Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 29  |  Issue : 2  |  Page : 143-146

A Rare Case of Giant Conjunctival Nevus with Amniotic Membrane Graft Reconstruction in Rural India


Rural Medical College, Pravara Institute of Medical Sciences, Loni, Maharashtra, India

Date of Submission01-Sep-2020
Date of Decision01-Nov-2020
Date of Acceptance01-Apr-2021
Date of Web Publication18-Jan-2022

Correspondence Address:
Dr. Priyanka D Asgaonkar
Third-Year Junior Resident, Rural Medical College, Pravara Institute of Medical Sciences, Loni bk 413736, Maharastra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njo.njo_41_20

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  Abstract 


Conjunctival nevi are the most common melanocytic tumors of the eye. The benign conjunctival nevus typically harbors conjunctival inclusion cysts that are detectable both clinically and histopathologically, which differentiates it from the other pigmented conjunctival lesions. They commonly affect teenagers and young adults. In our case, we have performed excision of the nevus with amniotic membrane grafting in which we have procured and processed the amniotic membrane ourselves.

Keywords: Benign conjunctival lesion, conjunctival, giant conjunctival nevus, nevus


How to cite this article:
Asgaonkar PD, Bankar GB, Pandit A, Badhe KP. A Rare Case of Giant Conjunctival Nevus with Amniotic Membrane Graft Reconstruction in Rural India. Niger J Ophthalmol 2021;29:143-6

How to cite this URL:
Asgaonkar PD, Bankar GB, Pandit A, Badhe KP. A Rare Case of Giant Conjunctival Nevus with Amniotic Membrane Graft Reconstruction in Rural India. Niger J Ophthalmol [serial online] 2021 [cited 2022 May 22];29:143-6. Available from: http://www.nigerianjournalofophthalmology.com/text.asp?2021/29/2/143/335918




  Introduction Top


Conjunctival nevus, complex-associated melanosis, primary acquired melanosis, and malignant melanomas form the pigmented lesions that arise from the conjunctiva.[1],[2] Owing to the variability in their clinical appearance, the diagnosis is very challenging. The nevi have junctional activity as seen on histopathological examination.[3] Furthermore, a large conjunctival nevus can be easily mistaken for a malignant melanoma, thus making the diagnosis and differential diagnosis a difficult task.[4],[5] They are usually benign pigmented tumors located in the bulbar conjunctiva and histopathologically there are different types of compound nevi, subepithelial nevi, and junctional nevi. Only about 5% of the conjunctival nevi are diagnosed as giant conjunctival nevus according to the survey published by Shields et al.[6] The term “giant nevus” is used when the basal diameter of conjunctival nevi is greater than 10 mm.


  Case Report Top


A 17-year-old female came to our ophthalmology outpatient department with the chief complaints of brownish-blackish discoloration in her left eye since childhood [Figure 1]a. The lesion was initially small in size and increased gradually over the years. She had a complaint that the lesion was visually unappealing. It was not associated with any diminution of vision, pain, tenderness, foreign body sensation, or discharge. There was no history of any ocular trauma, itching, change in color of the lesion, weight loss, or any other systemic complaints [Figure 2].
Figure 1 (a) left eye showing gaint conjunctival nevus, (b) AS-OCT image of conjunctival nevus showing intralesional cysts

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Figure 2 (a) Intraoperative photo of giant conjunctival nevus. (b) Giant nevus being excised. (c) Amniotic membrane graft procured and processed. (d) Amniotic membrane cut into required size (e) Conjunctival reconstruction with amniotic membrane

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On examination, her visual acuity was 6/6 in both eyes without correction, intraocular pressure in right eye was 13 mmHg and that of left eye was 15 mmHg, and ocular movements were free, full, and painless in all directions of gaze. On slit lamp examination, there was a single slightly elevated large pigmented lesion over the conjunctiva of about 2.5cm × 1.5 cm × 3 mm size, irregular in shape with well-defined smooth margins. The lesion extended from the nasal bulbar conjunctiva advancing supratemporally into the fornix, slightly encroaching the cornea from 9 o’clock to 11 o’clock. There was presence of a few enlarged feeding vessels and the lesion was freely mobile over the underlying sclera. Rest of the anterior segment examination and fundus examination of both eyes was within normal limits. Anterior segment optical coherence tomography (AS-OCT) was performed that showed variegate severity of posterior shadowing and multiple intralesional cysts. A B-mode ultrasound scan could not be performed due to financial constraints of the patient [Figure 1]b.

