Blue nevi of the palpebral conjunctiva: report of 2 cases and review of literature.

PURPOSE: To describe two patients with blue nevi of the palpebral conjunctiva and to review the existing literature on common and cellular blue nevi of the conjunctiva. METHODS: Report of two cases and literature review. RESULTS: We present two cases of blue nevi in the palpebral conjunctiva: an atypical cellular blue nevus of the left upper eyelid and a common blue nevus around the lacrimal punctum of the left lower eyelid. Both patients underwent full thickness eyelid excision with wide margins. There was no tumor recurrence at 11 and 4 months postoperatively. CONCLUSIONS: Blue nevi are a group of melanocytic tumors that rarely involve the ocular adnexa. They may arise in the palpebral conjunctiva and should be considered in the differential diagnosis of pigmented lesions in this location as they can mimic melanoma.

Very Challenging Cases to Diagnose: Concealed Foreign Bodies in the Upper Palpebral Conjunctiva Should Always Be Kept in Mind in Unresolved, Long-Lasting Chronic Ocular Pain.

Ocular pain is a common complaint, and anything that stimulates the sensory nerve terminals innervating the eye, the peripheral axons of neurons located in the trigeminal ganglion, can cause it. An undetected ocular foreign body sometimes masquerades as a common condition such as dry eye or other frequencies, which can misguide both the doctor and the patient into an endless cycle of ineffective therapies and incomplete diagnoses. In recent years, as the concept of neuropathic pain has become more widely recognized, cases of idiopathic ocular pain in which the actual cause of the discomfort is a foreign body seem to be increasingly misdiagnosed as neuropathy. This report reviews cases in which hidden foreign bodies were responsible for unresolved, long-lasting chronic ocular pain. All records referencing the phrase "foreign body removal" were extracted from the outpatient clinic notes recorded by the author (H.T.) between 2016 and 2018 at Ashikaga Red Cross Hospital using the search engine of the computerized record system. There were 3 cases that were very difficult to diagnose: (1) a very minute iron shard in a 72-year-old female cataract surgery patient, (2) a deeply hidden eyelash in a 60-year-old female with varicella-zoster virus-related keratoconjunctivitis, and (3) an extremely small grain of sand in an 83-year-old female diagnosed with dry eye. In all cases, the foreign body was detected in an area of the upper palpebral conjunctiva without typical pathognomonic signs. Removing the foreign bodies led to immediate and dramatic relief of long-lasting, previously unresolved chronic ocular pain.

Best technique for upper lid eversion.

AIM: Lid eversion is an essential component of contact lens aftercare. Hence, this study determined the best method of lid eversion based on three criteria: comfort, speed of administration and the area of the palpebral conjunctiva exposed. METHOD: Twenty-five participants (aged 20-34) had 6 different techniques applied in random order by the same clinician on two separate occasions: three involving a cotton bud placed on the extended upper eyelid either centrally, at the top of the tarsal plate or off-centre; one using the wooden end of the bud placed at the top of the tarsal plate; one using the clinician's index finger to evert the lid; and one using a silicone rubber, finger-shaped substitute. The participants judged the degree of discomfort of each technique on a visual analogue scale. The time to complete the task was timed with a stop-watch and the area of exposed palpebral conjunctiva was captured with a digital slit lamp and assessed using image analysis. RESULTS: There was no difference between the initial lid eversion or subsequent repeat in terms of comfort (F = 0.304, p = 0.586), time to complete (F = 3.075, p = 0.092) or area exposed (F = 2.311, p = 0.142). Lid eversion using fingers alone or the silicone substitute everter were similar in comfort (p = 0.312), being the most comfortable methods, with off-centre cotton bud eversion or the wooden end of the cotton bud the least comfortable techniques (F = 17.480, p < 0.001). The quickest method to perform was the wooden end of the cotton bud, followed by the silicone everter (F = 17.522, p < 0.001). The area of exposed palpebral conjunctiva was greatest using the silicone everter (F = 28.199, p < 0.001). CONCLUSIONS: Lid eversion had repeatable results, with the silicone everter placed at the top of the tarsal plate the most comfortable for the patient, quick to perform and exposed a greater area of tarsal plate than other techniques and therefore is recommended to clinicians.

