Various neoplastic or pseudoneoplastic lesions can clinically simulate conjunctival melanoma.1 We describe a patient who had unilateral argyrosis occurring in unusual circumstances who was referred to us with a probable diagnosis of conjunctival melanoma.
This 68-year-old patient had noticed, during the months preceding consultation, the presence of a pigmented spot mainly involving the lacrimal caruncle and bulbar conjunctiva of the inferior fornix of the right eye. This man, a photographic laboratory technician, was involved in a road accident 50 years previously and received a wound to the lower eyelid and lacrimal canaliculus of the right eye. He subsequently experienced bothersome epiphora and had developed the habit of wiping his tears while working in the darkroom with the same piece of cloth that he used to wipe developer and fixer solutions from his hands.
At clinical examination, he had a corrected visual acuity of 20/20 in both eyes. The anterior and posterior segments of the left eye had a normal appearance. The right eye had a scar extending from the forehead to the medial canthus, which was slightly lower than the contralateral medial canthus. The edge of the lower eyelid and lacrimal canaliculus were interrupted by a scarred notch situated between the lacrimal punctum and medial canthus (Figure 1). The skin of the lower eyelid was covered with small spots, sometimes coalescent, of a metallic grayish-brown (Figure 2). The ocular and palpebral conjunctiva, particularly in the inferior part, and the lacrimal caruncle was a dark grayish-brown (Figure 1). At high-power slitlamp examination, the cornea had finely granular grayish-brown deposits with a metallic appearance in the Descemet membrane and particularly numerous deposits in the inferior hemicornea (Figure 3). A subepithelial ring containing brownish particles was observed in the limbus. Intraocular pressure was 8 mmHg in both eyes, and ocular fundus examination did not reveal any abnormality. On the basis of the patient's clinical history and clinical examination results, the diagnosis of exogenous ocular argyrosis was proposed and subsequently confirmed by means of conjunctival biopsy.
Argyrosis of the lacrimal caruncle and ocular conjunctiva with dark perilimbic ring. Scarred section and defect of the inferior lacrimal canaliculus.
Metallic grayish-brown deposits in the palpebral skin.
Corneal argyrosis with grayish-brown deposits in the Descemet membrane.
Results of histological examination of the conjunctival epithelium were normal, but the superficial stroma contained numerous small blackish granules, sometimes situated immediately underneath the epithelium, but they did not induce any inflammatory reaction (Figure 4). Electron microscopy of the clumps of electron-dense deposits showed that they were both extracellular, associated with elastic fibers (Figure 5), and intracellular, situated inside intact cells (Figure 6), and that they sometimes clearly localized in secondary lysosomes (Figure 7). No specific treatment was proposed after confirmation of the definitive diagnosis.
Histological examination of the conjunctiva shows subepithelial silver deposits (hematoxylin-eosin, original magnification ×64).
Electron microscopy of the conjunctiva shows compact clumps of silver deposits between elastic fibers (original magnification×32 000).
Electron microscopy shows compact clumps of intracellular silver deposits (original magnification ×32 000).
Electron microscopy shows compact clumps of silver deposits in a secondary lysosome (original magnification×40 000).
Ocular argyrosis is a discoloration of the ocular tissues secondary to silver deposits. It can be either endogenous or exogenous, and its causes are mainly iatrogenic or occupational.
Exogenous ocular argyrosis used to be caused mainly by prolonged use of colloidal silver eyedrop preparations (Argyrol, Protargol) used as disinfectants.2- 4 Because these eyedrops are no longer used, this cause of disease has become exceptional. Apart from a few rare cases of accidental burns of the cornea during silver nitrate cauterization of the eyelid or limbic conjunctiva, argyrosis is now essentially an occupational disease caused by inadequate protection of the eyes in the workplace. According to a review of the literature5 and various published case reports and series, 4,6- 8 subjects exposed to argyrosis are workers in the silverware industry—polishers, engravers, smelters, silver platers, silver workers—factory workers manipulating silver nitrate, photographic film and x-ray film manufacturing workers, and photographic laboratory technicians.
In most cases, contact with the eye is indirect and caused by rubbing the eyes and eyelids with fingers contaminated by silver particles, and it is in all published cases bilateral. Silver deposits are formed in the conjunctiva, mainly in the inferior fornix, close to the medial canthus, lacrimal caruncle, perilimbic corneal epithelium, and Descemet membrane. The Bowman membrane is spared in exogenous argyrosis.3,4
The case presented here is unusual because of the series of events leading to unilateral corneal-conjunctival argyrosis that mimicked conjunctival melanoma. This patient, with a history of unrepaired traumatic section of the inferior lacrimal canaliculus 50 years previously, had bothersome lacrimation. He constantly wiped his tears with the same piece of cloth that he used to wipe his hands and that was covered with photographic developer and fixer solutions. Fixer solutions contain suspensions of silver salts derived from unexposed parts of the film, and the concentration of these salts gradually increases if the solution is not regularly renewed. This patient therefore transferred silver particles to his eye, mainly during periods with a high silver concentration in the fixer solution, which gradually led to the appearance of marked ocular argyrosis.
The clinical and histological features of the ocular lesion in this case correspond to those of exogenous argyrosis. Light microscopy of the conjunctiva showed that the silver deposits were essentially subepithelial; electron microscopy showed that they were both extracellular and intracellular, as in previously reported cases.3 Slitlamp examination of the cornea demonstrated that the silver deposits involved the Descemet membrane, which had a grayish-brown granular appearance, while the Bowman membrane was spared.
Clinical confusion between localized conjunctival argyrosis and conjunctival melanoma has already been reported after use of silver sutures for strabismus surgery in childhood.9- 11 However, to our knowledge, the case reported here is the first clinical and histological description of a case of exogenous unilateral occupational argyrosis mimicking a pigmented tumor of the conjunctiva. The unusual sequence of events leading to this case of argyrosis emphasizes the importance of meticulously obtaining clinical history, which may sometimes be sufficient to establish the diagnosis.
The authors have no relevant financial interest in this article.
Corresponding author and reprints: Leonidas Zografos, MD, Hôpital Ophtalmique Jules Gonin, 15, avenue de France, Case postale 411, 1000 Lausanne 9, Switzerland (e-mail: firstname.lastname@example.org).
Zografos L, Uffer S, Chamot L. Unilateral Conjunctival-Corneal Argyrosis Simulating Conjunctival Melanoma. Arch Ophthalmol. 2003;121(10):1483-1487. doi:10.1001/archopht.121.10.1483