eMedicine Specialties > Ophthalmology > Conjunctiva

Melanoma, Conjunctival: Treatment & Medication

Author: Manolette R Roque, MD, MBA, DPBO, FPAO, President and CEO, Chief of Service, Ocular Immunology and Uveitis, Consulting Staff, Cornea and Refractive Surgery, Eye Republic Ophthalmology Clinic; General Manager, Ophthalmic Consultants Philippines Co; Consulting Staff, CME Liaison, Section Chief of Ocular Immunology and Uveitis, Department of Ophthalmology, Asian Hospital and Medical Center
Coauthor(s): Barbara L Roque, MD, Full Partner, Ophthalmic Consultants Philippines Co, Chief of Service, Pediatric Ophthalmology and Strabismus, Consulting Staff, Orbit and Eye Plastics, EYE REPUBLIC Ophthalmology Clinic; C Stephen Foster, MD, FACS, FACR, FAAO, Clinical Professor of Ophthalmology, Harvard Medical School; Consulting Staff, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary; Founder and President, Ocular Immunology and Uveitis Foundation, Massachusetts Eye Research and Surgery Institution
Contributor Information and Disclosures

Updated: Dec 27, 2007

Treatment

Medical Care

Documentation by photography and observation for growth of lesions over regular intervals of time is recommended for small lesions.

  • The treatment of conjunctival melanoma is primarily surgical.
  • Finger et al presented a more conservative approach with topical mitomycin-C as an option.3 They concluded that topical mitomycin-C chemotherapy was tolerated as a treatment for conjunctival melanoma and PAM with atypia (10 patients with 2.5-year follow-up care).3

Surgical Care

The treatment of conjunctival melanoma is surgical, with complete removal of the tumor, if possible.

  • The suggestions of Shields in the surgical management of circumscribed conjunctival melanomas are advocated.
  • The "no touch" technique is essential throughout the procedure. No surgical instrument is used more than once in any area (addressing the concern of microscopically seeding tumor cells).
  • Treatment of primary conjunctival melanomas in the limbal region of the bulbar conjunctiva usually can be accomplished with initial localized absolute alcohol epitheliectomy.
  • This treatment is followed with wide (2-3 mm clear zone) local excision by a partial lamellar scleroconjunctivectomy.
  • The bed of excision, as well as the adjacent conjunctiva or cornea away from the nodule, is treated with supplemental double freeze-thaw cryotherapy by a specific technique (lifting the conjunctiva). It is important to treat the entire area of the lesion because untreated areas may lead to spread through local lymphatic channels. Laser therapy after excision also has been used.
  • If the tumors are located in the fornical or palpebral conjunctiva, wide surgical resection with alcohol treatment to the scleral base and cryotherapy to the surrounding conjunctiva is performed
  • Exenteration of the orbit sometimes is necessary for large melanomas that have invaded the orbit, but this procedure does not improve the prognosis. It may be performed for patients in whom the objective is to do local debulking of a tumor, because this procedure is not linked with increased patient survival. The use of radical neck dissection at the period of exenteration is not without controversy.
  • The poor survival rate, in spite of orbital exenteration, suggests that metastasis has already occurred at the time of treatment and confirms that the extent of the disease at diagnosis is the most important factor to determine the outcome. Considerable orbital invasion indicates the necessity for exenteration; however, subtotal exenteration can be carried out if no evidence of radial extension of the lesion to the skin of the anterior lid exists. Nodal involvement indicates extensive metastatic disease, but, occasionally, cases in which lesions were limited to regional nodes and cured by node resection have occurred.

Consultations

Radiation-oncologist

Medication

Antimetabolites

Mitomycin is an off-label drug that is used in ophthalmology. It is a potent chemotherapeutic agent that inhibits fibroblasts and, therefore, diminishes scarring after glaucoma filtering surgery. It has been used as an adjunct in pterygium surgery, photorefractive keratoplasty (PRK) haze management, and conjunctival melanoma management.


Mitomycin and/or mitomycin-C (Mutamycin)

An antibiotic isolated from the broth of Streptomyces caespitosus that has been shown to have antitumor activity. The primary preparation is meant for injection. Has since been used in ophthalmology as a topical adjunct to antifibrosis management.

