the adjunctive use of intraoperative and postoperative mitomycin C., Methods: A retrospective case review was conducted on 34 consecutive patients with histopathologically proven ocular surface squamous cell intraepithelial neoplasia who were treated from January 1, 1980, to December 31, 2008, at University of Iowa Hospitals and Clinics. Eyes in which a minimum follow-up period of 3 months was available were included in the statistical analysis., Results: Of 34 eyes, 32 met the inclusion criteria. Adjunctive therapy was provided with mitomycin C in 17 eyes, including 13 that had only postoperative treatment and 4 that had only intraoperative treatment. The adjunctive use of mitomycin C was associated with a significantly reduced prevalence of recurrence (5.9% vs. 66.7%; P = 0.0005). When the surgical margins were positive, the use of adjunctive mitomycin C was associated with a reduced prevalence of tumor recurrence (12.5% vs. 55.6%), but this difference was not statistically significant (P = 0.13). When surgical margins were negative, the adjunctive use of mitomycin C was significantly associated with a reduced prevalence of recurrence (0% vs. 83.3%; P = 0.002)., Conclusions: The adjunctive use of mitomycin C is significantly associated with a reduction in the prevalence of postoperative recurrences of ocular surface squamous cell intraepithelial neoplasia and should be considered as an adjunctive therapy even when surgical margins are negative.

Purpose: To describe a rare case of primary conjunctival clear cell carcinoma., Methods: The clinical history and pathologic findings were reviewed., Results: An 82-year-old white man presented with a lesion on his right conjunctiva for 8 months. An excisional biopsy was performed with wide margins and mitomycin C. Pathologic examination showed a papillary clear cell carcinoma of the conjunctiva. The patient has been followed for 6 months without recurrence., Conclusions: Primary clear cell carcinoma, a variant of squamous cell carcinoma, can occur in the conjunctiva.

A healthy 10-year-old girl developed synchronous, bilateral, temporal redness of the eyes regarded as sectoral conjunctivitis for 5 years that was unresponsive to topical steroids and antihistamines. Finely vascularized, minimally elevated, amelanotic or faintly focally pigmented, epibulbar conjunctival lesions were present bilaterally. The lesions were completely excised. Histopathologic and immunohistochemical evaluations confirmed that they were both predominantly junctional nevi with conspicuous chronic inflammation. Juvenile conjunctival nevi frequently have atypical histopathologic traits that in an adult could be suggestive of melanoma. The differential diagnosis of much less likely disorders includes leukemia, lymphoid tumor (salmon patch), and conjunctival sarcoidosis, among other conditions. The patient has had no recurrence 3 years after surgery.

Purpose: To report two cases of persistent epitheliopathy after treatment of conjunctival melanoma and review management options for this condition., Methods: Case report and literature review., Results: Persistent epitheliopathy, presumably resulting from limbal stem cell deficiency, is an uncommon complication of treatment of conjunctival malignant melanoma with surgical excision, cryotherapy, and mitomycin C. The Boston Ocular Surface Prosthesis was successful in improving vision, comfort, and epithelial status in our patients., Conclusion: Persistent epitheliopathy is a rare complication of treatment of conjunctival melanoma. The Boston Ocular Surface Prosthesis is a viable treatment option in this situation.

Purpose: To describe a case of conjunctival malignant melanoma (MM) arising from primary acquired melanosis in a patient with neurofibromatosis type 1 (NF-1)., Methods: Case report and literature review., Results: A 66-year-old woman with a history of NF-1 presented with extensive pigmentation of the left bulbar conjunctiva. Conjunctival biopsies demonstrated MM arising from primary acquired melanosis with atypia. Two excision and cryotherapy procedures did not completely eradicate the conjunctival pigment, which was then treated with topical mitomycin C. Subsequent biopsies and clinical examinations have revealed no remaining tumor., Conclusion: Conjunctival MM is uncommon in patients with NF-1 and can be successfully treated with excision, cryotherapy, and topical mitomycin C.