Lower Tear Meniscus Height Measurements Using Keratography and Swept-Source Optical Coherence Tomography and Effect of Fluorescein Instillation Methods.

Purpose: The first aim of this study was to compare inferior tear meniscus height (TMH) measured by keratography and swept-source optical coherence tomography (OCT). Effect of locations of fluorescein instillation and subjects' subjective sensation, and the TMH results were also investigated.Methods: Forty-one eyes from 41 healthy adults had TMH randomly measured by keratography (K5M, Oculus, Germany) and swept-source OCT (Casia SS-1000, Tomey Corp, Japan) at baseline, followed by touching either the inferior bulbar or inferior palpebral conjunctiva, randomly assigned, with a moistened fluorescein strip. Two-way analysis of variance (ANOVA) was used to compare TMH obtained from the two devices and three measurement conditions. Subjective sensation of conjunctival touch was obtained through a 4-point scale with zero representing no sensation, and one to three representing ocular sensation in an ascending order.Results: Two-way ANOVA revealed no significant difference in TMH between keratography and swept-source OCT (Factor (devices): F = 0.579, p = .451) while there was a significant difference among fluorescein instillations (Factor (conditions): F = 10.146, p < .001). Baseline TMH was around 0.25 mm, and increased to around 0.28 mm after instillation of fluorescein sodium. Ocular sensation was similar between the two conjunctival touch, and TMH was not significantly associated with ocular sensation.Conclusions: Keratography and swept-source OCT provided similar TMH results. Applying fluorescein sodium through moistened fluorescein strip could over-estimate TMH by around 0.03 mm. Applying moistened fluorescein strip at bulbar or palpebral conjunctival led to similar subjective sensations and did not affect TMH measurement.

Mucosa-associated lymphoid tissue lymphoma with metachronous involvement of the palpebral conjunctiva and bronchus: A case report.

A 61-year-old woman with a history of palpebral conjunctival mucosa-associated lymphoid tissue (MALT) lymphoma, treated with rituximab, was referred to the authors' hospital after follow-up positron emission tomography/computed tomography revealed 18F-fluoro-2-deoxy-d-glucose uptake in a tumor located in the left main bronchus. The diagnosis of MALT lymphoma was made by pathological and immunohistochemical findings homologous to previous palpebral conjunctival lesion via bronchoscopic biopsy. The disease was controlled with rituximab, cyclophosphamide, oncovin, and prednisolone (i.e., R-COP) chemotherapy. Although MALT lymphoma occurs in several organs, metachronous occurrence in the palpebral conjunctiva and bronchus is especially rare, and careful check-up is required to monitor for occurrence of systemic relapse.

Solitary circumscribed neuroma of the palpebral conjunctiva: A rare location.

PURPOSE: To report a case with solitary circumscribed neuroma (SCN) in the palpebral conjunctiva. METHODS: This is a retrospective observational case report of a 78-year-old female who showed a yellowish, smooth-surface, dome-shaped mass in the right lower palpebral conjunctiva near the punctum. The mass was completely removed under local anesthesia. RESULTS: Pathological examination revealed that it was composed of benign spindle-shaped cells and tapering nuclei arranged in bundles. Immunocytochemical analyses for the S100, neurofilament, CD34, and epithelial membrane antigens were all positive. These pathological findings were consistent with a SCN. At the 6-month follow-up, there was no evidence of recurrence. CONCLUSION: This is the first case report of SCN in the palpebral conjunctiva. Although SCN had similar clinicopathological features to other benign peripheral nerve sheath tumors, including neurofibroma and schwannoma, immunocytochemical analyses were helpful for correct diagnosis of this case.

Examining palpebral conjunctiva for anemia assessment with image processing methods.

