Right eye. A, Anaplastic conjunctival melanoma at the initial visit. B, Photographic documentation from a previous examination demonstrates no abnormal depigmentation of the eyelashes. C and D, Poliosis on the right upper eyelid adjacent to the pigmented conjunctival lesion.
Atypical, round, ovoid, and spindle-shaped cells with chromatin clumping and prominent nucleoli associated with lymphocytic and plasma cell infiltrate in tarsal conjunctiva adjacent to hair follicles, consistent with the diagnosis of primary-acquired melanosis with atypia (melanoma in situ). Note the absence of pigment within the hair follicle on the right and the absence of perifollicular inflammation. A, Hematoxylin-eosin, original magnification ×20. B, Hematoxylin-eosin, original magnification ×40.
de Alba Campomanes AG, O’Brien JM. Poliosis as a Manifestation of Conjunctival Melanoma. Arch Ophthalmol. 2008;126(7):1006-1007. doi:10.1001/archopht.126.7.1006
Acquired poliosis of the eyelashes is usually seen in conjunction with benign conditions. However, its appearance should prompt a careful examination to rule out malignant neoplasia. We report a case of conjunctival melanoma with eyelid poliosis.
A 71-year-old woman with a history of primary-acquired melanosis with atypia and recurrent anaplastic conjunctival melanoma of the right eye (Figure 1A) had a 2-month history of ocular pain and growth of 3 pigmented conjunctival lesions. A patch of white eyelashes on the lateral aspect of the right upper eyelid was noted adjacent to the pigmented palpebral conjunctival lesion (Figure 1C and D). The eyelid appeared thickened and inflamed. No other abnormality in the eyelid architecture was noted, and there was no vitiligo or intraocular inflammation. Previous examinations revealed no evidence of tumor recurrence and normal eyelash pigmentation (Figure 1B). The primary melanoma had been resected 4 years prior. At the time of excision, cryotherapy was used on the bulbar conjunctiva but not on the palpebral conjunctiva. The patient denied any topical medication use including prostaglandins or chemotherapeutic agents. Findings from histological examination of the area immediately adjacent to the poliosis revealed a conjunctival melanoma. There was no histological evidence of inflammatory cell infiltration or destruction of the hair follicle (Figure 2).
The term poliosis is used to describe a localized area of hair depigmentation. In the skin, it has been described in association with lesions such as intradermal nevi, giant congenital nevi, and halo nevi.1 Acquired poliosis of the eyelashes has been described in several ophthalmic conditions, including blepharitis, sarcoidosis, sympathetic ophthalmia, herpes zoster, Vogt-Koyanagi-Harada syndrome, vitiligo, tuberous sclerosis, following irradiation, and with topical administration of prostaglandin F2α analogues.2- 4 Although poliosis of the eyelid is usually associated with benign eyelid conditions, in this case it developed in conjunction with conjunctival melanoma. Poliosis associated with malignant neoplasms has only once been reported with malignant melanoma of the scalp.5 To our knowledge, there have been no prior reports of poliosis in association with conjunctival melanoma.
The pathogenesis of poliosis is not known. It has been suggested that it may be related to an inflammatory destruction of the melanocytes in the hair follicle, apoptosis of the follicular melanocytes, or a targeted autoimmune response.1,6 Perhaps the malignant cells initiate an immune response that cross reacts with the normal follicular melanocytes.5,6 In other conditions where poliosis is present, selective antibodies against melanocytes have been found.6 The poliosis in our case developed next to areas of atypical melanocytic proliferation, but there was no evidence of a dense inflammatory response around the hair follicle. Acquired poliosis of the eyelashes is an important clinical sign, and it should prompt careful examination of the tarsal conjunctiva for suspicious pigmented lesions.
Correspondence: Dr O’Brien, Division of Ocular Oncology, Department of Ophthalmology, University of California, San Francisco, 10 Koret Way, Box 0730, Room K-304, San Francisco, CA 94143-0730 (firstname.lastname@example.org).
Financial Disclosure: None reported.
Funding/Support: This work was supported by an unrestricted grant and the Lew R. Wasserman Merit Award from Research to Prevent Blindness, Inc, New York, New York, and by grant EY02162 to the Department of Ophthalmology, University of California, San Francisco, from the National Eye Institute, Bethesda, Maryland.