Successful removal of a conjunctival myxoma.

A 45-year-old woman presented with conjunctival myxoma in the right eye. A mixture of healon and trypan blue solution 0.06 mg was injected through a 27-gauge needle into the conjunctiva to delineate the lesion to achieve complete removal. This technique is effective in delineating the myxoma while preserving its integrity during removal. It may also help in lowering recurrence.

INTRODUCTION

Myxomas are benign slow-growing neoplasms of mesenchymal origin that occur in the heart, and other organs but very rarely in the eye.12 Conjunctival myxomas are extremely rare. Since the original published report in 1913, less than 30 cases have been published in PUBMED.

Conjunctival myxoma can be mistaken for other lesions including amelanotic nevi, squamous cell carcinoma, lymphoma, and conjunctival cyst. Here we report a successful removal of conjunctival myxoma using colored 2.3% sodium hyaluronate.

CASE REPORT

A 45-year-old female with no history of ocular trauma presented with painless swelling in the temporal bulbar conjunctiva of the left eye (OS) which had been present for 3 years. The lesion was diagnosed as a conjunctival cyst by her general physician. The patient was otherwise healthy. The visual acuity was 20/20 in the right eye (OD) and 20/25 OS, the intraocular pressure was 17 mmHg OD and 14 mmHg OS. Biomicroscopy OD was unremarkable, in the left eye, a 20 mm × 1.8 mm pink, translucent, soft, nontender mass was present [Figure 1a]. The lesion was well delineated, freely mobile over the sclera, and the overlying conjunctiva was congested. The remaining ocular examination was normal.

Figure 1

(a) Slit-lamp photography of the left eye showing a pink, translucent, soft, mass on the temporal bulbar conjunctiva, (b) Slit-lamp photography of the left eye after excision

A mixture of 0.5 mL of 0.06 of trypan blue 0.6% and 0.5 mL of Healon was made. The colored mixture was injected into the conjuctival lesion using a 27-gauge needle [Figure 2a]. The lesion became clearly defined and was completely excised [Figures 2b–c]. No leakage of the colored mixture was observed. An interrupted 8-0 Vicryl was used to suture the conjunctiva [Figure 2d].

Figure 2

(a) The mixture of healon and trypan blue was injected through a 27-gauge needle into the conjunctiva, (b) The conjunctiva is carefully separated from the conjunctival wall, (c) Complete resection of the conjunctival myxoma, (d) Interrupted 8-0 Vicryl was used to suture the conjunctiva

Postoperatively, 0.3% ofloxacine and 1 % prednisolone acetate drops were applied four times daily for 2 weeks. There has been no recurrence 1 year postoperatively [Figure 1b].

Histopathology reported a soft tissue mass with loose alcian-blue positive myxomatous stroma, proliferating spindle and stellate shaped cells, scattered mixed inflammatory cells, and some blood vessels [Figure 3]. The overall histological findings were suggestive of conjunctival myxoma. An echocardiogram was normal.

Figure 3

Conjunctival myxoma sample. Spindle and stellate shaped cells, scattered mixed inflammatory cells in addition to some blood vessels (H and E, ×400)

DISCUSSION

The incidence of conjunctival myxoma is 0.001-0.002% among conjunctival lesions.23 The mean age of the reported cases is 50 years (range, 18-80 years), with no gender predilection.2 This neoplasm presents as a nontender, slow-growing, yellow-pink, translucent, cystic, and/or solid well-circumscribed fleshy lesion. The majority of reported bulbar conjunctival myxomas have presented temporally similar to our case.

The differential diagnosis of conjunctival myxoma includes amelanotic nevus, amelanotic melanoma, fibrous histocytoma, lymphangioma, lymphoma, myxoid neurofibroma, spindle cell lymphoma, rhabdomyosarcoma, or myxoid liposarcoma. Conjunctival myxoma can be misdiagnosed as a conjunctival cyst. However, conjunctival myxoma reported to date have occurred in adults 18 of age or older, are painless, lack melanin, and rarely vascularized.2

The histopathology of conjunctival myxoma is unique, consisting of a few scattered spindle and stellate cells in a mucin matrix composed predominantly of hyaluronic acid and some chondroitin sulfate, reticulin fibers, scattered vasculature, and mature collagen fibers.2

The standard treatment for conjunctival myxoma is complete surgical excision.4

A similar technique in this report was applied in four patients with large conjunctival cyst; all cysts in these patients were completely removed while preserving cyst integrity.5

Ocular myxoma may be benign and localized or precede cardiac myxoma seen in Carney complex.6 Sudden death can occur in 16% of patients with cardiac myxoma.6 Therefore a thorough systemic examination is recommended, along with imaging studies to rule out cardiac myxoma.

In summary, complete excision can be achieved with the use of this technique and help in lowering the recurrence rate.