Conjunctival tumors

Hamartoma

Hamartomas are congenital overgrowths of normal tissue at their naturally occurring site. The most common are hemangiomas including infantile periocular (capillary) and cavernous. Infantile hemangioma is the more common and occurs as an isolated conjunctival lesion or may be continuous with an orbital or lid lesion (see Chapter 20 ). They appear as soft, red, vascular nodules shortly after birth and may grow for the first year and then involute years later ( Fig. 30.1 ). Most of these isolated conjunctival capillary hemangiomas do not need treatment. However, they often involute more rapidly if treated with topical timolol. Cavernous hemangiomas are typically larger and appear as multiloculated vascular masses. Because these do not regress spontaneously and may cause recurrent spontaneous subconjunctival hemorrhages, excision is the best treatment.

Choristoma

Choristomas are congenital tumors consisting of displaced tissue elements in an abnormal location. The most common conjunctival choristomas are dermoids and lipodermoids. Conjunctival dermoids are congenital, well-circumscribed, firm yellow-white solid masses with a predilection for the limbus. The surface can be smooth or coarse, with keratin and even hair formation ( Fig. 30.2 ). They may appear in isolation or as part of Goldenhar syndrome, which is also known as oculoauriculovertebral dysplasia, in which structures derived from the first branchial arch are affected resulting in preauricular appendages, deafness, and vertebral anomalies. Dermoids may be simply observed if asymptomatic, or excised if causing disfigurement or significant astigmatism. Lipodermoids (dermolipomas) are soft, mobile, yellow-colored lesions arising at the lateral canthal region and are typically observed ( Fig. 30.3 ).

Papilloma

Squamous papillomas are benign tumors that appear as pink vascular fronds of tissue arranged in a sessile or pedunculated configuration, often with corkscrew vessels ( Fig. 30.4 ). In children, papillomas have been documented to be associated with human papilloma virus (HPV; mostly subtypes 6, 11, and 16). They are often located in the inferior fornix or bulbar conjunctiva. They are typically solitary, but can be bilateral and multiple. Small lesions may be observed for spontaneous resolution, but larger tumors require excision with a no-touch technique in order to prevent the spread of the papilloma-related virus. Cryotherapy should be applied in a double freeze–thaw fashion to the surrounding conjunctival edges and the base of the tumor in order to reduce the risk of recurrence. Conjunctival papillomas tend to recur and, for these cases, topical or subconjunctival interferon alpha-2b may be used to prevent recurrence ( Fig. 30.5 ). Other treatment options include mitomycin C, oral cimetidine, and carbon dioxide laser vaporation.

A conjunctival papilloma in an infant or young child could result from acquisition of HPV during a vaginal delivery. The mother should be notified of this and referred for evaluation and treatment if necessary. If dysplasia is noted histopathologically, then the term “premalignant” is often used. If no dysplasia is noted, then the papilloma is benign.