Background

Conjunctival papilloma is a benign growth or tumor that occurs on the surface of the conjunctiva, thin membrane that lines the inside of eyelids and covers the white part of eye. It is caused by a viral infection, most commonly the human papillomavirus (HPV). Conjunctival papillomas can occur in both children and adults and may present as single or multiple growths on the conjunctiva.

These papillomas are typically pink or fleshy in appearance and can vary in size. They may cause symptoms such as redness, irritation, tearing, foreign body sensation, or blurred vision. Conjunctival papillomas are usually not malignant, but in rare cases, they can be associated with premalignant or malignant changes.

Epidemiology

Incidence and Prevalence:

• Conjunctival papilloma is a relatively rare condition.
• The exact incidence and prevalence rates vary across different populations and geographic regions.
• The incidence is highest among patients 20-39 years old.

Age and Gender:

• Conjunctival papilloma can occur at any age but is more commonly observed in children and young adults.
• It may also affect older individuals, particularly in cases associated with human papillomavirus (HPV) infection.
• There is no significant gender predilection, and it can affect both males and females.

Risk Factors:

• Human papillomavirus infection is the most common risk factor associated with conjunctival papilloma.
• Other risk factors may include sexually transmitted infections, history of genital warts, or close contact with individuals with HPV infection.

Anatomy

Pathophysiology

Conjunctival papilloma is a benign epithelial tumor that primarily affects the conjunctiva, the thin membrane covering the front surface of eye and inner surface of eyelids.

Pathogenesis:

• HPV infects the basal cells of the conjunctival epithelium, leading to cellular proliferation and the formation of papillary projections.
• The virus integrates its DNA into the host cell’s genome, causing disruption of cell cycle regulation and uncontrolled growth.
• The overgrowth of infected cells results in the development of papillomas, which can vary in size, shape, and appearance.

Immune Response:

• The immune response plays an important role in the development and clearance of conjunctival papillomas.
• The host immune system mounts a response to HPV infection, involving both innate and adaptive immune mechanisms.
• However, in some cases, the immune response may be insufficient to eliminate the virus, leading to persistent infection and papilloma formation.

Etiology

• The primary etiological factor for conjunctival papilloma is infection with human papillomavirus, particularly HPV types 6 and 11.
• HPV is a DNA virus that is transmitted through sexual contact but also transmitted vertically from mother to child during childbirth or through non-sexual contact.
• HPV infects the basal cells of the conjunctival epithelium, leading to cellular proliferation and the formation of papillary projections.

Genetics

Prognostic Factors

Recurrence:

• Conjunctival papillomas have the potential for recurrence, and the likelihood of recurrence depends on various factors.
• Recurrence rates range from approximately 10% to 70% depending on the extent of the initial lesion and the adequacy of treatment.

Histopathologic Features:

• The histopathologic features of conjunctival papilloma can provide prognostic information.
• Certain histologic subtypes, such as inverted and exophytic papillomas, may have different clinical behaviours and outcomes.

Involvement of the Ocular Surface:

• The location and involvement of the conjunctival papilloma on the ocular surface can influence the prognosis.
• Papillomas that extend onto the cornea or involve the limbus may have a higher risk of complications and poorer outcomes.

Size and Tumour Thickness:

• The size and thickness of the conjunctival papilloma can impact the prognosis.
• Larger or thicker lesions may be associated with a higher risk of recurrence or more challenging surgical management.

Presence of High-Risk Human Papillomavirus (HPV) Strains:

• Some studies suggest that the presence of high-risk HPV strains, such as HPV types 16 and 18, may be associated with a higher risk of recurrence and malignant transformation.

Clinical History

CLINICAL HISTORY

Age Group:

• Conjunctival papilloma can occur in individuals of all age groups, including children and adults.
• It is more commonly observed in younger individuals, with a peak incidence in second and third decades of life.

Physical Examination

PHYSICAL EXAMINATION

Inspection:

• The conjunctival papilloma is visually examined for its size, shape, color, and location on the conjunctiva.
• It appears as a fleshy, pink or flesh-colored, elevated growth with a rough or cauliflower-like surface.
• The lesion may be single or multiple and can vary in size from a few millimeters to several centimeters.

Visual Acuity:

• Visual acuity is assessed to determine if the papilloma is affecting vision.
• The presence of papilloma near the visual axis or involvement of the cornea may cause visual disturbances.

Slit Lamp Examination:

• A slit lamp examination is performed to examine the lesion in more detail.
• The papilloma is examined under magnification to assess its morphology, vascularity, and any associated features such as keratinization or pigmentation.
• The presence of any corneal involvement, such as neovascularization or opacities, is also evaluated.

