No abstract

Conjunctival malignant melanoma is a pigmented lesion of the ocular surface. It is an uncommon but potentially devastating tumor that may invade the local tissues of the eye, spread systemically through lymphatic drainage and hematogenous spread, and recur in spite of treatment. Despite its severity, the rarity of available cases has limited the evidence for diagnosis and management. This review will provide an overview of the epidemiology, presentation, diagnosis, management, and surveillance of conjunctival melanoma, with an emphasis on recent advances in biological therapies to treat this disease.

Purpose To evaluate the use of a commercially-available, high-resolution, spectral-domain optical coherence tomography (HR OCT) device in the diagnosis of corneal and conjunctival pathologies, with a focus on malignant lesions. Methods Eighty-two eyes of 71 patients were enrolled in this prospective case series, including 10 normal eyes, 21 with ocular surface squamous neoplasia (OSSN), 24 with a pterygium or pingueculum, 3 with lymphoma, 18 with pigmented conjunctival lesions (nevus, flat melanosis, or melanoma), and 6 with Salzmann’s nodular degeneration. Subjects were imaged using photography and HR OCT (RTVue, Optovue, Fremont, CA). When clinically indicated, surgery was performed and histopathologic specimens were correlated with OCT images. Results HR OCT was useful in differentiating among various lesions based on optical signs. Specifically, in OSSN, HR OCT findings included epithelial thickening and hyper-reflectivity, whereas pterygia and pinguecula showed a subepithelial mass under thinner epithelium. In lymphoma, a hypo-reflective, homogenous subepithelial mass was observed. Differentiating between pigmented lesions with HR OCT proved more difficult, but certain characteristics could be identified. Eyes with nevi and melanoma both displayed intensely hyper-reflective basal epithelial layers and discrete subepithelial lesions, but could be differentiated by the presence of cysts in nevi and intense shadowing of sublesional tissue in most melanomas. Conclusion We found that a commercially-available HR OCT was a useful non-invasive adjunctive tool in the diagnosis of ocular surface lesions.

Purpose To identify predictors of ocular surface squamous neoplasm (OSSN) recurrence after surgical resection. Design Retrospective case series. Participants Three hundred and eighty nine consecutive patients who underwent excisional biopsy for OSSN lesions at the Bascom Palmer Eye Institute from January 1, 2001, to September 20, 2010 Methods Review of pathology records and patient charts. Main Outcome Measures Identification of factors predictive of OSSN recurrence. Results Of 389 excised OSSN lesions, forty-four recurred during follow up. The 1 year recurrence rate was 10% and the 5 year recurrence rate was 21% with a mean time to recurrence in those with a recurrence of 2.5 years (standard deviation (SD) 3.4). Using the American Joint Committee on Cancer (AJCC) clinical staging system, T3 and T2 lesions portended a higher risk of recurrence compared to T1 (T2/T1: hazard ratio (HR) = 2.05, p=0.04; T3/T1: HR= 2.31, p=0.07). In addition, a location characteristic that increased the risk of tumor recurrence was tarsal involvement (AJCC T3 stage lesion) (HR=4.12, p = 0.007). Nasal location was associated with a decreased risk of tumor recurrence (HR=0.41, p=0.008). Pathologic characteristics significantly associated with tumor recurrence were the presence of positive margins (HR=2.73, p= 0.008) and higher grade lesions (carcinoma in situ and squamous cell carcinoma versus dysplasia) (HR=2.55, p=0.02). Treatment with adjuvant cryotherapy significantly decreased the risk of tumor recurrence (HR=0.51, p=0.03). In those patients with positive margins, the use of post-operative topical interferon therapy lowered the recurrence rate to a level similar to that of patients with negative margins. Conclusions Certain patient and tumor factors are associated with a higher risk of OSSN recurrence after surgical excision, such as tarsal tumor location and positive surgical margins. Post-operative adjuvant therapy should be considered in patients with high risk OSSN characteristics.

The development of optical coherence tomography (OCT) technology has helped to usher in a new era of in vivo diagnostic imaging of the eye. The utilization of OCT for imaging of the anterior segment and ocular surface has evolved from time-domain devices to spectral-domain devices with greater penetrance and resolution, providing novel images of anterior segment pathology to assist in diagnosis and management of disease. Ocular surface squamous neoplasia (OSSN) is one such pathology that has proven demonstrable by certain anterior segment OCT machines, specifically the newer devices capable of performing ultra high-resolution OCT (UHR-OCT). Distinctive features of OSSN on high resolution OCT allow for diagnosis and differentiation from other ocular surface pathologies. Subtle findings on these images help to characterize the OSSN lesions beyond what is apparent with the clinical examination, providing guidance for clinical management. The purpose of this review is to examine the published literature on the utilization of UHR-OCT for the diagnosis and management of OSSN, as well as to report novel uses of this technology and potential directions for its future development.