CC: 61 y.o. caucasian woman presenting for evaluation of corneal mass OS found on routine exam ~2 months previous.

HPI: Patient was unaware of lesion when initially discovered. She denied pain or visual changes. Denied any growth of the lesion since discovery. She lives at a residential care facility.

PMH/FH/POH: schizophrenia, diabetes, and myopia.

Medications: escitalopram oxalate, mupirocin, valproic acid, metformin, quetiapine fumarate, docusate, glipizide, lorazepam, and insulin.

EXAM
Best corrected visual acuities: 20/20 OD and 20/50 OS.
W: -4.25+1.25 X 081 OD, -4.75+1.25 X 166 OS
mRx: -3.25+3.00 X 066 OS (20/20)
Pupils: normal, no RAPD
Confrontational VF: normal
EOM: normal
IOP: normal
SLE: 3+ NS cataract OD, see below for OS.
DFE: normal OU.
ON: normal OU.

Mass on conjunctivae and cornea OS
http://webeye.ophth.uiowa.edu/eyeforum/tumor05112004.jpg

Magnified view of lesion OS
http://webeye.ophth.uiowa.edu/eyeforum/tumor2_05112004.jpg

Feel free to discuss the following:

What tests should you order (I'll post labs when asked for them)?

What's the differential diagnosis?

What's the diagnosis?

What is the treatment of choice, surgically and/or medically?

okay,

this is probably some sort of tumor. especially with the feeder vessel coming from the conj around 4 o'clock. looks like it's actually arising form the cornea, but it might be from the inferior conj (hard to tell in these pictures).

i would biopsy this (unsure of the depth - incisional vs. excisional?) and get pathology on this.

the differential includes benign and malignant tumors of the cornea and conjunctiva. there are a ton of these. it's possible this is a corneal squamous cell carcinoma (or conjunctival), or a melanoma from the conj that grew into the cornea. since it's one of these cases though, and someone other than andrew presented it, i bet it's some crazy rare tumor i've never heard of!

Ahhhh, I finally have internet access again. Moving can be a huge pain...

DDx:
1) Conjunctival melanoma (partially pigmented)
2) Conjunctival squamous cell carcinoma
3) Conjunctival nevus

The conjunctival feeder vessel is a more ominous sign as already noted and I don't think a simple nevus can have one.

She apparently has no known history of primary acquired melanosis or nevus. Apparently about 95% of cases of conjunctival melanoma will arise from one of these two conditions.

I'd vote for wide excisional biopsy due to suspicion of melanoma. You don't want to leave positive margins if possible.

i read that she didn't notice this growth AND that she was a schizophrenic, likely heavily medicated...so it could have been there forever...

likely a tumor, I would vote for small excisional biopsy, get a diagnosis, then proceed with PK if needed.

as for kind of tumor:

an epithelial-like tumor
lymphangioma
melanoma

likely not:
dermoid
foreign-body rxn
granulomatous rxn (hansen's sarcoid tb)

Discussion and diagnosis posted: http://webeye.ophth.uiowa.edu/eyeforum/case15.htm

with the sentinal vessel coming in it's pretty textbook for a melanoma....

Now I have to go read andrew's synopsis and see how things ended up for her. Poor thing.. that had to be terribly scary :(