Examining the hemoglobin level of blood is an important way to achieve the diagnosis of anemia, but it requires blood drawing and blood test. Examining the color distribution of palpebral conjunctiva is a standard procedure of anemia diagnosis, which requires no blood test. However, since color perception is not always consistent among different people, we attempt to imitate the way of physical examination of palpebral conjunctiva to detect anemia, so that computers can identify anemia patients automatically in a consolidated manner for a screening process. In this paper we propose two algorithms for anemia diagnosis. The first algorithm is intended to be simple and fast, while the second one to be more sophisticated and robust, providing an option for different applications. The first algorithm consists of a simple two-stage classifier. In the first stage, we use a thresholding decision technique based on a feature called high hue rate (HHR) (extracted from the HSI color space). In the second stage, a feature called pixel value in the middle (PVM) (extracted from the RGB color space) is proposed, followed by the use of a minimum distance classifier based on Mahalanobis distance. In the second algorithm, we consider 18 possible features, including a newly added entropy feature, some improved features from the first algorithm, and 13 features proposed in a previous work. We use correlation and simple statistics to select 3 relatively independent features (entropy, binarization of HHR, and PVM of G component) for classification using a support vector machine or an artificial neural network. Finally, we evaluate the classification performance of the proposed algorithms in terms of sensitivity, specificity, and Kappa value. The experimental results show relatively good performance and prove the feasibility of our attempt, which may encourage more follow-up study in the future.

The palpebral conjunctival epithelium thickness in young adults measured by optical coherence tomography.

OBJECTIVE: To measure the palpebral conjunctival epithelium thickness in young adults with optical coherence tomography (OCT). METHODS: A Cirrus HD-OCT 4000 system was used to image the superior palpebral conjunctival with the Anterior Segment 5 Line Raster scanning protocol at the central region in 36 male and 26 female subjects aged between 20 and 30 years of age with normal, healthy eyes. The palpebral conjunctival epithelium thickness was measured according to the difference in brightness on OCT between the epithelium and its underlying substantia propria. The measurements were respectively performed in the same subjects by two operators and the Bland-Altman plot and intraclass correlation coefficient (ICC) were used to measure the agreement between two operators. RESULTS: No difference in the palpebral conjunctival epithelium thickness was found between the males (34.00±5.78 µm) and females (33.67±4.51 µm) (t=0.2425, p=0.8095). The mean values of the superior palpebral conjunctival epithelium thickness from operator 1 and operator 2 were 33.81±5.04 µm and 34.74±4.28 µm, respectively. The analysis of inter-operator variability demonstrated a good agreement between two operators: ICC=0.944, F=17.787, p<0.001; on the Bland-Altman plot, the 95% limits included 100% of differences between the two operators and the maximal difference is 5 µm. CONCLUSION: The palpebral conjunctival epithelium thickness can be measured using OCT with a good repeatability.

Subconjunctival epidermoid cysts in Gorlin-Goltz syndrome.

Epidermoid cysts are common benign cysts which occur particularly on the skin of the face, neck and upper trunk. Subconjunctival location of these cysts is very rare and, until today, only seen in patients with Gorlin-Goltz syndrome. Histopathological examination of these cysts show similarities with odontogenic keratocysts, a typical clinical manifestation of Gorlin-Goltz syndrome.

Liquid nitrogen-cryopreserved tarsal plate and palpebral conjunctival transplantation for the repair of tarsal defects.

The objectives of this study were to compare the efficiency of three methods for repairing tarsal defects (glycerine-preserved, alcohol-preserved and cryopreserved tarsal plate and palpebral conjunctival transplantation) based on histopathological changes and apoptosis, and to evaluate the clinical effects of repairing tarsal defects by liquid nitrogen-cryopreserved tarsal plate and palpebral conjunctival transplantation. Forty-eight rabbit eyes with tarsal defects were equally divided into three groups and transplanted with tarsal plates and palpebral conjunctivae under the following conditions: Group 1, liquid nitrogen cryopreservation; Group 2, glycerine preservation; and Group 3, alcohol preservation. Histopathological changes in the transplants were observed by light microscopy 1 week, 1 month and 3 months postoperatively. Apoptosis was assessed by terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) staining. Clinically, transplantations of liquid nitrogen-cryopreserved tarsal plates and palpebral conjunctivae were performed in 30 eyes (29 cases) to repair tarsal defects caused by the excision of neoplasms. The postoperative inflammatory reaction and number of apoptotic cells in Group 1 were lower compared with those in Groups 2 and 3. Clinically, of the 30 eyes operated on, 14 were cured, 15 improved and 1 failed between 6 and 90 months of follow-up. Liquid nitrogen-cryopreserved tarsal plate and palpebral conjunctival transplantation is an easy, feasible and convenient procedure. Its effects are fairly favorable, with only a small rejection rate postoperatively. Therefore, it is an ideal method for repairing tarsal defects.

