Patient Presents With Eye Redness, Fleshy Overgrowth of the Bulbar Conjunctiva

August 4, 2017

A 66-year-old woman presented with conjunctival redness and irritation of the right eye. An eye exam revealed a painless, pink, fleshy patch with a smooth surface in the superior aspect of nasal bulbar conjunctiva of the right eye. A biopsy of the lesion was performed. What is the diagnosis?

A 66-year-old Caucasian woman presented with conjunctival redness and irritation of the right eye, as well as increased tear production of 6 months’ duration. Prior to seeing her ophthalmologist, she had noticed a palpable area in the upper inner quadrant of her right eye. An eye exam revealed a painless, pink, fleshy patch on the right eye, with a smooth surface in the superior aspect of the nasal bulbar conjunctiva. A mild ptosis on the right side was also noted.

There were no palpable preauricular, submandibular, or cervical lymph nodes. The physical examination was otherwise normal. Complete blood count, metabolic panel, serum lactate dehydrogenase levels, serum protein electrophoresis, and beta2-microglobulin levels were normal. MRI of the face and orbit (Top) revealed ill-defined, asymmetric soft tissue density and enhancement on the superior right orbit.

CT of the neck, chest, abdomen, and pelvis were negative. A conjunctival biopsy of the lesion was performed (Bottom). Histologic sections showed a monotonous population of predominantly small round lymphocytes with poorly defined, follicular-appearing dense areas extending into conjunctival epithelium. Immunophenotyping studies were positive for CD20, but negative for CD5, CD10, CD23, and CD3. Gene rearrangement analysis revealed rearrangement of the immunoglobulin gene with kappa light chain restriction.

What is the correct diagnosis?