Purpose: The aim of this work is to report the long-term results of using immunotherapy for the management of cornea and conjunctiva intraepithelial neoplasia and squamous cell carcinoma after surgical excision of the neoplasm., Methods: Ten eyes of 10 patients with cornea and conjunctiva intraepithelial neoplasia or squamous cell carcinoma had wide surgical excisions of the neoplasm after evaluation of the level of corneal involvement using ultrasound biomicroscopy. All eyes received topical cyclosporine A (0.05%) and topical mitomycin C (0.01%) 4 times daily for 12 weeks after surgery. All eyes were followed up every month for 6 months and then every 6 months for another 18 months., Results: All eyes showed total cure with no recurrence during the 2-year follow-up period. Epithelial toxicity (punctate keratopathy) occurred in 3 eyes, ocular irritation and mild conjunctival hyperemia in 5 eyes, and lid toxicity in 2 cases during the treatment with mitomycin C. There were no serious complications that necessitated stopping the treatment., Conclusion: During a 2-year follow-up period, the use of topical cyclosporine A (0.05%) combined with mitomycin C (0.01%) as an adjunctive treatment after surgical excision in cornea and conjunctiva intraepithelial neoplasia and squamous cell carcinoma was found to prevent tumor recurrence, especially in extensive lesions, when surgical excision cannot ensure a tumor-free margin.

Purpose: The functional long-term outcome after differentiated surgical therapy of solid corneal dermoids and subconjunctival lipodermoids with special regard to determinants for amblyopia will be assessed., Methods: Forty-six consecutive patients undergoing surgery for solid epibulbar dermoids, subconjunctival lipodermoids, or both were included. Visual acuity, refraction, keratometry, and degree of amblyopia were determined. Surgical therapy for corneal dermoids consisted of lamellar sclerokeratectomy, lamellar keratoplasty, corneoscleroplasty, and lamellar removal with autologous episcleral transplant. Surgical therapy for lipodermoids consisted of excision and reduction of the volume of the tumor. Follow-up examination was performed on average 4.5 years after surgical intervention., Results: A significant correlation between tumor volume and preoperative visual acuity could be observed in patients with solid corneal dermoids not occluding the optical axis. Visual acuity improved significantly from 0.21 +/- 0.4 to 0.35 +/- 0.4 after surgery of corneal dermoids. Most eyes had concomitant hyperopia. Postoperative visual acuity correlated positively with preoperative visual acuity (P = 0.0001). After tumor excision, hyperopia and astigmatism were not reduced significantly on average. Nineteen of 47 patients suffered from amblyopia. Amblyopia was more often observed in patients with preoperative hyperopia > or =2 diopters and astigmatism >2 diopters. Visual acuity, refraction, and astigmatism were not changed significantly by surgery in patients with subconjunctival lipodermoids., Conclusions: Epibulbar dermoids require differentiated surgical therapy. Amblyopia is a major threat of solid corneal dermoids. The incidence of amblyopia seems to depend on preoperative occlusion of the optical axis and preoperative degree of hyperopia and astigmatism.

Purpose: To report an extremely rare case of an extensive conjunctival-corneal invasive squamous cell carcinoma., Methods: A healthy 68-year-old man referred to our department with a moderately elevated hyperemic nodular mass on his right ocular surface. The lesion was completely covering the corneal surface and involved the temporal limbus with bulbar conjunctiva. Surgical excision was performed with 2-mm tumor-free margins documented histologically and double-freeze cryotherapy was applied 360 degrees for inhibition of tumor recurrence., Results: Histopathologic examination showed a moderately differentiated squamous cell carcinoma. The patient achieved a complete excision with no evidence of recurrence during the follow-up period of 12 months., Conclusions: This case points out the potential for a total covering of the cornea by squamous cell carcinoma. Wide surgical excision and double freeze-thaw cryotherapy may decrease the recurrence.

Purpose: To report 3 cases of primary adenoid cystic carcinoma originating from the accessory and/or ectopic lacrimal glands of the conjunctiva., Methods: We examined 3 conjunctival tumors histopathologically. The specimens were fixed in 10% formalin. Sections were cut at 5 microm, and the slides were stained with hematoxylin-eosin, periodic acid-Schiff, alcian blue, and colloidal iron methods., Results: We report 3 conjunctival tumors that histopathologically proved to be adenoid cystic carcinomas that had arisen from the accessory lacrimal glands of the conjunctiva (cases 1 and 2) and from ectopic lacrimal gland tissue (case 3). The age of the patients ranged between 53 and 68 years. In 2 of the cases, the tumor involved the tarsal conjunctiva. The third patient had a mass involving the limbal conjunctiva and two thirds of the cornea inferiorly. Histopathologically, acini of accessory lacrimal glands of the conjunctiva were found near the neoplastic lobules in 2 of the tumors. Foci of perineural invasion were observed in 1 of the tumors (case 1). Follow-up examination showed no evidence of recurrence or metastatic disease in cases 1 and 2 (10 and 8 years, respectively). In case 3, the patient was alive and without any evidence of recurrence 1 year after surgical excision of the mass., Conclusions: Adenoid cystic carcinoma arising from the accessory lacrimal glands of the conjunctiva is a rare occurrence. Only 2 previously reported cases have appeared in the literature, and to our knowledge, there are no reports of this tumor arising from ectopic lacrimal gland tissue in the conjunctiva. Follow-up studies are mandatory to evaluate the biologic behavior of the tumor.