A Case of Rosai-Dorfman Disease Affecting the Palpebral Conjunctiva

PURPOSE: To report a single case of Rosai-Dorfman disease of the palpebral conjunctiva with a review of the relevant literature. CASE SUMMARY: A 39-years-old woman presented with a palpebral conjunctival mass 3 weeks in duration on both eyes. The patient had a history of excisional biopsy of lymphadenitis and wanted to remove the mass for cosmetic reasons. An excisional biopsy was performed to obtain a diagnosis for proper management. The histopathologic examination of the lesion showed an intensive proliferation of monotonous and histiocytoid cells beneath the epidermis. Immunohistochemical staining for the S-100 protein was positive and anti-CD1A antibody was negative. Five months after mass excision, there was no evidence of recurrence.

Isolated Langerhans Cell Histiocytosis in the Palpebral Conjunctiva of an Adult Patient

PURPOSE: To report a case of isolated Langerhans cell histiocytosis (LCH) in the palpebral conjunctiva of an adult patient. METHODS: A 39-year-old male presented with a mass of one month's duration on the palpebral conjunctiva of his left upper lid. The lesion had gradually progressed. The mass was non-tender, relatively well circumscribed, yellowish white, flat, firm, and 5 mm x 8 mm in size. Otherwise, the ophthalmic examination was completely normal, including the anterior and posterior segments. Based on the clinical picture, an infiltrative/neoplastic lesion was suspected. Incision biopsy was performed to obtain a diagnosis for proper management. RESULTS: The histopathologic examination of the lesion showed an intensive proliferation of monotonous and histiocytoid cells beneath the epidermis. Immunohistochemical study revealed that the tumor cells were positively stained in the cytoplasm with anti CD1A antibody and anti S-100 antibody. The patient was then referred to the Oncology Department for evaluation. A detailed systemic examination, and the laboratory and radiologic investigations ruled out systemic involvement. The diagnosis of isolated LCH was finally made. Three months later, the lesion underwent remission without any treatment. CONCLUSIONS: This rare disorder may also present as a solitary lesion on the palpebral conjunctiva in adults, and so it should be kept in mind during the differential diagnosis of a conjunctival mass in an adult.

Mucoepidermoid Carcinoma of the Palpebral Conjunctiva

PURPOSE: We report our experience with a case of a nodular lesion of the lower palpebral conjunctiva with histologic features consistent with mucoepidermoid carcinoma. METHODS: A 72 year-old man presented with a left lower palpebral conjunctiva lesion. 3 x 3 mm sized flat pedunculated yellowish red mass was observed. Incisional biopsy proved the mass a mucoepidermoid carcinoma and wide local resection was conducted. RESULTS: Hematoxylin and eosin-stained sections showed lobules of tumor cells, consisting of predominantly epidermoid cells and scattered islands of mucin-secreting cells. Mucicarmine-stained sections demonstrated strong positivity, consistent with the diagnosis of mucoepidermoid carcinoma. CONCLUSIONS: In any case presenting palpebral conjunctival lesion, mucoepidermoid carcinoma should be differentiated, and it is necessary to confirm the diagnosis through biopsy.

Cyst Between the Levator Aponeurosis and the Palpebral Conjunctiva

Cysts of accessory lacrimal gland are rare. They are generally retension cysts that result from obstruction of the excretory duct and are found between the palpebral conjunctiva and the levator aponeurosis. We experienced three cases of subconjunctival cyst in the upper fornix. Histopathological examination showed the cysts lined by two layers and occasionally one layer of epithelium. These cysts seem to be originated from Krause's gland, considering their anatomical location and histopathological findings.