History
General approach
A good ocular history is not only essential but also critical in making the correct diagnosis.
Knowing the patient's age and the anatomic location of the tumor or tumorlike lesion (eg, inverted papillomas [Schneiderian or mucoepidermoid papillomas] typically involve the mucous membrane of the nose, paranasal sinuses, and lacrimal sac) is helpful for the ophthalmologist. The conjunctiva rarely is affected.
A change in size and shape should raise the index of suspicion for a possible neoplastic proliferation. However, other reasons may contribute to the change in size. Cystic lesions may increase in size secondary to accumulation of fluids and/or acellular debris. An inflammatory response may cause a benign lesion to increase in size.
Most conjunctival tumors are isolated lesions. However, in a small percentage, conjunctival lesions may be an extension of systemic disease (ie, Lhermitte-Duclos disease, Cowden syndrome).
A history of congenital, bilateral, or multifocal conjunctival lesions strongly suggests an underlying systemic disease. Therefore, a profound systemic workup is warranted.
History associated with conjunctival papilloma
Squamous cell papilloma
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Usually seen in younger patients
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History of maternal HPV infection at the time of parturition
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A past history of tumor excision with recurrence
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Refractive to past medical and surgical treatments
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No decrease or loss of visual acuity
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A history of a sibling with the same condition
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A history of cutaneous warts at extraocular sites
Limbal papilloma
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Seen in older adults
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History of UV exposure
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Possible decrease or loss of visual acuity
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Recurrence after excision, not common
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History of chronic conjunctivitis refractive to medications
Physical
Key features to assist an ophthalmologist in examining a surface tumor are discussed below.
Tumor location
Knowing the probability of finding a tumor in a specific anatomic location greatly assists the ophthalmologist not only in making the diagnosis but also, and more importantly, in prioritizing the differential diagnosis.
Approximately 25% of all lesions involving the caruncle are papillomas.
Squamous cell carcinoma is seen commonly in the interpalpebral zone adjacent to the limbus and rarely appears elsewhere. Although possible, a diagnosis of squamous cell carcinoma would be questionable if remote from the limbus.
Tumor color
Tumor color provides important clues and clinical judgment based on the following:
Pigmented lesions suggest a melanocytic origin.
Salmon-colored lesions are associated with lymphoid tumors.
Pale or dull yellow lesions are associated with xanthomas.
Tumor topography
In evaluating, attention should be made to the tumor's surface, to include the tumor's texture and edge.
The conjunctiva surface appearance is altered predictably in epithelial tumors (ie, the surface epithelium is raised, cobblestone, and/or acanthotic).
In differentiating from epithelial tumors, tumors arising from the substantia propria tend to have a smooth epithelial surface.
Tumor edges between normal conjunctiva and diseased conjunctiva may appear abrupt, as seen in conjunctival papilloma or conjunctival intraepithelial neoplasia (CIN).
In cases where the edges are ill-defined, lymphoid tumors should be considered.
Tumor growth pattern
The pattern of growth may be described as solitary, diffuse, or multifocal.
Solitary growth is seen in conjunctival papilloma.
Diffuse growth, although rare, is associated with conjunctival intraepithelial neoplasia, sebaceous carcinoma (pagetoid spread), lymphoma, and reactive lymphoid hyperplasia.
Tumor consistency
Tumor consistency can be described as solid, soft, or cystic.
Tumor consistency is established by palpation, which is useful in evaluating and diagnosing subepithelial tumors.
Palpation is performed under topical anesthesia during the slit lamp examination, using a cotton-tip applicator.
This technique is beneficial in determining whether an epithelial tumor has invaded the underlying supporting tissue. Most papillomas are freely mobile over the sclera. An epithelial tumor that has already invaded the underlying connective tissue will feel fastened to the globe when tenderly pushed from side to side.
Clinical signs
Clinical signs associated with squamous cell papilloma (infectious papilloma) are as follows:
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This lesion is benign and self-limiting.
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It is seen commonly in children and young adults.
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Most lesions are asymptomatic without associated conjunctivitis or folliculitis.
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Anatomically, it commonly is located in the inferior fornix, but it also may arise in the limbus, caruncle, and palpebral regions.
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The lesion may be bilateral and multiple.
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Grossly, squamous cell papilloma appears as a grayish red, fleshy, soft, pedunculated mass with an irregular surface (cauliflowerlike).
Clinical signs associated with limbal papilloma are as follows:
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This lesion is typically benign.
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It is seen commonly in older adults.
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Anatomically, the lesion commonly occurs at the limbus or the bulbar conjunctiva.
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These lesions may spread centrally toward the cornea or laterally toward the conjunctiva.
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Visual acuity may be affected if the lesion grows centrally.
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These lesions almost always are unilateral and single.
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They tend to have variable proliferation potential with a tendency to slowly enlarge in size.
Clinical signs associated with inverted conjunctival papilloma are as follows:
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This lesion is slow growing and is seen commonly in the nose, paranasal sinuses, or both. The lacrimal sac and the conjunctiva are uncommon sites.
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The lesion is unilateral and unifocal and does not recur after surgical excision.