Purpose: To report a case of conjunctival intraepithelial neoplasia in a patient treated with tacrolimus after liver transplantation for hepatic carcinoma., Methods: Description of the initial clinical presentation of a patient, tumor management, and 15-month follow-up., Results: A 70-year-old man presented with a conjunctival intraepithelial neoplasia that developed on the site of a preexisting pterygium. After total surgical removal and additional application of mitomycin, local tumor control was achieved., Conclusions: We describe a case of intraepithelial conjunctival neoplasia in a patient treated with systemic tacrolimus. Local tumor control was achieved at 15 months after appropriate surgical management.

Purpose: To describe an invasive spindle cell carcinoma of the conjunctiva managed by full-thickness eye wall resection., Methods: A 51-year-old man developed a conjunctival mass that was excised and proved to be a spindle cell carcinoma. A tumor recurrence 20 months later was evaluated by ultrasound biomicroscopy (UBM) and managed by full-thickness eye wall resection and scleral graft., Results: UBM depicted an epibulbar mass with deep invasion through the limbus to Descemet membrane. The tumor was removed by full-thickness eye wall resection and scleral graft., Conclusions: Deep scleral invasion of conjunctival spindle cell carcinoma can sometimes be managed by local resection rather than irradiation or enucleation.

Purpose: To describe a case of recurrent, advanced conjunctival papillomatosis, treated by oral cimetidine (CIM) combined with secondary surgical intervention and an application of intraoperative mitomycin C., Methods: Case report and literature review., Results: A 9-year-old boy suffered from recurrent, progressive, diffuse multifocal conjunctival papillomatosis over the left upper and lower palpebral and the fornical conjunctiva. He underwent 3 separate surgeries; however, they did not prevent tumor recurrence. The recurrent lesions were more severe and extensive than before the surgeries. To avoid postoperative symblepharon, ankyloblepharon, dry eye, and possible corneal neovascularization after extensive lesion excision, oral CIM at a dosage of 200 mg 4 times daily was administered for 4 months before surgery. A debulking excision of the residual tumor with an intraoperative application of mitomycin C was performed as a secondary therapy after the main mass decreased in size. Postoperative oral CIM was continued for 6 months. The papillomatosis cleared without recurrence or symblepharon, ankyloblepharon, conjunctival scarring, or corneal neovascularization after 4 years of follow-up examinations., Conclusion: Oral CIM can be used as an initial, nonsurgical strategy for treating cases of massive, recalcitrant conjunctival papillomatosis. If there is tumor shrinkage, surgical debulking with applications of mitomycin C may be sufficient to eliminate any residual tumor tissue without inducing conjunctival scarring or corneal neovascularization.

Purpose: To report a case of bilateral papilloma virus-positive conjunctival intraepithelial neoplasm and the treatment results of using adjunctive interferon alpha-2b., Methods: Case report and literature review., Results: A 73-year-old man underwent subtotal excisional biopsy of the 270-degree gelatinous limbal lesion of the right eye to avoid creating a limbal deficiency and cicatricial change. Total excisional biopsy of the temporal elevated leukoplakic limbal lesion was performed on his left eye. Histology examination showed bilateral intraepithelial neoplasia, and human papilloma virus-16 and -18 were detected by polymerase chain reaction in both lesions. Two supplemental perilesional injections of interferon alpha-2b in the right eye were given, and the residual mass decreased in size gradually and completed clinical resolution 7 weeks following initial surgery. Although no recurrence was noticed in the right eye, recurrence of the conjunctival intraepithelial neoplasm lesion was noticed in the left eye., Conclusion: Adjunctive therapy might lower CIN recurrence rate, especially in extensive lesions, when surgical excision cannot ensure a tumor-free margin. Our bilateral case provided a good control example for the recurrence with or without adjunctive therapy.

