Liquid Nitrogen Cryotherapy of Conjunctival Lymphangiectasia: A Case Series

Conjunctival lymphangiectasia is characterized by dilated and prominent lymphatic channels within the conjunctiva. The condition is usually unilateral unless associated with Turner syndrome or Nonne-Milroy-Miege disease. Symptoms may include ocular irritation, dryness, epiphora, blurred vision, and pain.¹

The etiology of lymphangiectasia is unknown. Simple excision is a therapeutic option described to treat this condition.¹ A prior article reported a single case of liquid nitrogen cryotherapy to treat conjunctival lymphangiectasia.²

Five eyes of 4 patients with epiphora, eye irritation, eye redness, and episodic blurred vision were examined at the Casey Eye Institute, Portland, Oregon. Ocular examination revealed swelling of the conjunctiva with transparent lymphangiectatic vessels on the globe.

Prior to cryotherapy, an incision was made in the involved conjunctiva with 0.12-mm forceps and sharp Westcott scissors. A 1- to 2-mm² portion of tissue was excised and sent to pathology in formalin for pathologic diagnosis. The clinical suspicion of conjunctival lymphangiectasia was confirmed by the ophthalmic pathologist's description of noninflamed large lymphatic vessels.

Cryotherapy was performed using a Brymill CRY-AC-3 liquid nitrogen unit (Brymill Cryogenic Systems, Ellington, Connecticut). A 1.5-mm polytetrafluoroethylene (Teflon)–coated cryoprobe was used to perform a double freeze-thaw of the involved conjunctiva for 1 to 2 seconds in 2 freeze-thaw cycles. Thawing took approximately 5 to 10 seconds. Erythromycin eye ointment was placed on the eye after the procedure. Patients were seen in follow-up at 1 day, 2 weeks, 3 months, 6 months, and yearly thereafter.

Five eyes of 4 patients (3 men and 1 woman) with biopsy-proven conjunctival lymphangiectasia underwent liquid nitrogen cryotherapy. The symptoms and signs of conjunctival lymphangiectasia resolved within 2 weeks after treatment in all 5 eyes. The average age was 53 years and the average follow-up duration was 24.5 months. There were 2 recurrences in this case series: the first occurred at 1 and 3 years in the same eye of the same patient and the second occurred at 6 months in a different subject (subjects 1 and 3) (Table). The average time to recurrence of conjunctival lymphangiectasia was 18 months. Repeat cryotherapy led to resolution of recurrent conjunctival lymphangiectasia in all subjects treated.

Liquid nitrogen cryotherapy is effective in treating conjunctival lymphangiectasia probably by collapsing the lymph vessel walls onto each other with a cryogenic burn and also by scarring down the conjunctiva to the underlying globe. In addition, cryotherapy has been shown to kill the endothelium of blood vessels, and it would make sense that the endothelium lining the large lymphatic vessels is also damaged through the cryogenic burn.³

Alternative treatments for conjunctival lymphangiectasia have been described, with surgical excision alone reported in a case series by Meisler et al.¹ In that series, 3 eyes had conjunctival resection without recurrence after 2 years of follow-up. In another case report by Jordan and Anderson,⁴ a carbon dioxide laser was used to successfully treat what was described as a conjunctival lymphangioma. Behrendt et al⁵ used β-radiation to successfully treat a case of conjunctival lymphangioma. A case report from Egypt by Wasfy⁶ described the use of cryotherapy to successfully treat a case of conjunctival lymphangiectasia, although the type of cryogen and the technique were not explained.

Liquid nitrogen cryotherapy has been proven to be safe and effective for conjunctival malignant neoplasms, and it also appears to be efficacious in the treatment of other ocular conditions, including benign conjunctival vascular tumors, advancing wavelike epitheliopathy, superior limbic keratoconjunctivitis, pterygia, and conjunctival amyloidosis.³

Based on this case series, liquid nitrogen cryotherapy could be considered an effective surgical alternative in the treatment of conjunctival lymphangiectasia. Repeat cryotherapy may be indicated should recurrent lymphangiectasia occur.

Correspondence: Dr Fraunfelder, Casey Eye Institute, Oregon Health and Science University, 3375 SW Terwilliger Blvd, Portland, OR 97239-4197 (eyedrug@ohsu.edu).

Financial Disclosure: Dr Fraunfelder is a consultant for Brymill and Ono Pharmaceuticals.

Funding/Support: This study was supported in part by an unrestricted grant to Casey Eye Institute from Research to Prevent Blindness.

Previous Presentations: This article is based on a presentation at the 145th Annual Meeting of the American Ophthalmological Society; May 17, 2009; Half Moon Bay, California; the presentation was subsequently published in Trans Am Ophthalmol Soc. 2009;107.