Poliosis As a Manifestation of Conjunctival Melanoma

Interestingly, monoclonal IgG and IgG light chains vealed no evidence of tumor recurrence and normal eye- appear to bind copper in these disease states but are not lash pigmentation (Figure 1B). The primary melanoma known to do so in vitro. In at least 1 case, the copper- had been resected 4 years prior. At the time of excision, carrying protein was sequenced in an attempt to deter- cryotherapy was used on the bulbar conjunctiva but not mine whether it shared the N-terminal Asp-Ala-His on the palpebral conjunctiva. The patient denied any topi- amino acid sequence known to bind copper in albumin, cal medication use including prostaglandins or chemo- but no such sequence was found.5 Sequences as simple therapeutic agents. Findings from histological examina- as Gly-His are capable of binding copper under certain tion of the area immediately adjacent to the poliosis circumstances, especially if they are repeated, rendering revealed a conjunctival melanoma. There was no histo- it difficult to determine the location of a potential bind- logical evidence of inflammatory cell infiltration or de- ing site based on sequence alone. Myeloma protein is struction of the hair follicle (Figure 2). known to accumulate in the eye as an amyloid, and although individual myeloma proteins do not appear to Comment. The term poliosis is used to describe a local- bind copper, closely packed myeloma proteins may be ized area of hair depigmentation. In the skin, it has been able to do so. described in association with lesions such as intrader- mal nevi, giant congenital nevi, and halo nevi.1 Ac- Rona Z. Silkiss, MD quired poliosis of the eyelashes has been described in sev- Dustin Pomerleau, MD eral ophthalmic conditions, including blepharitis, Andrew Sorenson, MD sarcoidosis, sympathetic ophthalmia, herpes zoster, Vogt- David Vastine, MD Koyanagi-Harada syndrome, vitiligo, tuberous sclero- J. Brooks Crawford, MD sis, following irradiation, and with topical administra- tion of prostaglandin F2␣ analogues.2-4 Although poliosis Correspondence: Dr Pomerleau, Department of Oph- of the eyelid is usually associated with benign eyelid con- thalmology, California Pacific Medical Center, 2340 Clay ditions, in this case it developed in conjunction with con- St, Fifth Floor, San Francisco, CA 94115 (dustypomerleau junctival melanoma. Poliosis associated with malignant @gmail.com). neoplasms has only once been reported with malignant Financial Disclosure: None reported. melanoma of the scalp.5 To our knowledge, there have 1. Ellis PP. Ocular deposition of copper in hypercupremia. Am J Ophthalmol. 1969; been no prior reports of poliosis in association with con- 68(3):423-427. junctival melanoma. 2. Lewis RA, Falls HF, Troyer DO. Ocular manifestations of hypercupremia associated with multiple myeloma. Arch Ophthalmol. 1975;93(10):1050-1053. The pathogenesis of poliosis is not known. It has been 3. Hawkins AS, Stein RM, Gaines BI, Deutsch TA. Ocular deposition of copper suggested that it may be related to an inflammatory de- associated with multiple myeloma. Am J Ophthalmol. 2001;131(2):257-259. 4. Martin NF, Kincaid MC, Stark WJ, et al. Ocular copper deposition associated struction of the melanocytes in the hair follicle, apopto- with pulmonary carcinoma, IgG monoclonal gammopathy and hypercupre- sis of the follicular melanocytes, or a targeted autoim- mia: a clinicopathologic correlation. Ophthalmology. 1983;90(1):110-116. mune response.1,6 Perhaps the malignant cells initiate an 5. Probst LE, Hoffman E, Cherian MG, et al. Ocular copper deposition associated with benign monoclonal gammopathy and hypercupremia. Cornea. 1996; immune response that cross reacts with the normal fol- 15(1):94-98. licular melanocytes.5,6 In other conditions where polio- 6. Garg S, Jampol LM, Lewis RA, Penner JA. Corneal copper deposition second- sis is present, selective antibodies against melanocytes ary to a variant of multiple myeloma: 30-year catamnesis. Arch Ophthalmol. 6 2006;124(1):130-132. have been found. The poliosis in our case developed next to areas of atypical melanocytic proliferation, but there was no evidence of a dense inflammatory response around the hair follicle. Acquired poliosis of the eyelashes is an important clinical sign, and it should prompt careful ex- Poliosis as a Manifestation amination of the tarsal conjunctiva for suspicious pig- of Conjunctival Melanoma mented lesions.

