It is important that malignant or potentially malignant conjunctival tumors be completely removed with as little manipulation as possible. The most appropriate surgical method differs with limbal tumors, extralimbal tumors, and primary acquired melanosis (PAM) (1,2,3,4). The surgical techniques are reported in detail in the literature (1) and are briefly described herein. Limbal lesions are generally best managed by localized alcohol corneal epitheliectomy, removal of the main mass by a partial lamellar scleroconjunctivectomy, and supplemental double freeze thaw cryotherapy. Tumors located in the extra-limbal conjunctiva are managed by alcohol application, wide circumferential surgical resection, and cryotherapy.

There are no rigid methods for management of PAM of the conjunctiva. In general, it is best managed by alcohol epitheliectomy, removal of suspicious pigmented foci, quadratic staging biopsies, and cryotherapy from the underside of the conjunctiva. In all cases, a “no-touch” method is used and direct manipulation of the tumor is avoided in an effort to prevent tumor cell seeding into a new area (1). During this surgery, it is often prudent to place punctual plugs in the upper and lower canaliculus to prevent seeding of tumor cells in the lacrimal drainage system.

Certain ancillary approaches are frequently employed in conjunction with primary surgical resection of selected conjunctival lesions. These methods include mucous membrane or amniotic membrane grafting, topical chemotherapy or immunotherapy, and radiotherapy. Grafting is used when large portions of conjunctival tumors are excised and tissue is required to close the defect. Topical mitomycin C, 5-fluoroacil, and interferon are used primarily as alternatives to further surgical resection of superficial lesions of the bulbar conjunctiva and cornea, particularly conjunctival/corneal intraepithelial neoplasia and PAM. Radiotherapy is used primarily for cases of squamous cell carcinoma, melanoma, or other conjunctival neoplasms in which further surgical excision is not feasible to achieve good tumor control and in which orbital exenteration is becoming the only therapeutic option.

Regarding topical chemotherapy, we have primarily employed mitomycin C. It is administered by applying one drop of 0.04% mitomycin four times daily for 7 days and then withholding the drug for 1 month. This 2-week cycle is repeated two or three times, depending on the observed response as determined mainly by slit-lamp biomicroscopy. Topical chemotherapy has been highly successful in controlling selected superficial conjunctival malignancies.