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Original Investigation
June 22, 2017

Handheld In Vivo Reflectance Confocal Microscopy for the Diagnosis of Eyelid Margin and Conjunctival Tumors

Author Affiliations
  • 1Department of Medical, Surgical, and Neurological Science, Dermatology Section, University of Siena, S Maria alle Scotte Hospital, Siena, Italy
  • 2Department of Ophthalmology, University Hospital of Saint-Etienne, Saint-Etienne, France
  • 3Department of Dermatology, University Hospital of Saint-Etienne, Saint-Etienne, France
  • 4Biology, Engineering and Imaging of Corneal Graft Laboratory, EA2521, Jean Monnet University, Saint-Etienne, France
  • 5Department of Pathology, University Hospital of Saint-Etienne, Saint-Etienne, France
  • 6French University Institute, Paris, France
JAMA Ophthalmol. Published online June 22, 2017. doi:10.1001/jamaophthalmol.2017.2019
Key Points

Question  What is the diagnostic accuracy of handheld in vivo reflectance confocal microscopy for diagnosis of conjunctival tumors?

Findings  In an observational study of 295 lesions, in vivo reflectance confocal microscopy showed respective sensitivity and specificity values of 100% and 93% for conjunctival and 98% and 90% for eyelid margin malignant tumors.

Meaning  These data suggest that in vivo reflectance confocal microscopy has good diagnostic accuracy for conjunctival tumors and could help clinicians to diagnose these lesions correctly.


Importance  The clinical diagnosis of conjunctival and eyelid margin tumors is challenging, and new noninvasive imaging techniques could be valuable in this field.

Objective  To assess the diagnostic accuracy of handheld in vivo reflectance confocal microscopy (IVCM) for the diagnosis of eyelid margin and conjunctival tumors.

Design  A prospective observational study was conducted at University Hospital of Saint-Etienne from January 2, 2011, to December 31, 2016 (inclusion of patients until December 31, 2015, and follow-up until December 31, 2016). A total of 278 consecutive patients with eyelid margin or conjunctival lesions were included. Conjunctival lesions were diagnosed with a conventional clinical examination using a slitlamp and by handheld IVCM. Final diagnoses were established by histopathologic examination for 155 neoformations suspicious for being malignant through clinical and/or IVCM examination that were excised and on follow-up of 12 months or longer for the remaining 140 lesions.

Main Outcomes and Measures  Sensitivity, specificity, and positive and negative predictive values for malignant tumors of the conjunctiva and eyelid margin were calculated using clinical examination with slitlamp and handheld IVCM.

Results  In the 278 patients (136 [48.9%] females; mean [SD] age, 59 [21] years), a total of 166 eyelid margin and 129 conjunctival lesions were included in the analysis. Of the 155 excised neoformations with a histopathologic diagnosis, IVCM showed higher sensitivity compared with clinical examination conducted with the slitlamp for malignant tumors of the eyelid margin (98% vs 92%) and conjunctiva (100% vs 88%). The specificity for malignant eyelid margin tumors was higher for IVCM than for slitlamp examination (74% vs 46%), but slightly less for malignant conjunctival tumors (78% vs 88%). Analysis of all neoformations (155 excised and 140 in follow-up) confirmed these differences in the diagnostic accuracy of the clinical examination and IVCM. The presence of hyperreflective Langerhans cells mimicking malignant melanocytes was the main cause for misdiagnosis of malignant conjunctival tumors with IVCM.

Conclusions and Relevance  Handheld IVCM could be a useful tool for the identification of malignant conjunctival tumors. Further studies are required to confirm the usefulness of this device and identify possible features that can differentiate Langerhans cells from malignant melanocytes to prevent the misdiagnosis of melanoma using IVCM.