Ophthalmologists can be involved in managing malignant conjunctival lesions, most often-pigmented conjunctival lesions, primary acquired melanosis, conjunctival melanoma, conjunctival and corneal squamous neoplasia, and squamous cell carcinomas. Nicholas T. Iliff, MD, described how these pathologies are best approached. Dr. Iliff is Maurice Bendann, Violet Bendann, Constance Bendann and Charles E. Iliff Professor of Ophthalmology, professor of plastic surgery, and director—oculoplastic surgery, The Wilmer Eye Institute, The Johns Hopkins University School of Medicine, Baltimore.

Lymphomas—salmon-colored lesions of the conjunctiva—are more often diagnosed by ophthalmologists, but managed by oncologists, who do the staging and patient evaluation elsewhere. Following biopsy, which is obtained by the ophthalmologist, the specimen is sent for histological and cytometric analysis. The most common type of this pathology involving the conjunctiva is mucosal associated lymphocytic tissue lymphomas that are low grade and respond well to relatively low-centigrade radiation of the orbit.

Dr. Iliff advised that pigmented conjunctival lesions should be monitored for growth, color change, and inflammation. He also urged a low threshold for biopsy and excision particularly in a recently occurring lesion.

Primary acquired melanosis, a frequently seen premalignant lesion, is golden or chocolate colored without cysts and has cellular atypia. Without atypia, the lesion can be followed. The lesion is flat, has indistinct edges, can be unifocal or multifocal, and should also be monitored carefully for changes. Focal lesions can be excised. Other options are cryotherapy, application of mitomycin C, or a combination therapy. With diffuse lesions, multiple biopsies should be performed.

"Treatment of primary acquired melanosis does not ensure that the patient will not develop melanoma," he emphasized.

Conjunctival melanomas, which can be pigmented or not and may have cysts, can be elevated or nodular with indistinct edges, unifocal or multifocal, and can develop from primary acquired melanomas, a nevus, or de novo. Excision (including a lamellar partial sclerectomy if the limbus is involved) and cryotherapy are the therapeutic approaches, with application of mitomycin C when extensive primary acquired melanosis is present. In more advanced cases of melanoma, exenteration and node dissection may be necessary. Dr. Iliff recommended follow-up every 6 months consisting of a head and neck computed tomography or magnetic resonance imaging and positron emission tomography.

Dysplasia can be slightly elevated and may be white and inflamed. That lesion often cannot be differentiated from carcinoma in situ, which has the same characteristics, according to Dr. Iliff. Carcinoma in situ, which is pale with tiny vascular buds, can be treated with cryotherapy, excision, mitomycin C, interferon, or phototherapeutic keratectomy.

Invasive squamous cell carcinoma requires a deep excision that must include the lamellar underlying scleral margin. Cryotherapy includes the base and surrounding conjunctiva. Treatment is followed by metastatic workup and monitoring.