The conjunctiva is the thin transparent membrane covering the white of the eye, the sclera, and the inner surface of the eyelids. Growths that arise in this membrane are called conjunctival tumors. Because they sit in a directly visible area, they are often noticed early; most of my patients come because they have seen a lump or a change in colour in the mirror.
The majority of these growths are benign. Even so, malignant tumors such as melanoma and squamous cell carcinoma do arise in the conjunctiva, and in their early stages they can resemble benign lesions. My basic approach follows from that: a lesion on the ocular surface should be shown to be benign, by examination or where necessary by pathology, rather than dismissed on appearance.
Not every lump on the eye is a concern, but the following features call for assessment:
Small lesions with regular borders that have not changed for years, such as naevi and pingueculae, need no surgery. They are followed with periodic examination and photographs. I also explain to my patients what to watch for so they can notice change themselves.
This is the foundation of treatment. Where malignancy is possible, the lesion is removed whole with a margin of healthy tissue and without touching the lesion itself, a technique that matters because it prevents tumor cells being spread into the surrounding tissue. After excision the surface at the corneal edge is smoothed, and the tumor bed may be treated with freezing to destroy any residual cells.
Wide excisions leave a bare area that has to be covered, using an autograft from the patient's own conjunctiva or amniotic membrane. Very large defects may need an oral mucous membrane graft. Covering the surface properly both speeds healing and prevents adhesions forming between lid and globe, a subject covered on the symblepharon page.
Chemotherapy and immune-stimulating agents given as drops onto the surface are used in diffuse superficial disease and where surgical margins are not sufficient. In selected cases radiotherapy can be delivered through a plaque placed on the ocular surface. Melanoma and lymphoma with systemic spread are managed together with medical oncology.
The type of lesion removed determines how closely a patient is followed. Recurrence is not expected with benign tumors, though review in the first year is still advised. Squamous cell carcinoma and melanoma can recur, so follow-up continues for years and is not confined to the eye. Recurrences caught early are far simpler to treat, and that is the real reason for regular review.
The most effective preventive step is reducing ultraviolet exposure: ultraviolet-filtering sunglasses that also shield from the side, and a wide-brimmed hat, matter particularly for outdoor workers. Stopping smoking lowers the risk of squamous cell carcinoma.
If you notice a growing lump on the eye, a mole that is darkening or spreading, tissue that bleeds on its own, persistent one-sided redness or a palpable mass on the inner surface of the lid, I would advise an examination. Related conditions are collected under ocular surface diseases.
Ayşe Dolar Bilge MD, FEBOphth.
Ophthalmologist, Oculoplastic Surgery
As an Ophthalmologist, Dr. Ayşe Dolar Bilge, I provide diagnosis and treatment services with my experienced team.
Most lumps on the white of the eye are benign, chiefly pinguecula, naevus and cyst. A lesion that has grown or darkened over recent months, developed prominent vessels, become fixed to the underlying tissue or bled spontaneously should be assessed. Deciding on appearance alone is not sound; the distinction is made by examination and, where needed, pathology.
Conjunctival naevi usually stay unchanged for life, and slight darkening during adolescence or pregnancy is expected. Increasing size, irregular spread of pigment, new areas of pigment and the development of prominent feeding vessels are the findings that call for follow-up. Photographic surveillance is used, and where doubt persists the lesion is excised and examined pathologically.
Where malignancy is possible, the mass is removed whole with a margin of healthy tissue and without touching the lesion directly. The tumor bed may be treated with freezing to destroy residual cells. After wide excision the bare area is covered with a patch of the patient's own conjunctiva or with amniotic membrane. The excised tissue is always sent for pathology.
Most benign lesions do not become cancerous. There are exceptions: melanoma arising within a conjunctival naevus is rare but possible, and the diffuse pigment change called primary acquired melanosis can give rise to melanoma. Similarly, precursor lesions of the surface epithelium can progress over time to squamous cell carcinoma. That is why lesions that change deserve follow-up.
Yes. Ultraviolet exposure is a leading risk factor, particularly for squamous cell carcinoma, and it also contributes to pterygium and pinguecula. Rates are higher in outdoor workers and in people living in sunny climates. Ultraviolet-filtering sunglasses that shield from the side, together with a wide-brimmed hat, are the most effective protection. Stopping smoking also lowers the risk.
Recurrence is not expected with benign tumors, though I still advise review during the first year. Squamous cell carcinoma and melanoma can recur, so follow-up continues for years and is not limited to the eye. Because recurrences caught early are far simpler to treat, regular review counts as part of the treatment in these conditions.
A soft, painless salmon-coloured elevation on the white of the eye suggests a lesion arising from lymphoid tissue, which may be benign lymphoid hyperplasia or a lymphoma. Biopsy makes the distinction. When lymphoma is diagnosed, a whole-body assessment follows, since it may be part of a systemic disease.
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