Eyelid and Conjunctival Evaluation:

• The eyelids and adjacent conjunctiva are examined for any associated lesions, such as papillomatous growths or signs of inflammation.
• The presence of associated symptoms like redness, discharge, or irritation is noted.

Lymph Node Examination:

• The regional lymph nodes, particularly preauricular and submandibular nodes, are palpated for any enlargement or tenderness.
• Lymph node involvement may indicate spread of the papilloma or underlying pathology.

Age group

Associated comorbidity

Associated Comorbidity or Activity:

• Conjunctival papilloma is often seen in individuals with a history of HPV infection or exposure.
• Risk factors for HPV infection include a history of multiple sexual partners, unprotected sexual activity, and immunosuppression.
• Immunocompromised individuals, such as those with HIV/AIDS or organ transplant recipients, may have an increased risk of
• developing conjunctival papilloma.

Associated activity

Acuity of presentation

Acuity of Presentation:

• Conjunctival papilloma typically presents as a slow-growing, painless mass or lesion on the conjunctiva.
• The lesion may appear as a fleshy, pink or flesh-colored, elevated growth with a rough or cauliflower-like surface.
• In some cases, multiple papillomas may be present.

Differential Diagnoses

DIFFERENTIAL DIAGNOSIS

Conjunctival Squamous Papilloma:

• Conjunctival squamous papilloma is the most common benign conjunctival tumor and may present with similar features to conjunctival papilloma.
• It is characterized by a pink or fleshy elevated growth with a papillary or verrucous surface.
• Histologically, it shows hyperplasia of squamous epithelium.

Conjunctival Nevus:

• Conjunctival nevus is a benign melanocytic lesion that can resemble conjunctival papilloma.
• It appears as a pigmented, well-circumscribed lesion on the conjunctiva.
• It may have a flat or slightly elevated surface and may show features such as pigmented cells and nests on histopathological examination.

Conjunctival Lymphoma:

• Conjunctival lymphoma, particularly mucosa-associated lymphoid tissue (MALT) lymphoma, can present as a conjunctival mass.
• It may mimic conjunctival papilloma in terms of its appearance.
• Histological examination and immunohistochemical staining are required to differentiate lymphoma from papilloma.

Conjunctival Cyst:

• Conjunctival cysts, including epithelial inclusion cysts and retention cysts, can resemble papilloma.
• They appear as fluid-filled, translucent lesions on the conjunctiva.
• Cysts can be distinguished from papilloma based on their lack of vascularity and characteristic histological features.

Pinguecula and Pterygium:

• Pinguecula and pterygium are common conjunctival degenerative conditions that may resemble conjunctival papilloma.
• They typically appear as raised, yellowish-white or pinkish growths on the conjunctiva.
• Differentiation is based on their characteristic location, absence of papillary or cauliflower-like surface, and histological features.

Laboratory Studies

Imaging Studies

Procedures

Histologic Findings

Staging

Treatment Paradigm

TREATMENT REGIMEN

Modification of Environment:

• No specific environmental modifications are required for the treatment of conjunctival papilloma.

Administration of Pharmaceutical Agents (Drugs):

• Observation: Small and asymptomatic conjunctival papillomas may not require treatment and can be observed for any changes in size or symptoms.
• Topical Medications: Antiviral medications (e.g., interferon alpha-2b, cidofovir) may be used in certain cases to manage recurrent or extensive papillomas.

Intervention with a Procedure:

• Surgical Excision: Surgical removal is the mainstay of treatment for conjunctival papilloma.
• Excision with or without cautery or cryotherapy can be performed.
• Excision may be done using various techniques, including snip excision, shave excision, or full-thickness excision.
• Laser Ablation: Laser therapy, such as carbon dioxide (CO2) laser or argon laser, can be used to remove papillomas.
• Electrosurgery: Electrosurgical techniques, such as electrocautery or electrodissection, may be utilized to remove the papillomas.
• Cryotherapy: Cryotherapy involves freezing the papilloma with liquid nitrogen to destroy the lesion.
• Topical Mitomycin C: Mitomycin C, an antineoplastic agent, can be applied topically after surgical excision to reduce the risk of recurrence.

Phase of Management:

• Follow-up: Regular follow-up visits are necessary to monitor for recurrence or any complications after treatment.
• Long-term Monitoring: Since conjunctival papillomas have the potential for recurrence, long-term monitoring is essential to detect any new lesions or changes in existing ones.

by Stage

by Modality

Chemotherapy

Radiation Therapy

Surgical Interventions

Hormone Therapy

Immunotherapy

Hyperthermia

Photodynamic Therapy

Stem Cell Transplant

Targeted Therapy

Palliative Care

Medication

Future Trends

Media Gallary

References

Conjunctival papilloma: A histopathologically based restrospective study.onlinelibrary.wiley.com