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1 Department of Ophthalmology, University of Minnesota, Minneapolis, MN, USA
2 Department of Pathology, University of Minnesota, Minneapolis, MN, USA
3 UCLA/Jules Stein Eye Institute, Los Angeles, CA, USA
4 Apple Hill Eye Center, 25 Monument Road, Suite 297, York, PA 17403, USA
Correspondence to:
Andrew J W Huang
MD, Department of Ophthalmology, University of Minnesota, 516 Delaware Street SE, 9th Floor, Minneapolis, MN 55455, USA; huang088@umn.edu
Accepted for publication 1 October 2004
Keywords: corticosteroids; benign lymphoid hyperplasia
Appropriate treatment of subconjunctival benign lymphoid hyperplasia (BLH) has been unclear. Most have noted poor response to oral or topical corticosteroids. Many recommend observation. Radiotherapy has been used, but there are risks of vision loss.
In this case, we found dramatic response to local subconjunctival injection of long acting corticosteroids, which may represent a therapeutic option for subconjunctival benign lymphoid hyperplasia.
Case report
A 72 year old woman noticed an enlarging mass on the nasal conjunctiva over the previous year. She denied any discomfort, diplopia, or visual changes. She was pseudophakic in both eyes, and did not have any past ocular trauma, infection, or eye disease. She had a history of hypothyroidism, multiple myeloma, tuberculosis, and pulmonary sarcoidosis. Two months before presentation she was found to have colon carcinoma treated with colectomy and chemotherapy. She was reportedly free of any tumour metastasis.
Her visual acuity was 20/30 in the right eye and 20/40 in the left, and extraocular motility was full in both eyes. Examination revealed a salmon coloured, raised, and moderately firm patch on the nasal conjunctiva of the right eye without significant neovascularisation (fig 1A). Dilated fundus examination was unremarkable. A head MRI scan showed moderate enlargement of the medial rectus muscle without involvement of the muscle tendon. A simple biopsy (2 mmx2 mmx1 mm) of the lesion was performed.
Figure 1 (A) Slit lamp photograph of the patient’s right eye on initial presentation. Note the size, salmon colour and raised appearance of the lesion. (B) Slit lamp photograph of the same lesion 2 months later following subconjunctival injection of triamcinolone. The subconjunctival lesion appeared to have completely resolved with no obvious remnants seen on the sclera or conjunctiva. (Reproduced with permission.)
Pathological examination revealed benign lymphohistiocytic infiltrates (fig 2). The lymphoid reaction showed a predominance of T cells (CD3+), numerous histiocytes, and a smaller number of B cells (CD20+). There was no evidence of neoplastic plasma cells, metastatic carcinoma, or well defined sarcoid granulomas.
Figure 2 Haematoxylin and eosin staining, 10x magnification of the lesion biopsied in figure 1A. Note the abundance of lymphocytes seen more clearly in the magnified section in the lower right part of the figure. Also note the predominance of T cells (CD 3+) with a less numerous population of B cells (CD20+) typical of benign lymphoid hyperplasia.
The patient elected to have surgical treatment over other options including observation. The patient received a 20 mg/0.5 ml subconjunctival injection of triamcinolone (in 0.5 ml in the nasal bulbar conjunctiva) just superior to the mass. On follow up examination 2 months later, the patient continued to deny any discomfort or visual changes and was very pleased about her response to the treatment. Remarkably, the lesion completely resolved being no longer visible or palpable (fig 1B). This patient unfortunately died 9 months later from complications secondary to a fall, but during this time there was no recurrence of the conjunctival lesion.
Comment
A patient presenting with a slow growing salmon coloured subconjunctival mass should always raise suspicion of neoplastic causes. Patients with ocular BLH and lymphoma will often have the similar presenting symptoms and demographic profiles. In addition they appear very similar radiologically,1 and thus definitive diagnosis requires tissue biopsy. A pathological diagnosis of BLH traditionally requires reactive follicles, polyclonality, and the absence of cytological atypia.2 Lymphoproliferative lesions can occur throughout the ocular adnexa, and some studies suggest a more benign course for conjunctival BLH compared to those in the orbit.3 Coupland et al found that of 112 cases, 32 (29%) were in the conjunctiva, 52 (46%) in the orbit and the remainder in the eyelid, lacrimal gland, and caruncle.4 The optimal treatment for BLH is uncertain. Many recommend frequent observation. Others have tried focal radiotherapy with some success,5 but there is a significant risk of vision loss.6 In a recent review of 117 cases of conjunctival lymphoproliferative lesions, 17% were BLH, 22% were atypical lymphoid hyperplasia, and 56% were lymphoma.7 In these cases 9% were observed, 42% had complete excisional biopsy, 4% had biopsy and cryotherapy, 44% had biopsy and external beam irradiation, and 6% had biopsy and chemotherapy.7
In this case report, we found a dramatic response to local subconjunctival injection of a long acting corticosteroid. The corticosteroid near the reactive follicle must have been sufficient to suppress lymphocyte proliferation. This response may represent a therapeutic option for BLH.
References
Knowles DM, Jakobeic FA. Malignant lymphoma and lymphoid hyperplasia occurring in the ocular adnexa. In: Knowles DA, ed. Neoplastic hematology. Baltimore: Williams & Wilkins, 1992:1009–46.
Cockerham GC, Jakobiek FA. Lymphoproliferative disorders of the ocular adnexa. Int Ophthalmol Clin 1997;37:39–59.
Knowles DM, Jakobiek FA, McNally L, et al. Lymphoid lyperplasia and malignant lymphoma occurring in the ocular adnexa (orbit, conjunctiva, and eyelids): a prospective multiparametric analysis of 108 cases during 1977 to 1987. Hum Pathol 1990;21:959–73.
Coupland SE, Krause L, Delecluse H-J, et al. Lymphoproliferative lesions of the ocular adenexa. Analysis of 112 cases. Ophthalmology 1998;105:1430–41.
Keleti D, Flickinger JC, Hobson SR, et al. Radiotherapy of lymphoproliferative diseases of the orbit. Surveillance of 65 cases. Am J Clin Oncol 1992;15:422–7.
Bessel EM, Henk JM, Whitelocke RAF, et al. Ocular morbidity after radiotherapy of orbital and conjunctival lymphoma. Eye 1987;1:90–96.
Shields CL, Shields JA, Carvalho C, et al. Conjunctival lymphoid tumors. clinical analysis of 117 cases and relationship to systemic lymphoma. Ophthalmology 2001;108:979–84.