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Eye Case Study

An up-close look at a common eye lesion.

A 35-year-old woman presented to the emergency department reporting a three day history of right eye redness and pain. She endorsed constant irritation and redness, and she denied fever, itching, tearing, visual changes, or trauma to the eye. She reported that she had spent the prior week camping in the woods. On examination, the patient had a raised whitish-yellowish lesion on the nasal conjunctiva of her right eye, surrounded by mild erythema (Fig. 1 below). Her visual acuity was 20/20 bilaterally, and no foreign bodies or corneal abrasions were noted on fluorescein exam.

What are you looking at? 


Diagnosis: Pingueculitis

A pinguecula is a common degenerative eye lesion, which typically appears as a yellowish to whitish elevated protrusion on the conjunctiva at the 9 or 3 o’clock position. Unlike pterygium, they do not cover the cornea. Prevalence increases with age.

Acute inflammation of a pinguecula results in pingueculitis. Treatment of pingueculitis includes (1) eye protection from sun, wind and dust (which are thought to contribute to pinguecula), (2) artificial tears, and (3) topical steroids, topical NSAIDs, or topical anti-histamines in cases of severe symptoms. Patients treated with steroids should be given prompt ophthalmology follow-up.

The patient was discharged with artificial tears and topical steroids. She followed up in the ophthalmology clinic the next day and reported improvement in her symptoms.


REFERENCES

  1. Azhar SS. Acute Red Eye. Am Fam Physician. 2007 Sep 15; 76 (6):857-8. http://www.aafp.org/afp/2007/0915/p857.html
  2. Mimura et al. Severity and Determinants of Pinguecula in a Hospital-Based Population. Eye Contact Lens. 2011 Jan; 37 (1):31-5. doi: 10.1097/ICL.0b013e3181f91f2f.
  3. Gerstenblith A, Rabinowitz M, “Cornea” in The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease. 6th ed.

Amy, a 22-year-old student, saw her optician for a routine eye examination. He noted the presence of a small lesion on the inside of her left lower lid. Amy did not recall this from previous eye tests. She was fair skinned with multiple moles but no past or family history of skin cancer.

She was mildly myopic and also occasionally wore contact lenses. She had not experienced any discomfort, discharge or bleeding from the eye. Following her optician's recommendation, she decided to see her GP and the lesion was photographed and kept under regular review.

She was also advised to keep an eye on her other moles and report any changes to her doctor. Several months later the pigmented lesion appeared to increase in size and Amy consulted her GP again.

She was referred for an urgent opthalmological opinion, which concluded the lesion was benign naevus. However given the change it was excised as a day case procedure.

The procedure was uneventful and routine histology confirmed the benign nature of the lesion and Amy was reassured.

Rare diagnosis
Ocular melanoma is a rare eye tumour in adults with around 500 new cases diagnosed every year. Uveal melanoma is the most common type and occurs around the choroid, ciliary body and iris. Another type known as conjunctival melanoma can also occur more rarely on the conjunctiva or eyelid.

Excessive exposure to sunlight is an important contributory factor, particularly in fair, blue-eyed individuals. The incidence is also slightly higher in men and peaks around 55 years of age.

A strong family history is a risk factor and there is an association with dysplastic naevus syndrome (>100 moles on the body). Tumours can also metastasise to the eye from other parts of the body.

Melanomas can be asymptomatic or present with change in eye colour, pain, red or bulging eyes or visual loss. When assessing eyes an 'ABCDE approach' to skin lesions should still be used. Any changes in size or pigmentation are significant pointers to whether it should be referred for excision and histological confirmation. Ophthalmoscopy, ultrasound, skin biopsy or CT/MRI scans can be used to reach a diagnosis.

Treatment
Treatment is aimed at curing the cancer and preserving vision although the latter may not always be possible. Radiotherapy, thermotherapy or surgery can all be used as treatment options.

Local tumour control can be achieved in around 90 per cent of patients. However tumours are often not found early and metastases can be present in 40 per cent of patients at five years. Apart from metastases - most commonly to the liver, lungs or bone - other complications include visual loss or retinal detachment.

Treatment for large eye melanomas is more likely to lead to visual loss through enucleation (removal of the eyeball) than small ones.

In conclusion, ocular melanoma remains a rare but important cancer in patients. Patients will need regular follow up with X-rays or scans for many years even after successful treatment.

  • Dr Aziz is a GP in Bristol

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