Adult

Topical preparation: 0.02% (0.2 mg/mL) and 0.04% (0.4 mg/mL)
For glaucoma: Apply once with a cellulose sponge during the procedure for 2-4 min, and wash copiously with BSS
For pterygium: Apply once with a cellulose sponge during the procedure for 2-4 min, and wash copiously with BSS and/or apply topically 1 gtt bid to qid for a variable length of time
For conjunctival melanoma: Apply topically 1 gtt bid to qid for a variable length of time

Pediatric

Not established

Systemically administered, interactions have been reported with bone marrow depressants, doxorubicin, live viral vaccines, and vinca alkaloids

Patients who have demonstrated a hypersensitive or idiosyncratic reaction to it in the past; if used systemically, contraindicated in patients with thrombocytopenia, coagulation disorder, or an increase in bleeding tendency due to other causes; recent chicken pox, herpes zoster, and impaired renal function

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Several precautions exist when using mitomycin systemically, to include shortness of breath and severe bronchospasm reported following administration of vinca alkaloids in patients who had previously or simultaneously received mitomycin; a few cases of adult respiratory distress syndrome have been reported in patients receiving mitomycin in combination with other chemotherapy and maintained at FIO2 concentrations greater than 50% perioperatively; in ophthalmology, precautions on its prolonged topical use may lead to nonhealing ulcers and/or scleral melting

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References
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References

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  106. Zografos L, Uffer S, Chamot L. Unilateral conjunctival-corneal argyrosis simulating conjunctival melanoma. Arch Ophthalmol. Oct 2003;121(10):1483-7. [Medline].

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Further Reading

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Keywords

conjunctival melanoma, malignant melanoma of the conjunctiva, malignancy, tumor, exenteration, cryotherapy

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Contributor Information and Disclosures

Author

Manolette R Roque, MD, MBA, DPBO, FPAO, President and CEO, Chief of Service, Ocular Immunology and Uveitis, Consulting Staff, Cornea and Refractive Surgery, Eye Republic Ophthalmology Clinic; General Manager, Ophthalmic Consultants Philippines Co; Consulting Staff, CME Liaison, Section Chief of Ocular Immunology and Uveitis, Department of Ophthalmology, Asian Hospital and Medical Center
Manolette R Roque, MD, MBA, DPBO, FPAO is a member of the following medical societies: American Academy of Ophthalmic Executives, American Society of Cataract and Refractive Surgery, American Society of Ophthalmic Administrators, American Uveitis Society, International Ocular Inflammation Society, Philippine Medical Association, Philippine Ocular Inflammation Society, and Philippine Society of Cataract and Refractive Surgery
Disclosure: Nothing to disclose.

Coauthor(s)

Barbara L Roque, MD, Full Partner, Ophthalmic Consultants Philippines Co, Chief of Service, Pediatric Ophthalmology and Strabismus, Consulting Staff, Orbit and Eye Plastics, EYE REPUBLIC Ophthalmology Clinic
Disclosure: Nothing to disclose.

C Stephen Foster, MD, FACS, FACR, FAAO, Clinical Professor of Ophthalmology, Harvard Medical School; Consulting Staff, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary; Founder and President, Ocular Immunology and Uveitis Foundation, Massachusetts Eye Research and Surgery Institution
C Stephen Foster, MD, FACS, FACR, FAAO is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology, American Association of Immunologists, American College of Rheumatology, American College of Surgeons, American Federation for Clinical Research, American Medical Association, American Society for Microbiology, American Uveitis Society, Association for Research in Vision and Ophthalmology, Massachusetts Medical Society, Royal Society of Medicine, and Sigma Xi
Disclosure: Nothing to disclose.

Medical Editor

Brian A Phillpotts, MD, Former Vitreo-Retinal Service Director, Former Program Director, Clinical Assistant Professor, Department of Ophthalmology, Howard University College of Medicine
Brian A Phillpotts, MD is a member of the following medical societies: American Academy of Ophthalmology, American Diabetes Association, American Medical Association, and National Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Simon K Law, MD, PharmD, Assistant Professor of Ophthalmology, Jules Stein Eye Institute; Chief of Section of Ophthalmology Surgical Services, Department of Veterans Affairs Healthcare Center, West Los Angeles
Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology
Disclosure: Nothing to disclose.

Managing Editor

Christopher J Rapuano, MD, Professor, Department of Ophthalmology, Jefferson Medical College; Co-Chairman of the Cornea Service, Co-Chairman of Refractive Surgery Department, Wills Eye Hospital
Christopher J Rapuano, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, Eye Bank Association of America, Pennsylvania Medical Society, and Philadelphia County Medical Society
Disclosure: Allergan Honoraria Speaking and teaching; Allergan Consulting fee Consulting; Alcon Honoraria Speaking and teaching; Inspire Honoraria Speaking and teaching; RPS Ownership interest Other

CME Editor

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

 
 
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