SCIENTIFIC CORRESPONDENCE Amniotic membrane transplantation in the management of conjunctival malignant melanoma and primary acquired melanosis with atypia

Aim—To evaluate the eYcacy of amniotic membrane transplantation (AMT) for the management of conjunctival malignant melanoma and primary acquired melanosis (PAM) with atypia. Methods—Four consecutive patients with histologically proved invasive, primary conjunctival malignant melanoma were treated with wide surgical excision and AMT. Amniotic membrane grafts were harvested and processed under sterile conditions according to a standard protocol. The grafts were sutured to the margins of the surface defect. In one case, AMT was combined with a corneoscleral graft. Results—A satisfactory result and rapid postoperative recovery with few, transient side eVects was noted in three patients with limbal/epibulbar melanomas. In another patient with an extensive lesion, involving the epibulbar, forniceal, and palpebral conjunctiva, AMT following wide excision was complicated by symblepharon formation and restricted ocular motility. Monitoring of local recurrence was facilitated by the transparency of the thin graft in all cases. The postoperative follow up time varied between several months and 3 years. In one case, local recurrence of PAM was observed and treated using topical mitomycin. Conclusions—AMT is a useful technique for the reconstruction of both small and large surface defects that result from the surgical excision of conjunctival malignant melanoma and PAM. This method facilitates wide conjunctivectomy, although its role in repairing larger defects involving the fornix or palpebral conjunctiva still needs to be established. The transparency of amniotic membrane allows for monitoring of tumour recurrence, which is—together with superior cosmesis—an advantage over thicker (for example, buccal) mucous membrane grafts. (Br J Ophthalmol 2001;85:658–661) The surgical management of conjunctival malignant melanoma constitutes a clinical challenge, especially when the tumour is large or arises multifocally, as in primary acquired melanosis (PAM) with atypia. For both conditions, wide conjunctivectomy may be indicated. The most radical method of eradicating diseased conjunctiva is orbital exenteration. This mutilating operation has been largely abandoned as a primary procedure, as it does not lead to increased survival in patients with conjunctival malignant melanoma. Instead, most clinicians now reserve orbital exenteration to locally control advanced stages of this neoplasm. More conservative and patient friendly surgical techniques include the “bare sclera” or “primary closure” methods for smaller lesions and the use of autografts or allografts to replace larger areas of excised conjunctiva. Non-surgical methods to treat conjunctival malignant melanoma and PAM include cryotherapy, radiotherapy, and topical chemotherapy, which are now mostly used as adjunctive tools in the management of these neoplasms. 3 The use of fetal membrane allografts, including both amnion and chorion, for ophthalmic purposes was first reported by de Rotth in 1940. Recently, amniotic membrane transplantation (AMT) was introduced by Tseng and colleagues for the management of patients with corneal defects, pterygia, neoplasia, and symblepharon. Amniotic membrane promotes epithelialisation and inhibits fibrosis. The techniques to harvest and preserve human amniotic membranes have been well established. The use of this graft is considered safe, as long as the preparation is done according to a standard protocol. Recently, a case of successful AMT was reported in a patient with an amelanotic corneal and limbal malignant melanoma originating from PAM. This prompted us to use AMT for surface reconstruction following wide excision of conjunctival malignant melanomas. We report on our experience with AMT in the management of four such cases. Patients and methods Between 1998 and 2000, four patients with primary conjunctival malignant melanoma Br J Ophthalmol 2001;85:658–661 658 Rotterdam Eye Hospital, Oculoplastic Service