A written informed consent was taken prior to the surgery. Excision of the tumor and cryotherapy of scleral bed were performed under local anesthesia. Fresh amniotic membrane graft was used for reconstruction of the ocular surface that was sutured using 8-0 vicryl sutures [Figure 3] a and e. The amniotic membrane was obtained after elective lower segment cesarean section after taking an informed consent from the donor and screening for human immunodeficiency virus (HIV) and hepatitis B serum antigen (HBS Ag). The graft obtained from placenta was washed free of blood clots and chorion with balanced salt solution containing 50 micro grams/mL of penicillin, 50 µg/mL of streptomycin, 100 µg/mL of neomycin, and 3 µg/mL of amphotericin B. With the epithelial side upward, the amniotic membrane was uniformly spread on sterilized nitrocellulose paper cut as per the requirement and used immediately [Figure 3]c and d. The resected conjunctival tissue was sent for histopathological evaluation that showed the presence of nests of nevus cells both in the basal epithelial and in the superficial subepithelial stromal layer. These cells were oval to spindle shaped with moderate to scanty cytoplasm with brown pigments and hyperchromatic nuclei; nucleus to cytoplasm ratio was increased. There was no obvious mitosis or single cell infiltration or any definitive evidence of malignancy noted, and it thus was labelled as a compound type of conjunctival nevus [Figure 4].
Figure 3 Histopathology photo of giant conjunctival nevus

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Figure 4 Post operative photo after 6 months of surgery

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Following surgery, the patient was started on topical moxifloxacin eye drops qid for 1 week and topical steroid eyedrops qid, which were slowly tapered over a period of 4 weeks. Also, the upper fornix was swiped with an antibiotic coated glass rod four times daily on different occasions for a period of 1 week. The patient was evaluated the next day after surgery; there was mild congestion, watering with sutures intact and graft in place. The patient was followed up after 1 week, 1 month, 3 months, and 6 months. The graft was well in place with no adhesions, congestion, and recurrence, and eye movements were normal in all directions of gaze. The graft was in place even after 6 months (merged with the surrounding conjunctiva).


  Discussion Top


Of all the melanocytic lesions of conjunctiva, giant nevi form only a small subgroup, thus making it a rare entity. The differential diagnosis of these lesions is difficult as they have an extended conjunctival involvement and a variegated clinico morphological appearance. These lesions can be easily confused with a malignant melanoma. Even though the chances for a benign giant conjunctival nevus to turn into a malignant lesion is very low (less than 1%), a careful intervention of the same is very important.[7]

In our case, the presence of a few enlarged feeding vessels over the lesion and the initial clinic-morphological picture aroused a suspicion of a conjunctival melanoma.

The epithelial walled intralesional cysts in conjunctival nevi are usually chronic in nature and indicate their epithelial origin, suggesting the benign nature of the lesion.[3],[4] A conjunctival melanoma rarely shows the presence of intralesional cysts; however, cystic nevi with features of intralesional cysts can act as a precursor for development of a melanoma in the future.[8] AS-OCT is a very informative tool when it comes to diagnosis of conjunctival nevi.[9] Also, B scan can provide cross-sectional 3D volume scan analysis and presence of intralesional cysts.[10]

Surgical removal of such a large conjunctival lesion can be a significant therapeutic challenge. Conjunctival, mucosal, and amniotic membrane grafts can be used for the reconstruction of large conjunctival defects, although amniotic membrane grafts are superior.[11],[12] Amniotic membrane has a wide clinical application as it contains abundant growth factors, anti-inflammatory proteins, promotes epithelization, inhibits fibrosis, and suppresses inflammation and bacterial growth.[13],[14]


