Medical Care
Observation and patient reassurance are indicated for squamous cell papillomas. These lesions may regress spontaneously over time. Seeding may follow excision, resulting in multiple new lesions. For limbal papillomas, excision is indicated to rule out neoplastic changes.
Cryotherapy is indicated for squamous cell papillomas. Less scarring occurs, and the recurrence rate is low. It is not indicated for limbal papillomas because this procedure does not distinguish between benign papillomas and malignant papillomas. The double-freeze-thaw method is preferred and appears to be the most effective technique.
Dinitrochlorobenzene (DNCB): Petrelli et al demonstrated success with DNCB in the treatment of recurrent conjunctival papillomas. [7] This treatment modality is reserved for cases when surgical excision, cryoablation, and other treatment modalities have failed. The patient is sensitized to DNCB. Once sensitized, DNCB is applied directly to the papilloma. The mechanism for this treatment appears to be the delayed hypersensitivity reaction causing the tumor to regress; however, the exact mechanism is unknown.
Interferon is an adjunct therapy to surgical excision of recurrent and multiple lesions. Alpha interferon is given intramuscularly (daily for 1 mo, 2-3 times/wk for the next 6 mo, then tapered off). Lass et al indicated both nonrecurrence and recurrence of conjunctival lesions. [8] However, those recurring lesions tend to be less severe in clinical presentation. Because of its antiviral and antiproliferative properties, this form of therapy is designed to suppress tumor cells; it is not curative. Additionally, topical interferon alpha-2b has been shown to be an effective adjunct therapy for small-to-medium size lesions but not for large lesions without surgical debulking. Topical interferon alpha-2b can be utilized as an adjunctive therapy for recurring conjunctival papilloma. [9, 10] More recently, topical alpha-2b interferons have shown to be successful in treating not only primary conjunctival papilloma but also conjunctival intraepithelial neoplasia. [11]
Mitomycin-C is an adjunct therapy to surgical excision. Mitomycin-C is indicated for recalcitrant conjunctival papillomas or those refractive to past multiple treatments. Hawkins et al reported complete regression of conjunctival papilloma 9 months after surgical excision followed by intraoperative mitomycin-C application. [12] Mitomycin-C (0.3 mg/mL) is applied via a cellulose sponge to the involved area(s) after surgical excision. The sponge is held in place for 3 minutes. The treated area is irrigated copiously with normal saline after mitomycin-C application. Complications include symblepharon, corneal edema, corneal perforation, iritis, cataract, and glaucoma.
Oral cimetidine (Tagamet): Although commonly used to treat peptic ulcer disease, cimetidine has shown to be effective in the treatment of recalcitrant conjunctival papilloma. Shields et al demonstrated dramatic tumor regression with nearly complete resolution in an 11-year-old boy treated with cimetidine. [13] Chang et al indicated that oral cimetidine can be used as an initial treatment modality in cases where the lesion is quite large and recalcitrant. [14] Apart from its antagonistic effect on H2 receptors, cimetidine has been found to enhance the immune system by inhibiting suppressor T-cell function and augmenting delayed-type hypersensitivity responses.
Carbon dioxide (CO2) laser: Schachat et al and Jackson et al reported this treatment modality to be safe and most effective. [15, 16] It is indicated for recalcitrant conjunctival papillomas. The procedure is performed easily. This procedure allows for precise tissue excision with minimal blood loss and trauma to tissue. Rapid healing of tissues occurs without significant scarring, edema, or symblepharon formation. Recurrence is low, resulting from the destruction of viral particles and papillomatous epithelial cells. Gentamicin ointment twice a day for 7-10 days is prescribed postoperatively to allow proper healing and reepithelialization.
Other treatment modalities include electrodesiccation, topical acids, topical cantharidin, and intralesional bleomycin.
Surgical Care
Excision is indicated for squamous cell and limbal papillomas.
Performing an excisional biopsy is recommended for adults to rule out premalignancy changes.
In the pediatric population, performing an excisional biopsy is less clear. This is a surgical procedure requiring general anesthesia. To justify the risk of anesthesia, this procedure is indicated in cases where the lesion is causing significant symptoms, (ie, cosmetically disfiguring, has not regressed, appearance of new lesion).
An excisional biopsy is preferred to an incisional biopsy whenever possible.
Consultations
A consult with a general pathologist or, ideally, an ophthalmic pathologist is recommended.
Long-Term Monitoring
For patients who undergo cryoablation, CO2 laser, or surgical excision for conjunctival papilloma, posttreatment follow-up care is usually at 5 days, at 1 month, and then at 1 year.
Patients on a medical regimen should receive monthly follow-up care for possible adverse effects until the medication is discontinued. Then, these patients should receive annual follow-up care to check for recurrence of the lesion.
Inpatient & Outpatient Medications
The following are recommended medications:
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Cimetidine
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Alpha interferon
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Gentamicin ointment
