444
British Journal ofOphthalmology, 1992,76,444-446
Recurrent malignant melanoma of the corneal stroma: a case of 'black cornea' A D A Paridaens, C M Kirkness, A Garner, J L Hungerford
Institute of Ophthalmology, Department of Pathology A D A Paridaens A Garner Moorfields Eye Hospital, Cornea Clinic C M Kirkness* Moorfields Eye Hospital, Oncology Clinic J L Hungerford
*Cuffent address: Tennent Institute of Ophthalmology, University of Glasgow, Glasgow Correspondence to: Dr A D A Paridaens, Institute of Ophthalmology, Department of Pathology, 17/25 Cayton Street, London EC1V 9AT. Accepted for publication 12 December 1991
capsule, and inferior fornix. A donor corneal Abstract A 39-year-old Caucasian woman with a history graft was then sutured to the edges of the corneal of recurrent conjunctival melanoma of her host defect using interrupted 10/0 Nylon. The right eye developed an intrastromal heavily conjunctiva was closed over the bare scleral pigmented malignant melanoma, which component of the donor corneal graft, so that the involved the whole corneal diameter. The graft was covered to the level of the host limbus. Postoperatively, there was a mild corneal patient was treated by corneoscleral lamellar keratoplasty and there has been no evidence of stromal haze and the epithelial defect of the recurrent neoplasm during 4 years of foliow- donor graft healed within 2 weeks. Some pigment up. This apparently unique presentation of and interface irregularity was noted at the graft malignant melanoma ofthe cornea is illustrated host interface at 10 o'clock and both superficial and the differential diagnosis of corneal and deep neovascularisation were seen at 6 o'clock. One year after the surgery, the cosmetic pigmentation is discussed. result was very satisfactory (Fig 1B) and no noticeable changes of the pigmentation and vascularisation were observed, except for a small Malignant melanoma of the cornea is very area of flat pigmentation of the corneal edge at uncommon. Though primary corneal melanoma the 10-11 o'clock position. The best corrected has been reported'"5 this neoplasm is usually seen visual acuity was 6/9 (20/30) with - 5 D. Because in association with an adjacent limbal or con- of anisekonia the patient was fitted with a daily junctival melanocytic lesion. We describe a wear soft contact lens, which was well tolerated. patient with a history of recurrent conjunctival Topical steroid therapy has been continued in melanoma who presented with a black cornea gradually decreasing dosage (currently prednidue to extensive malignant melanocytic invasion solone drops, 3% twice daily). On her last visit in May 1991, 4 years after into corneal stroma. removal of the corneal malignant melanoma, the visual acuity was 6/9 and there was no evidence of recurrence of frank malignancy. Case report In February 1987 a 39-year-old Caucasian woman was referred to Moorfields Eye Hospital with a 9year history of recurrent malignant melanoma of HISTOPATHOLOGY her right conjunctiva. The diagnosis had been Histopathological examination of sections of the established by excision biopsies of temporal cornea and adjacent sclera showed a small focus perilimbal pigmented tumours in 1983 and 1985, of residual or recurrent malignant melanoma at which showed that the melanoma originated the periphery of the cornea within the superficial from an area of primary acquired melanosis stroma (Figs 3 and 4). Heavily pigmented cells with atypia. No additional cryotherapy or were observed between stromal lamellae across the entire corneal diameter, almost reaching the e irradiation had been given. She complained of having had right photo- resection margin on the opposite side. The phobia and blurred vision for several months. corneal epithelium was atrophic but otherwise On examination there was extensive and dense normal and there was no appreciable stromal pigmentation of the entire cornea, interfering vascularisation. Some infiltration of the adjacent with the central visual axis (Fig IA). Slit-lamp bulbar conjunctiva by neoplastic cells was also examination showed involvement of superficial seen together with mild inflammation in the corneal stroma. There was evidence of melanosis underlying stroma. Within the conjunctiva the of the temporal limbus but no nodular disease tumour was intraepithelial. Separate specimens was noted. No further areas of conjunctival from the vicinity of the lateral rectus muscle, the pigmentation were seen. The right visual acuity inferior Tenon's capsule, and from the nasal was 6/18 with pinhole and 6/36 unaided. The left conjunctiva showed no abnormality. unaided visual acuity was 6/6. The intraocular pressure was 10 mm Hg in both eyes. The left eye showed no abnormalities. Discussion In June 1987 a corneoscleral lamellar Pigmentation of the cornea is grossly or keratoplasty was performed. More than two biomicroscopically visible and is of several thirds of the thickness of the whole cornea were origins including ocular inflammation, conjuncexcised en bloc with a scleral component in the tival melanocytic lesions, anterior segment inferotemporal quadrant, which resulted in a trauma, the pigment dispersion syndrome,6 and keyhole shaped defect with a diameter of 15 mm drugs.7 8 Depositions of metals, blood pigments, by 24 mm (Fig 2). In addition diagnostic biopsies lipids, and lipofuscin9 may mimic the goldwere taken from nasal conjunctiva, Tenon's brown to black melanin pigmentation.