  Conclusion Top


Out of the vast variety of melanocytic lesions of conjunctiva, the giant conjunctival nevi form only a rare subgroup. Anterior segment OCT (AS-OCT) and B-mode ultrasound scans help to detect the intralesional cysts and thus confirm the benign nature of the lesion and differentiate it from the malignant ones. Surgical excision should always be considered in case of suspected lesions and thus exclude malignancy. Amniotic membrane graft is an effective and economical treatment of such large conjunctival lesions and is considered as an easy and secure option in reconstructive and regenerative ophthalmology.

Declaration of patient consent

The authors certify that they have obtained patient consent forms. In the forms, the patient(s) has/have given his/her/their consent for his/her/their images and other information to be published in the journal. The patient understand that their names and initials will not be disclosed and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Shields CL, Shields JA. Tumors of the conjunctiva and cornea. Surv Ophthalmol 2004;49:3-24.  Back to cited text no. 1
    
2.
Oellers P, Karp CL. Management of pigmented conjunctival lesions. Ocul Surf 2012;10:251-63.  Back to cited text no. 2
    
3.
Harooni H, Schoenfield LR, Singh AD. Current appraisal of conjunctival melanocytic tumors: classification and treatment. Future Oncol 2011;7:435-46. doi: 10.2217/fon.11.12. PMID: 21417906.  Back to cited text no. 3
    
4.
Zembowicz A, Mandal RV, Choopong P. Melanocytic lesions of conjunctiva. Arch Pathol Lab Med 2010;134:1785-92.  Back to cited text no. 4
    
5.
Shields CL, Fasiudden A, Mashayekhi A, Shields JA. Conjunctival nevi: clinical features and natural course in 410 consecutive patients. Arch Ophthalmol 2004;122:167-75.  Back to cited text no. 5
    
6.
Shields CL, Regillo AC, Mellen PL, Kaliki S, Lally SE, Shields JA, Giant conjunctival nevus: clinical features and natural course in 32 cases. JAMA Ophthalmol 2013;131:857-63.  Back to cited text no. 6
    
7.
Folberg R, Jakobiec FA, Bernardino VB, Iwamoto T. Benign conjunctival melanocytic lesions: clinicopathologic features. Ophthalmology 1989;96:436-61.  Back to cited text no. 7
    
8.
Esposito E, Zoroquiain P, Mastromonaco C, Morales MC, Belfort Neto R, Burnier M. Epithelial inclusion cyst in conjunctival melanoma. Int J Surg Pathol 2016;24:562-7.  Back to cited text no. 8
    
9.
Shields CL, Belinsky I, Romanelli-Gobbi M et al. “Anterior segment optical coherence tomography of conjunctival nevus. Ophthalmology 2011;118:915-9.  Back to cited text no. 9
    
10.
Hassani RTJ, Liang H, El Sanharawi M et al. En-face optical coherence tomography as a novel tool for exploring the ocular surface: a pilot comparative study to conventional B-scans and in vivo confocal microscopy. Ocul Surf 2014;12:285-306.  Back to cited text no. 10
    
11.
McQuilling JP, Vines JB, Mowry KC. In vitro assessment of a novel, hypothermically stored amniotic membrane for use in a chronic wound environment. Int Wound J 2017;14:993-1005.  Back to cited text no. 11
    
12.
Tseng SC, Espana EM, Kawakita T, Di Pascuale MA, Li W, He H et al. How does amniotic membrane work? Ocul Surf 2004;2:177-87. doi: 10.1016/s1542-0124(12)70059-9. PMID: 17216089.  Back to cited text no. 12
    
13.
Adzick NS, Lorenz HP. Cells, matrix, growth factors, and the surgeon. The biology of scarless fetal wound repair. Ann Surg 1994;220:10-18.  Back to cited text no. 13
    
14.
Friedman RJ, Rigel DS, Kopf AW. Early detection of malignant melanoma: the role of physician examination and self examination of the skin. CA Cancer J Clin 1985;35:130-51.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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