What is the treatment for conjunctival papilloma?

Treatment for Conjunctival Papilloma

Surgical excision with adjunctive therapy is the recommended treatment for conjunctival papilloma to prevent recurrence and ensure complete removal of the lesion.

Clinical Features and Etiology

Conjunctival papilloma is a benign neoplastic lesion of epithelial origin that presents as an exophytic growth on the conjunctiva. Key characteristics include:

• Most commonly affects adults in their third and fourth decades of life
• More prevalent in males (73%) than females (27%) 1
• Common locations include the caruncle (43%), palpebral conjunctiva (29%), bulbar conjunctiva (14%), and fornix (14%) 1
• Etiological factors include:
  • Human papillomavirus (HPV) infection (typically types 6,11, and occasionally type 33)
  • UV exposure
  • Smoking
  • Immunodeficiency 2

Diagnostic Approach

Diagnosis typically involves:

• Clinical examination: Identifying exophytic, sessile, or pedunculated growth with papillary projections
• Appearance: Pink or white lesions depending on keratinization level
• Imaging:
  • Swept Source Optical Coherence Tomography (SS-OCT) to rule out infiltration into sclera or cornea
  • In vivo confocal microscopy (IVCM) to evaluate cellular changes 2
• Histopathological confirmation: Gold standard for definitive diagnosis 3

Treatment Options

1. Surgical Management (First-line)

• Complete surgical excision with adjunctive therapy is the primary treatment approach 1
• Surgical excision alone has been associated with higher recurrence rates (statistically significant, p=0.039) 1
• Adjunctive therapies to consider with surgical excision:
  • Cryotherapy to the surgical margins
  • Double freeze-thaw technique

2. Topical Interferon Alpha-2b

• Effective for small to medium-sized papillomas without signs of malignancy
• Dosage: 1 million IU/ml eye drops applied 4 times daily 2
• Treatment duration: Typically 3-5 months
• Complete regression has been observed after 3 months of treatment 2
• Can be used as:
  • Primary therapy for smaller lesions
  • Adjuvant therapy following surgical excision for recurrent cases 4
• Possible side effect: Superficial keratitis 4

3. Laser Therapy

• Carbon dioxide (CO2) laser therapy can be considered for recurrent papillomas that are refractory to other treatments 5
• Particularly useful when surgical excision, cryotherapy, and immunotherapy have failed

Risk Factors for Recurrence

Recurrence rates for conjunctival papilloma are approximately 22.7% 1. Factors significantly associated with recurrence include:

• Bulbar conjunctival papilloma with corneal involvement (p=0.043)
• Surgical excision without adjunctive therapy (p=0.039) 1

Treatment Algorithm

1. Initial presentation:

   • For small to medium lesions without signs of malignancy: Consider topical interferon alpha-2b (1 million IU/ml, 4 times daily for 3-5 months)
   • For larger lesions or those with concerning features: Proceed to surgical excision with adjunctive cryotherapy

2. Recurrent lesions:

   • Surgical re-excision with adjunctive cryotherapy plus topical interferon alpha-2b
   • For multiple recurrences: Consider CO2 laser therapy

3. Follow-up:

   • Long-term follow-up is essential due to risk of recurrence
   • Monitor for malignant transformation, especially in cases with multiple recurrences 1

Important Considerations

• Malignant transformation is rare but possible, especially in cases with multiple recurrences
• HPV vaccination does not guarantee prevention of conjunctival papilloma 1
• Treatment should be more aggressive for bulbar conjunctival papillomas with corneal involvement due to higher recurrence risk

By following this treatment approach, most conjunctival papillomas can be effectively managed with minimal risk of recurrence and preservation of visual function.