should be noted, with the following considered:

Is there a single lesion, or is it multifocal? Is the lesion pigmented or amelanotic?

Where is it located—on the bulbar conjunctiva, at the limbus, in the fornix, on the palpebral conjunctiva?

Does the lesion extend onto the cornea? Is the lesion solid or cystic?

Is it flat or elevated?

Is the lesion fixed to the underlying tissues, or is it mobile? Is there a feeder vessel?

The entire ocular surface should be examined, including the entire superior fornix, which requires eyelid eversion. The clinician should document the appearance and extent of the lesion, using either photographs or a detailed diagram. This aids in surgical planning if the lesion is to be removed, or in following the lesion if observation is recommended.

Management of Patients With Conjunctival Tumors

An experienced clinician will often have an opinion about the nature of a conjunctival lesion after completion of the history and physical examination. However, definitive diagnosis almost always requires tissue for histologic evaluation. Lesions that cause concern for possible malignancy are

elevated lesions

extensive pigmented lesions, even if flat lesions fixed to the underlying tissues lesions with a large feeder vessel

These lesions should be managed as described in the following sections.

Many conjunctival lesions are not worrisome for malignancy (eg, inclusion cysts); others will be indeterminate based on the history and the results of the clinical examination. For these cases, observation may be a reasonable option. If observation is elected, regular ophthalmic examinations are essential. If growth or changes in the characteristics of the lesion are documented, one should proceed to surgery.

Surgical Treatment

The standard surgical treatment of a suspicious lesion of the conjunctiva is complete removal of the tumor, including 4 mm of uninvolved tissue surrounding the lesion when possible. The surgeon attempts to avoid touching the tumor during removal (a “no touch” technique) in order to prevent inadvertent seeding of the remaining conjunctiva with tumor cells. Incisional biopsies should be avoided for the same reason, especially in pigmented lesions of the conjunctiva. Involvement of the corneal epithelium is managed using alcohol-assisted​ epithelial curettage with a surgical blade, with care taken to avoid violation of the Bowman membrane, which is a natural barrier to tumor extension into the corneal stroma. Some lesions may require lamellar sclerectomy for complete removal. Cryotherapy at the time of ocular surface surgery has been shown to improve the prognosis,

especially in conjunctival melanoma.

Once the tumor is removed, additional manipulations should be performed with clean surgical instruments in order to reduce the chance of tumor seeding. Primary conjunctival closure or a conjunctival autograft may be considered if the conjunctival defect is small. Ocular surface reconstruction with amniotic membrane transplantation is useful in the management of conjunctival lesions and allows for wider tumor margins with less risk of postoperative scarring. Amniotic membrane also facilitates reepithelialization and reduces postoperative inflammation. The graft should be cut slightly larger than the defect and may be attached with fibrin-based​ tissue adhesive. If tissue adhesive is not available, either absorbable (9-0 or 10-0 polyglactin) or nonabsorbable (10-0 nylon) suture may also be used to fixate the graft. If more than two-thirds of the limbus is removed, chronic epitheliopathy may result. Stem cell transplantation using tissue harvested from the fellow eye of the patient may eventually be required.

Once removed from the ocular surface, the lesion can be placed on filter paper and the edges labeled to facilitate histopathologic diagnosis. Care should be taken to avoid damage to the specimen during removal, as any damage could make the lesion more difficult to interpret. The clinical history is relevant to the pathologist’s interpretation of the lesion; thus, the label should include the following information: the age and ethnicity of the patient, the duration of the lesion, and whether the lesion has changed clinically. Diagnosis of conjunctival tumors can be challenging, especially for general pathologists. If possible, conjunctival tumors should be read by an ophthalmic pathologist. Immunostaining can help in distinguishing benign from malignant lesions. Histopathologic findings of various ocular surface tumors are reviewed in BCSC Section 4, Ophthalmic Pathology and Intraocular Tumors.

Topical Chemotherapy

Topical chemotherapy can be used in the management of ocular surface tumors as primary treatment before or instead of surgical tumor removal or, more commonly, as an adjunctive therapy after tumor excision. An advantage of topical chemotherapy is that it treats the entire ocular surface. For squamous lesions, topical interferon-α2b is first-line therapy. Topical mitomycin C (MMC) or 5- fluorouracil (5-FU) may be considered for squamous lesions that do not respond to interferon-α2b. For atypical melanocytic lesions, MMC is the most commonly used agent.

Topical interferon-α2b is very well tolerated. Recent reports have suggested the use of topical interferon-α2b as primary therapy for tumors in the squamous cell family; however, one potential disadvantage of this course of treatment is the lack of histopathologic diagnosis. In addition, the effectiveness of topical interferon-α2b in the treatment of melanotic tumors has not been proven. Since there is some overlap in the appearance of various tumors (eg, amelanotic conjunctival melanoma may resemble squamous cell carcinoma), there is concern that if chemotherapy is elected and the tumor does not respond, valuable time in the management of a potentially deadly lesion may have been lost. Another disadvantage of topical interferon-α2b is that it is expensive and may take several months to work. Some authors advocate using topical interferon-α2b before definitive surgical removal, with the purpose of trying to shrink large ocular surface squamous tumors preoperatively.

The optimal topical chemotherapy regimen has not been determined in controlled studies, but, typically, topical interferon-α2b is given 4 times daily until clinical response occurs, usually within 2 to 4 months. Topical MMC, because of its potential toxicity, is typically administered for short