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Publication Exclusive: Woman presents with forniceal lesions in left eye
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A 32-year-old woman was referred to the New England Eye Center by an optometrist for conjunctival cysts and concern for a possible neoplasm in the left eye.
History
The patient initially presented 1 month prior for a routine eye exam. She mentioned that she had noticed bumps in her left inferior fornix 1 year prior. Her only symptom at that time was itching of the left eye that had since resolved. She did not have any current ocular or systemic complaints. She had no ocular or medical history. Her surgical history consisted only of an appendectomy at the age of 24 years. She took no medications and did not have any known drug allergies. Social history was significant only for secondhand smoke exposure.
Examination
On examination, the patient’s uncorrected visual acuity was 20/20 in both eyes. Pupils were round, equal and reactive without afferent pupillary defect. IOP was 15 mm Hg in both eyes. Extraocular motility and confrontation visual fields were within normal limits. Examination of the conjunctiva of the right eye was unremarkable. The conjunctiva of the left eye, including the inferior fornix, initially appeared normal.
With further downward pressure, multiple conjunctival lesions deep within the fornix were revealed. Additionally, there was a mass under the left upper lid that was not previously noted. The remainder of the exam, including dilated funduscopic exam, was unremarkable.
What is your diagnosis?
Forniceal lesions
The differential diagnosis for this patient with multiple forniceal masses includes neoplastic, inflammatory and infectious causes.
Neoplastic causes include lymphoma, squamous cell carcinoma, metastasis, amelanotic melanoma and amyloid. These are often difficult to discern from each other except by biopsy. Often these will present as fleshy pink or yellow masses.
Inflammatory causes include lymphoid hyperplasia, sarcoidosis, allergic response or granulomas. Sarcoidosis typically appears as small, tan, distinct granulomatous nodules on the palpebral surface of the conjunctiva.
Infections such as chronic follicular conjunctivitis may present similarly.
Click here to read the full publication exclusive, Grand Rounds at the New England Eye Center, published in Ocular Surgery News U.S. Edition, August 10, 2015.