Conjunctival melanoma is potentially lethal

However, it is possible that other intangible factors also affect tumour recurrence, such as the surgeon's experience and tumour manipulation at surgery (we prefer “no touch” technique with no direct forceps manipulation of the tumour). Hence, it would probably be better for the patient to have a rare tumour managed at a centre where there are surgeons who have had experience with this disease. With other cancers, management at specialised centres has been found to be statistically beneficial to reduce recurrence and improve patient life prognosis.^4,5

Anastassiou and associates reported 32% tumour related mortality at 5 years. Thus, we must understand that conjunctival melanoma is potentially lethal. The authors found that mortality was related to nodular or mixed growth pattern, deep tumour invasion into the substantia propria, tumour location in unfavourable sites such as the caruncle and palpebral, plical, and forniceal conjunctiva, and incomplete tumour excision. The authors admit that 46 of the 69 tumours were incompletely excised and had tumour to the margin of resection. They explain that this is related to the large size of tumour at the time of referral to their tertiary centres and also the numerous surgeons involved in the patient care. Alleviation of this problem in the future might be achieved if the patient is referred to the specialised centre at the time the initial diagnosis is suspected so that exact margins can be ascertained and controlled initial resection performed by a team specialised in ocular oncology. In our analysis of 150 consecutive patients referred with conjunctival melanoma to our tertiary centre, it was apparent that surgical technique was important in the univariate analysis of tumour recurrence and metastasis.³ For example, incisional biopsy was a risk for tumour recurrence. Therefore, we strongly advise referring physicians to avoid incisional biopsy of conjunctival melanoma. It is preferable that the diagnosis be made on examination and excisional biopsy results. Additionally, we found that excisional biopsy alone without supplemental alcohol keratectomy or conjunctival cryotherapy posed a risk for metastasis. Perhaps the supplemental treatment controls the surrounding subclinical disease. The importance of the initial surgical technique is underscored by these findings. We believe that meticulous surgical planning using a “no touch” technique, supplemental alcohol corneal epitheliectomy, and conjunctival cryotherapy may be most beneficial to the patient.^6,7