445
Recurrent malignant melanoma of the corneal stroma: a case of 'black cornea'
Fig 3A
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41
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Fig IA
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British Journal ofOphthalmology, 1992,76,444-446
Recurrent malignant melanoma of the corneal stroma: a case of 'black cornea' A D A Paridaens, C M Kirkness, A Garner, J L Hungerford
Institute of Ophthalmology, Department of Pathology A D A Paridaens A Garner Moorfields Eye Hospital, Cornea Clinic C M Kirkness* Moorfields Eye Hospital, Oncology Clinic J L Hungerford
*Cuffent address: Tennent Institute of Ophthalmology, University of Glasgow, Glasgow Correspondence to: Dr A D A Paridaens, Institute of Ophthalmology, Department of Pathology, 17/25 Cayton Street, London EC1V 9AT. Accepted for publication 12 December 1991
capsule, and inferior fornix. A donor corneal Abstract A 39-year-old Caucasian woman with a history graft was then sutured to the edges of the corneal of recurrent conjunctival melanoma of her host defect using interrupted 10/0 Nylon. The right eye developed an intrastromal heavily conjunctiva was closed over the bare scleral pigmented malignant melanoma, which component of the donor corneal graft, so that the involved the whole corneal diameter. The graft was covered to the level of the host limbus. Postoperatively, there was a mild corneal patient was treated by corneoscleral lamellar keratoplasty and there has been no evidence of stromal haze and the epithelial defect of the recurrent neoplasm during 4 years of foliow- donor graft healed within 2 weeks. Some pigment up. This apparently unique presentation of and interface irregularity was noted at the graft malignant melanoma ofthe cornea is illustrated host interface at 10 o'clock and both superficial and the differential diagnosis of corneal and deep neovascularisation were seen at 6 o'clock. One year after the surgery, the cosmetic pigmentation is discussed. result was very satisfactory (Fig 1B) and no noticeable changes of the pigmentation and vascularisation were observed, except for a small Malignant melanoma of the cornea is very area of flat pigmentation of the corneal edge at uncommon. Though primary corneal melanoma the 10-11 o'clock position. The best corrected has been reported'"5 this neoplasm is usually seen visual acuity was 6/9 (20/30) with - 5 D. Because in association with an adjacent limbal or con- of anisekonia the patient was fitted with a daily junctival melanocytic lesion. We describe a wear soft contact lens, which was well tolerated. patient with a history of recurrent conjunctival Topical steroid therapy has been continued in melanoma who presented with a black cornea gradually decreasing dosage (currently prednidue to extensive malignant melanocytic invasion solone drops, 3% twice daily). On her last visit in May 1991, 4 years after into corneal stroma. removal of the corneal malignant melanoma, the visual acuity was 6/9 and there was no evidence of recurrence of frank malignancy. Case report In February 1987 a 39-year-old Caucasian woman was referred to Moorfields Eye Hospital with a 9year history of recurrent malignant melanoma of HISTOPATHOLOGY her right conjunctiva. The diagnosis had been Histopathological examination of sections of the established by excision biopsies of temporal cornea and adjacent sclera showed a small focus perilimbal pigmented tumours in 1983 and 1985, of residual or recurrent malignant melanoma at which showed that the melanoma originated the periphery of the cornea within the superficial from an area of primary acquired melanosis stroma (Figs 3 and 4). Heavily pigmented cells with atypia. No additional cryotherapy or were observed between stromal lamellae across the entire corneal diameter, almost reaching the e irradiation had been given. She complained of having had right photo- resection margin on the opposite side. The phobia and blurred vision for several months. corneal epithelium was atrophic but otherwise On examination there was extensive and dense normal and there was no appreciable stromal pigmentation of the entire cornea, interfering vascularisation. Some infiltration of the adjacent with the central visual axis (Fig IA). Slit-lamp bulbar conjunctiva by neoplastic cells was also examination showed involvement of superficial seen together with mild inflammation in the corneal stroma. There was evidence of melanosis underlying stroma. Within the conjunctiva the of the temporal limbus but no nodular disease tumour was intraepithelial. Separate specimens was noted. No further areas of conjunctival from the vicinity of the lateral rectus muscle, the pigmentation were seen. The right visual acuity inferior Tenon's capsule, and from the nasal was 6/18 with pinhole and 6/36 unaided. The left conjunctiva showed no abnormality. unaided visual acuity was 6/6. The intraocular pressure was 10 mm Hg in both eyes. The left eye showed no abnormalities. Discussion In June 1987 a corneoscleral lamellar Pigmentation of the cornea is grossly or keratoplasty was performed. More than two biomicroscopically visible and is of several thirds of the thickness of the whole cornea were origins including ocular inflammation, conjuncexcised en bloc with a scleral component in the tival melanocytic lesions, anterior segment inferotemporal quadrant, which resulted in a trauma, the pigment dispersion syndrome,6 and keyhole shaped defect with a diameter of 15 mm drugs.7 8 Depositions of metals, blood pigments, by 24 mm (Fig 2). In addition diagnostic biopsies lipids, and lipofuscin9 may mimic the goldwere taken from nasal conjunctiva, Tenon's brown to black melanin pigmentation.
445
Recurrent malignant melanoma of the corneal stroma: a case of 'black cornea'
Fig 3A
14~~~~~~~q 40
41
9
Fig IA
V
I
'A
_*
iti
a
we
4
z gIIF.r,*