cquired poliosis of the eyelashes is usually seen Alejandra G. de Alba Campomanes, MD, MPH in conjunction with benign conditions. How- Joan M. O’Brien, MD ever, its appearance should prompt a careful ex- A Correspondence: Dr O’Brien, Division of Ocular Oncol- amination to rule out malignant neoplasia. We report a ogy, Department of Ophthalmology, University of Cali- case of conjunctival melanoma with eyelid poliosis. fornia, San Francisco, 10 Koret Way, Box 0730, Room K-304, San Francisco, CA 94143-0730 (obrienj@vision Report of a Case. A 71-year-old woman with a history .ucsf.edu). of primary-acquired melanosis with atypia and recur- Financial Disclosure: None reported. rent anaplastic conjunctival melanoma of the right eye Funding/Support: This work was supported by an un- (Figure 1A) had a 2-month history of ocular pain and restricted grant and the Lew R. Wasserman Merit Award growth of 3 pigmented conjunctival lesions. A patch of from Research to Prevent Blindness, Inc, New York, New white eyelashes on the lateral aspect of the right upper York, and by grant EY02162 to the Department of Oph- eyelid was noted adjacent to the pigmented palpebral con- thalmology, University of California, San Francisco, from junctival lesion (Figure 1C and D). The eyelid appeared the National Eye Institute, Bethesda, Maryland. thickened and inflamed. No other abnormality in the eyelid architecture was noted, and there was no vitiligo or 1. Yosipovitch G, Feinmesser M, Mutalik S. Poliosis associated with a giant con- intraocular inflammation. Previous examinations re- genital nevus. Arch Dermatol. 1999;135(7):859-861.

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C D

Figure 1. Right eye. A, Anaplastic conjunctival melanoma at the initial visit. B, Photographic documentation from a previous examination demonstrates no abnormal depigmentation of the eyelashes. C and D, Poliosis on the right upper eyelid adjacent to the pigmented conjunctival lesion.

A B

Figure 2. Atypical, round, ovoid, and spindle-shaped cells with chromatin clumping and prominent nucleoli associated with lymphocytic and plasma cell infiltrate in tarsal conjunctiva adjacent to hair follicles, consistent with the diagnosis of primary-acquired melanosis with atypia (melanoma in situ). Note the absence of pigment within the hair follicle on the right and the absence of perifollicular inflammation. A, Hematoxylin-eosin, original magnification ϫ20. B, Hematoxylin-eosin, original magnification ϫ40.

2. Roberts A, Kaye LC, Memon A, Parslew R, Kaye SB. Unilateral poliosis of the ous sclerosis: a population based study. Br J Ophthalmol. 2001;85(4):420-423. eyelashes in children associated with vitiligo. J AAPOS. 2005;9(3):295-296. 5. Dunn CL, Harrington A, Benson PM. Melanoma of the scalp presenting as 3. Chen CS, Wells J, Craig JE. Topical prostaglandin F2␣ analog induced poliosis. poliosis circumscripta. Arch Dermatol. 1995;131(5):618-619. Am J Ophthalmol. 2004;137(5):965-966. 6. Kim SK, Do JE, Kang HY, Kim YC. Poliosis developing in a melanocytic nevus. 4. Rowley SA, O’Callaghan FJ, Osborne JP. Ophthalmic manifestations of tuber- Eur J Dermatol. 2007;17(4):347-348.

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