Introduction
Papilloma is a histopathological term describing specific morphology of tumors. Conjunctival papilloma is a benign growth that arises from the stratified squamous epithelium of the conjunctiva.1 They can be classified as pedunculated or sessile. The pedunculated type is synonymous with infectious conjunctival papilloma and squamous cell papilloma. The sessile type is synonymous with limbal conjunctival papilloma as they are believed to arise from UV radiation exposure and are non infectious. A strong association exists between development of conjunctival papilloma and human papilloma virus (HPV) types 6 and 11.2 These are known to occur both in children and adults with the highest incidence between 21 and 40 years and there is a male preponderance.3, 4 The most common sites for conjunctival papilloma are bulbar conjunctiva,5 palpebral conjunctiva3 and caruncle.4, 6
Case Report
Case 1
A 60-year-old male presented with recurrent limbal conjunctival swelling in left eye. He had history of gradually increasing conjunctival swelling since six months. Patient gave history of excision of similar swelling at the same location 9 months back. The failure of first excision biopsy done 9 months back could be due to high recurrence rate of upto 27% seen in conjunctival papillomas. The patient did not have any major symptoms except for mild discomfort but he reported gradual increase in size of swelling. On examination, the swelling was present inferiorly from 5 to 8 o` clock position at limbus. The swelling was sessile and was encroaching towards cornea (Figure 1).
Case 2
A 70-year-old male presented with complaints of diminution of vision, watering, forgien body sensation, photophobia and blepahrospasm. The patient had history of gradually increasing conjunctival growth since 9 months. The patient gave history of excision of similar swelling one and a half year back. On examination, his visual acuity was hand movements, conjunctival growth covering 270 degree of limbal area and extending over whole of the cornea was noticed (Figure 2).
Excisional biopsy of the swelling was performed under local anaesthesia. Excision was done with aim of clearing 1mm of normal conjunctival tissue. The swelling was found to be growing onto the cornea at the limbus. Limbal area was cleared with use of diamond burr. Double freeze thaw method of cryotherapy was applied at the base of remaining conjunctival tissue (Figure 3). Mitomycin C (0.3 mg/ ml) was applied to the base of the growth for 3 minutes (Figure 4). This was followed by copious irrigation and application of cryotherapy. The excised tissue was sent for histopathological examination which confirmed the diagnosis of benign conjunctival papilloma and confirmed marginal clearance of excised tissue. (Figure 5). Patient was started post operatively on chloramphenicol eye drops and mitomycin C eye drops (0.002%) for a period of 3 months to prevent recurrence.(Figure 6)
Both the patients were followed over a period of two years. The patient in case 2 had remarkable improvement in symptoms and his visual acuity improved to 6/18 (Figure 7). There were no signs of recurrence of lesion. Both the patients are still being followed up for recurrence of lesions.(Figure 8 )
Discussion
The recurrence rates of conjunctival papilloma has been reported to range from 3% to 27%.4, 5, 6 Various adjunctive therapeutic modalities have been described to prevent recurrence such as CO2 laser, adjunctive cryotherapy, topical mitomycin C or interferon alpha 2b and post-operative use of oral cimetidine.3, 4, 7, 8, 9, 10, 11, 12, 13 Conservative treatment involves observation and reassuring the patient as lesions may regress spontaneously.14 Regression of the lesion was observed after use of topical interferon alpha 2b in small to medium lesions.15, 16 Cryotherapy is used as adjunctive therapy especially in recurrent lesions. Double freeze thaw method is preferred and it causes minimal scarring. Use of topical antimetabolites like Mitomycin C and 5 Flurouracil has been reported to prevent recurrence. Co2 laser has been found to be safe and effective. Dinitrochlorobenzene (DNCB) is reserved for cases where other treatment modalities as surgical excision and cryoablation have failed.14, 17
Conclusion
Conjunctival papillomas are benign tumours with a minimal propensity toward malignancy. The risk is malignant transformation is noticed especially in papillomas with inverted growth pattern or reccurence.18 Long term surveillance is required in these patients.
