Korean J Ophthalmol.  2012 Oct;26(5):383-387. 10.3341/kjo.2012.26.5.383.

Excision with Corneoscleral Lamellar Keratoplasty and Amniotic Membrane Transplantation of a Corneal Displaced Recurrent Conjunctival Melanoma

• Kim EC
• Kim MS
• Kang NY

• KMID: 1397490
• DOI: http://doi.org/10.3341/kjo.2012.26.5.383

Abstract

An 81-year-old woman with a raised pigmented nodule over her left cornea for 7 months duration was examined. Dark conjunctival pigmentation was observed in the upper bulbar fornix conjunctiva. She had previously undergone primary surgical excision of a malignant conjunctival melanoma four years earlier. The tumor separated easily from the corneal surface, but remained slightly attached to the corneoscleral surface. A corneoscleral lamellar dissection of 3 mm in width and 2 mm in depth as well as a corneoscleral lamellar keratoplasty for the reconstruction of the corneoscleral defect were performed. The wide upper bulbar and fornix conjunctiva were excised, and an amniotic membrane transplantation was performed. Biopsy revealed an invasive melanoma with a depth of 1 mm. Left, right, and inferior tumor margins of the corneoscleral lesion and the pigmentary lesion in the conjunctiva were free of the tumor. After surgery, 0.04% mitomycin was administered topically 4 times daily for 4 weeks. There was no recurrence 2 years after surgery, and systemic evaluation revealed no metastasis.

Keyword

Amniotic membrane; Lamellar keratoplasty; Malignant melanoma

MeSH Terms

Aged, 80 and over
Amnion/*transplantation
Conjunctival Neoplasms/*surgery
*Corneal Transplantation
Female
Humans
Melanoma/*surgery
Neoplasm Recurrence, Local
Recurrence

Figure

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  Fig. 1 (A) Pigmented lesion on the bulbar conjunctiva and cornea of the left eye. (B) Epithelioid melanoma cells infiltrations were observed by hematoxylin & eosin stain (×400). This patient had an epithelioid conjunctival melanoma with corneal displacement. The pictures were taken 4 years previously.

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  Fig. 2 Surgical excision of a corneal-displaced recurrent conjunctival melanoma, and reconstruction with corneoscleral lamellar keratoplasty and amniotic membrane transplantation. (A) Preoperative finding. (B) Corneoscleral lamellar dissection with a width of 3 mm and a depth of 2 mm was performed. (C) Donor corneoscleral lamellar tissue was prepared. (D) Corneoscleral lamellar keratoplasty was performed. (E) Pigmentary lesion of the wide upper bulbar and fornix conjunctival was excised. (F) Amniotic membrane transplantation was performed.

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  Fig. 3 (A) Preoperative corneal displaced recurrent conjunctival melanoma. (B) Postoperative ocular findings showing a well-removed pigmented mass and well-attached corneoscleral lamellar keratoplasty. (C) Epithelioid melanoma cells can be observed by hematoxylin & eosin stain (×400). (D) Positive staining for HMB 45 in melanoma cells (×200).

Reference

1. Layton C, Glasson W. Clinical aspects of conjunctival melanoma. Clin Experiment Ophthalmol. 2002. 30:72–79.

2. Kim SY, Lee SB, Yang SW. A case of conjunctival malignant melanoma with extensive corneal displacement. J Korean Ophthalmol Soc. 2005. 46:1235–1239.

3. Shields CL. Conjunctival melanoma: risk factors for recurrence, exenteration, metastasis, and death in 150 consecutive patients. Trans Am Ophthalmol Soc. 2000. 98:471–492.

4. Anastassiou G, Heiligenhaus A, Bechrakis N, et al. Prognostic value of clinical and histopathological parameters in conjunctival melanomas: a retrospective study. Br J Ophthalmol. 2002. 86:163–167.

5. Paridaens AD, McCartney AC, Minassian DC, Hungerford JL. Orbital exenteration in 95 cases of primary conjunctival malignant melanoma. Br J Ophthalmol. 1994. 78:520–528.

6. Damato B, Coupland SE. Management of conjunctival melanoma. Expert Rev Anticancer Ther. 2009. 9:1227–1239.

7. Shields JA, Shields CL, De Potter P. Surgical management of circumscribed conjunctival melanomas. Ophthal Plast Reconstr Surg. 1998. 14:208–215.

8. Finger PT. Topical mitomycin chemotherapy for malignant conjunctival and corneal neoplasia. Br J Ophthalmol. 2006. 90:807–809.

9. Lederman M, Wybar K, Busby E. Malignant epibulbar melanoma: natural history and treatment by radiotherapy. Br J Ophthalmol. 1984. 68:605–617.

10. Schechter BA, Schrier A, Nagler RS, et al. Regression of presumed primary conjunctival and corneal intraepithelial neoplasia with topical interferon alpha-2b. Cornea. 2002. 21:6–11.

11. Dalla Pozza G, Ghirlando A, Busato F, Midena E. Reconstruction of conjunctiva with amniotic membrane after excision of large conjunctival melanoma: a long-term study. Eur J Ophthalmol. 2005. 15:446–450.

12. Paridaens D, Beekhuis H, van Den Bosch W, et al. Amniotic membrane transplantation in the management of conjunctival malignant melanoma and primary acquired melanosis with atypia. Br J Ophthalmol. 2001. 85:658–661.

13. Sandinha T, Russell H, Kemp E, Roberts F. Malignant melanoma of the conjunctiva with intraocular extension: a clinicopathological study of three cases. Graefes Arch Clin Exp Ophthalmol. 2007. 245:431–436.

14. Wenkel H, Rummelt V, Naumann GO. Malignant melanoma of the conjunctiva with intraocular extension. Arch Ophthalmol. 2000. 118:557–560.

15. Kim JW, Abramson DH. Topical treatment options for conjunctival neoplasms. Clin Ophthalmol. 2008. 2:503–515.

16. Chalasani R, Giblin M, Conway RM. Role of topical chemotherapy for primary acquired melanosis and malignant melanoma of the conjunctiva and cornea: review of the evidence and recommendations for treatment. Clin Experiment Ophthalmol. 2006. 34:708–714.

17. Shields CL, Shields JA, Armstrong T. Management of conjunctival and corneal melanoma with surgical excision, amniotic membrane allograft, and topical chemotherapy. Am J Ophthalmol. 2001. 132:576–578.

18. Midena E, Angeli CD, Valenti M, et al. Treatment of conjunctival squamous cell carcinoma with topical 5-fluorouracil. Br J Ophthalmol. 2000. 84:268–272.

19. Finger PT, Sedeek RW, Chin KJ. Topical interferon alfa in the treatment of conjunctival melanoma and primary acquired melanosis complex. Am J Ophthalmol. 2008. 145:124–129.