Definition

Conjunctival tumors are neoplasms that develop in the conjunctiva, the membrane covering the eyelids and the forepart of the eyeball, which helps prevent dry eyes. These tumors range from benign to malignant, with the five most common types being Nevus, Ocular Surface Squamous Neoplasia (OSSN), Primary Acquired Melanosis (PAM), melanoma, and lymphoma.

Conjunctival tumors are more prevalent in Western Asia compared to Southeast Asia. Research indicates that in Asians, these tumors present at a younger age and have a higher risk of metastasis compared to Caucasians. Additionally, cases in Southeast Asia are more common in women than men, with a ratio of 3:2.

Causes

Ocular Surface Squamous Neoplasia (OSSN) is one of the most common ocular tumors, characterized by a high recurrence rate and significant morbidity. Sunlight exposure, particularly from activities such as sailing, construction, or cattle jobs, is a primary cause. Coexisting conditions like Human Immunodeficiency Virus (HIV) and Human Papilloma Virus (HPV) also increase susceptibility to OSSN.

Primary Acquired Melanosis (PAM) and melanoma are pigmented conjunctival tumors. PAM is a preliminary diagnosis for ocular melanoma prior to histological examination, and it is believed to be strongly associated with sunlight exposure.

Lymphoma is characterized by an increased number of immune cells and can affect various body parts, including the eye. Ocular lymphomas include Hodgkin lymphoma, non-Hodgkin lymphoma, central nervous system non-Hodgkin lymphoma, primary vitreoretinal lymphoma, and uveal lymphoma. The primary cause of lymphoma is an impaired immune system, which can result from infections or genetically inherited immune disorders.

Risk Factor

Several risk factors are associated with the development of conjunctival tumors, particularly Ocular Surface Squamous Neoplasia (OSSN) and Primary Acquired Melanosis (PAM):

1. Sun exposure, particularly to UVB rays.
2. Cigarette smoke exposure.
3. Vitamin A deficiency.
4. Eye injury.
5. Comorbidities such as HIV, HPV, Hepatitis B, and Hepatitis C.

For lymphoma in the eye, additional risk factors include:

1. Autoimmune diseases, such as rheumatoid arthritis.
2. Disorders or diseases that compromise the immune system.
3. Acquired Immunodeficiency Syndrome (AIDS).
4. Use of immunosuppressive medications, such as post-organ transplant treatments.

Symptoms

In patients with OSSN, symptoms may include a round lump on the eye surface with surrounding blood vessels. Often, symptoms are absent in the early stages. The lumps typically appear in sun-exposed areas, such as the edge of the eye near the nose or the outer edge, and rarely spread beyond the eyeball.

Patients with PAM may present with pigmented or darker areas compared to surrounding tissue, in one or both eyes. The average age at diagnosis is 56 years. Patients may also experience floaters, which are perceived as fine dust or floating objects in the visual field. These abnormalities can vary in size and may displace the pupil.

Patients with eye lymphoma may experience floaters, visual disturbances, red eyes, and double vision. If the tumor involves the central nervous system, symptoms may include headaches, nausea, unilateral weakness, and seizures.

Diagnosis

In patients with Ocular Surface Squamous Neoplasia (OSSN), diagnosis is made through several examinations:

1. Wound staining: Fluorescein, lisamine green, or rose bengal are used to assess the size and extent of the lesion.
2. Slit lamp examination: This allows for a detailed and close-up view of the eyeball surface.
3. Optical Coherence Tomography (OCT): A non-invasive technique to clearly visualize the retina and assess the thickness of its layers to detect any abnormalities.
4. Confocal microscopy: Utilizes laser technology to create three-dimensional images of the sample, providing a clearer picture to aid in treatment selection.
5. High-frequency ultrasound: Determines the extent of damage caused by the tumor.

For patients with Primary Acquired Melanosis (PAM), several diagnostic tests can be performed:

1. Immunohistochemical analysis: This involves a biopsy, where a small tissue sample is taken from the suspected area and examined microscopically.
2. Physical examination: Assessing eyelid involvement through eversion of the eyelid to check the inner surface for any lumps, which can indicate melanoma.

In patients with ocular lymphoma, the following tests may be conducted:

1. Optical Coherence Tomography (OCT): Examines the retina for abnormalities.
2. Ultrasonography (USG): Evaluates injuries behind the retina, the degree of retinal detachment, and optic nerve thickening.
3. Cytology: Involves examining tissue taken from the vitreous or retinal layer.
4. Immunohistochemistry: Uses chemical dyes to examine lymphoma tissue.
5. Magnetic Resonance Imaging (MRI): Provides detailed images of the soft tissues in and around the eye.

Management

Before initiating therapy, the physician will inquire about the onset of symptoms, recurrence tendencies, and prior treatments. Some patients may receive topical treatments with medications such as Interferon-alpha 2b, mitomycin C, and fluorouracil.

In cases of suspected PAM, a biopsy is typically performed to determine the type and severity of the tumor, using either excisional or incisional biopsy techniques. Additionally, cryotherapy may be employed for areas suspected of having PAM. If PAM has infiltrated corneal tissue, additional therapy with mitomycin C and alcohol-assisted tissue removal may be indicated. All treatments should be conducted under medical supervision and guidance.

For lymphoma, treatment options include chemotherapy and radiotherapy. Chemotherapy involves direct injection or administration of medication to the affected eye, while radiotherapy uses high-energy radiation to target and destroy lymphoma cells. The choice of therapy is individualized based on the severity and specific circumstances at diagnosis. Patients should consult with their doctor to determine the most appropriate treatment plan.

Complications

The most common complication in patients with conjunctival tumors is recurrence, with about half of the cases experiencing recurrence within a few years, often with more malignant characteristics. Other complications include vision impairment or loss in one or both eyes, disruption of peripheral vision, and glaucoma due to increased intraocular pressure. Advanced tumors may metastasize to other parts of the body, such as bones, lungs, or liver.

Ocular lymphoma can lead to central nervous system disorders, such as seizures and body weakness, with masses spreading to the central nervous system causing visual field issues.

Prevention

To prevent conjunctival tumors, consider the following measures:

1. Use protective eyewear when riding motorcycles or working with objects that could potentially injure the eyes.
2. Use sunglasses with added protection against UV rays, especially during outdoor activities or work.
3. Quit smoking.

When to See a Doctor?

Seek medical attention if you experience any of the following symptoms, indicating potential conjunctival tumors:

1. Vision problems in one or both eyes.
2. Central nervous system disturbances, such as headaches, vomiting, seizures, or weakness in one part of the body.
3. Eye pain accompanied by headaches and vomiting.
4. Darker lumps or spots on the eye that increase in size or cause additional symptoms, such as redness.

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