Conjunctival Keloids

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Article initiated by:

Christine Wang MS, MD

All contributors:

Colleen Halfpenny, M.D., Christine Wang MS, MD

Assigned editor:

Mary Daly, MD

Review:

Assigned status Update Pending

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Conjunctival keloid, also known as conjunctival fibrosis, is a rare condition characterized by the formation of excessive scar tissue on the conjunctiva, the thin, transparent membrane that covers the white part of the eye and lines the inside of the eyelids. The abnormal growth of fibrous tissue in the conjunctiva can lead to various ocular symptoms and cosmetic concerns.

Disease Entity

Conjunctival keloid is a benign condition that occurs when there is an abnormal healing response following conjunctival injury or surgery. It is considered a variant of keloid formation, which is characterized by an excessive and prolonged proliferation of collagen fibers in the skin or other connective tissues. Conjunctival keloids can cause discomfort, visual disturbances, and aesthetic changes in the affected eye.

Causes

The exact cause of conjunctival keloid formation is not fully understood. However, it is believed to result from an exaggerated response of the body's healing process, particularly in individuals with a genetic predisposition to keloid formation. Some authors believe in some genetic cases, an inherent abnormality in the cellular differentiation process within the limbal region allows the conjunctiva to display "spontaneous" growth of the dermal epithelium. Several factors may contribute to the development of conjunctival keloids, including:

• Surgical trauma: Conjunctival keloids can occur as a complication of ocular surgeries, such as pterygium excision, strabismus surgery, or glaucoma filtration surgery.
• Ocular injuries: Severe trauma or injury to the conjunctiva, including burns, chemical exposures, or mechanical trauma, may trigger the formation of keloid scars.
• Inflammatory conditions: Chronic inflammation of the conjunctiva, such as chronic allergic conjunctivitis or autoimmune diseases, may increase the risk of conjunctival keloid formation.
• Genetics

Symptoms

The presence of conjunctival keloid may cause various symptoms, which can vary depending on the size, location, and extent of the keloid. Common signs and symptoms associated with conjunctival keloids include:

• Ocular irritation: Itching, burning sensation, or foreign body sensation in the affected eye.
• Visual disturbances: Keloids located near the cornea or in the visual axis can lead to blurred vision or astigmatism.
• Cosmetic concerns: Conjunctival keloids may cause noticeable cosmetic changes, such as raised or discolored areas on the conjunctiva.

Diagnosis

A diagnosis of conjunctival keloid is typically made based on a comprehensive eye examination and a thorough medical history. The following diagnostic procedures may be conducted:

• Visual acuity test: Determines the clarity of vision using an eye chart.
• Slit lamp examination: Provides a detailed view of the conjunctiva and the extent of the keloid using a specialized microscope.
• Biopsy: In some cases, a small tissue sample may be taken for laboratory analysis to confirm the diagnosis and rule out other pathological conditions.

Comparison to Other Conjunctival Masses

Conjunctival keloids can resemble other types of conjunctival masses, such as conjunctival nevi, papillomas, or squamous cell carcinomas. It is important to differentiate conjunctival keloids from these other lesions for appropriate management and treatment. Here are some distinguishing features:

• Conjunctival nevi: Nevi are pigmented lesions that typically appear as brown or black spots on the conjunctiva. Unlike keloids, they do not exhibit excessive fibrous tissue growth or raised scar-like appearance. Nevi are usually stable and do not cause significant symptoms unless they undergo malignant transformation.
• Papillomas: Conjunctival papillomas are benign growths caused by viral infections, particularly human papillomavirus (HPV). They appear as pink or flesh-colored, finger-like projections on the conjunctiva. Unlike keloids, papillomas are not characterized by fibrosis or scar formation.
• Squamous cell carcinomas: Squamous cell carcinomas are malignant tumors that can develop on the conjunctiva. They may present as thickened, irregular, or ulcerated lesions. Unlike keloids, squamous cell carcinomas show signs of uncontrolled cell growth and can invade surrounding tissues. Prompt evaluation and appropriate management are crucial for squamous cell carcinomas.

Treatment

The treatment of conjunctival keloid aims to alleviate symptoms, improve visual function, and address cosmetic concerns. The following treatment options may be considered:

• Conservative measures: Lubricating eye drops or ointments can help alleviate ocular irritation and dryness associated with conjunctival keloids.
• Corticosteroid injections: Injecting corticosteroids directly into the keloid can help reduce inflammation and shrink the size of the lesion.
• Surgical excision: Surgical removal of the keloid may be considered for cases where conservative measures have been ineffective. However, the risk of recurrence should be carefully considered.
• Radiation therapy: In certain cases, radiation therapy may be used as an adjuvant treatment after surgical excision to prevent keloid recurrence.
• Cryotherapy: Freezing the keloid with liquid nitrogen can be used as an alternative or adjunct