Purpose: To report squamous cell carcinoma (SCC) of the conjunctiva in patients with atopic eczema., Methods: A retrospective study of six patients with conjunctival SCC associated with atopic eczema. Clinical and pathologic records were reviewed., Results: Ten patients with conjunctival SCC were seen from October 1999 to May 2002 at the Department of Ophthalmology at the University of Essen. Six of 10 patients had also atopic eczema. These six patients were treated either with local excision and ocular surface reconstruction or proton beam radiotherapy. None of the patients had local recurrences or metastases., Conclusion: Atopic eczema is a common dermatological disease. An association with conjunctival SCC has not been reported so far. Squamous cell carcinoma has also been found in patients with AIDS and other immunosuppressed individuals. The dysfunction of T lymphocytes found in these disorders might play a crucial role in the malignant transformation of conjunctival tissue. Because of the reported frequency of SCC, patients with atopic eczema should be monitored for abnormalities.

Purpose: To evaluate the efficacy of intraoperative mitomycin-C in excision of ocular surface neoplasia for prevention of recurrence., Methods: Seven patients (eight eyes), three men and four women, aged 56 to 87 years (mean, 73.8 years), with lesions suspicious for corneal or conjunctival neoplasia, were operated on between October 1998 and March 2000. During excision of the lesion, mitomycin-C 0.02% was applied intraoperatively for 5 minutes. In two cases, excision was combined with conjunctival limbal autograft transplantation. All excised lesions were sent for histopathologic evaluation., Results: During the follow-up period ranging from 6 to 28 months (mean, 16 months) one patient (one eye) died of an unrelated cause. Histopathologic study showed four cases of squamous cell carcinoma, one case of carcinoma in situ, two cases of dysplasia, and one case of actinic keratosis. Of the eight eyes, no clinical recurrence of the lesion occurred in seven eyes, whereas one eye with squamous cell carcinoma showed mild recurrence 5 months after surgery and was successfully treated with topical mitomycin-C. Up to the last follow-up of this case 10 months later, the lesion did not recur., Conclusion: The excision of conjunctival and corneal epithelial neoplasia combined with the intraoperative use of mitomycin-C seems to reduce the recurrence rate. The combined use of mitomycin-C and conjunctival limbal autograft transplantation in two cases did not alter the surgical outcome. More cases and a longer follow-up are needed to establish the efficacy of such an approach.

Purpose: To report two cases of conjunctival epithelial neoplasias occurring after long-term systemic cyclosporine therapy in organ transplant recipients., Methods: Case report. Each patient underwent an excision of an extensive limbal conjunctival lesion, followed by a histopathologic analysis., Results: Histopathologic examination results revealed a carcinoma in situ and a squamous cell carcinoma in patients 1 and 2, respectively. Recurrence occurred in patient 1, who needed topical mitomycin C 0.02% treatment. No recurrence was observed in patient 2 after a follow-up of 24 months., Conclusion: To our knowledge, these are the first reported cases of its kind after longterm systemic cyclosporine therapy. Further studies will be needed to determine the exact role of cyclosporine in the induction of conjunctival epithelial neoplasias and the need for regular ophthalmologic examination of transplant recipients.

Purpose: To report the efficacy of topical mitomycin C in preventing local recurrences after incomplete surgical excision of conjunctival squamous cell neoplasia., Methods: Four patients presented with unilateral conjunctival tumors. Excisional biopsy results revealed conjunctival intraepithelial neoplasia with an intact basement membrane. Neoplastic cells were present in at least one of the surgical borders of the excised conjunctiva in all four cases. Patients were treated with topical mitomycin C 0.02% three times daily for 2 weeks to prevent recurrences., Results: All four patients were free of clinically detectable tumors after a mean follow-up period of 20 months (range, 16-23 months). Side effects included mild discomfort, redness, photophobia, and punctate epithelial keratopathy that subsided on discontinuation of the medication., Conclusion: Postoperative topical mitomycin C application may be a useful adjunct to prevent recurrences in patients with incompletely excised conjunctival squamous cell neoplasia.

A 73-year-old man had only light perception vision from a slowly enlarging fleshy papillomatous mass covering the entire cornea. The lesion was excised completely, leaving a clear corneal bed and 20/25 vision. Histopathologically, the lesion was found to be squamous cell carcinoma in situ with early microinvasion of the basement membrane. Viral studies for human papilloma virus were negative. This case represents a massive superficial involvement of the cornea by squamous cell carcinoma and shows the resistance of Bowman's membrane to tumor penetration.