病例2 25岁男性，主诉右眼痒，粉红色新生物生长半年
CASE 2 A 25-year-old male complaining of itchy and pink neoplasm in right eye for half a year
见图1-2。See Fig. 1-2.
图1-2 右眼泪阜处可见约6mm×6mm的粉红色分叶状肿块，表面光滑，每个小叶中央可见血管Fig. 1-2 A pink lobulated mass of approximately 6mm×6mm is seen at the lacrimal caruncle with a smooth surface and blood vessels at the center of each lobule
鉴别诊断
Differential Diagnosis
◎ 结膜乳头状瘤：是结膜上皮组织呈乳头状增生的良性肿瘤，根据发病部位可分为结膜型和角膜缘型，与人乳头状瘤病毒(human papillomavirus, HPV)感染有关。结膜型多发于儿童或青年，多为单眼发病，好发于泪阜、内眦皱襞及穹窿结膜，外观呈桑葚状或菜花状隆起于结膜表面，粉红色，有蒂，活动度好；角膜缘型少见，好发于中老年人，常起于球结膜并向角膜表面生长，外观呈半透明或粉红色，扁平膜状或草莓样隆起，基底较宽，较为固定。
◎ Conjunctival papilloma: most are benign tumor with papillary hyperplasia of conjunctival epithelium, which is related to human papillomavirus (HPV) infection and can be classif ied as conjunctival type and limbal type according to the location of tumor. Conjunctival type is mostly monocularly found in children and young adults,usually occurring in lacrimal caruncle, inner canthus fold and fornix, with a classic mulberry like or caulif lower like appearance, pink and pedicled appearance rising from the surface of conjunctiva, and with good mobility. Limbal type is rare and often occurs in the elderly. It usually starts from the bulbar conjunctiva and grows towards the cornea surface, with the appearance of translucent or pink, f lat membrane or strawberry like protuberance and wide base,and is relatively f ixed.
◎ 角膜缘皮样瘤：先天性良性肿瘤，出生后即可发现，常位于颞下方角膜缘，可累及角膜，多呈半圆形、黄白色或粉红色隆起的实质性肿块，表面可见毛囊。
◎ Limbal dermoid: Congenital benign tumor, usually located in the inferotemporal quadrant of the limbus,can involve the cornea. Lesions are usually semicircular,yellow-white or pink, solid, fairly well circumscribed,elevated, and can have hair arising from their surface.
◎ 皮样脂肪瘤：少见，多为双侧，常表现为颞上方较大的黄白色的球结膜下实质性病变，内含脂肪和皮肤组织，表面可见毛囊。
◎ Dermolipoma: rare, mostly bilateral. Yellow-white, solid tumor, usually occurring under the bulbar conjunctiva superotemporally, containing fat and skin tissue, with hair follicles on the surface.
病史询问
Asking History
◎ 询问发病时间和肿块的生长情况。初发还是复发。
◎ Ask the onset time and growth rate of the mass. Whether it was initial or recurrent.
◎ 是否伴有红肿、异物感、刺痒、疼痛及分泌物。
◎ Whether accompanied by redness, foreign body sensation,itching, pain, secretion.
◎ 过敏性鼻炎和结膜炎病史。是否有揉眼的习惯。眼表手术史、外伤史及全身疾病史。
◎ History of anaphylactic rhinitis and conjunctivitis. Habit of eye rubbing. History of ocular surface surgery, trauma and systemic diseases.
检查
Examination
◎ 视力和眼压。
◎ Visual acuity and IOP.
◎ 对外眼及眼表进行裂隙灯检查。检查肿块的大小、部位，是单发还是多发，无蒂（基底部宽而扁平）还是有蒂（藻样），观察其外观、色泽和边界。
◎ Slit lamp examination of the external eye and ocular surface. Check the size, location, color, margine, surface,single or multiple, sessile (wide base and flattish prof ile) or pedunculated (frond-like).
实验室检查
Lab
◎ 病理活检（图1-3）。
◎ Biopsy (Fig. 1-3).
◎ 尿道脱落细胞及肿瘤组织HPV检测。
◎ HPV testing in tumor tissue and exfoliated cells.
诊断
Diagnosis
结膜鳞状上皮乳头状瘤。
Conjunctival squamous papilloma.
图1-3 病理诊断：鳞状上皮乳头状瘤Fig. 1-3 Pathologic diagnosis: Squamous cell papil
鳞状上皮乳头状瘤（如感染性乳头状瘤、病毒性结膜乳头状瘤）由狭窄的有蒂基底发出的多个分叶组成。各个分叶被结缔组织围绕，中央血管化；分叶内可见急性和慢性炎症细胞；上皮为棘皮状、无角质化的复层鳞状上皮，无异型性；大量杯状细胞伴随急性炎症细胞同时出现；可见挖空细胞；基底膜完整。Squamous cell papillomas (eg, infectious papilloma, viral conjunctival papilloma) are composed of multiple branching fronds emanating from a narrow pedunculated base. Individual fronds are surrounded by connective tissue, each having a central vascularized core. Acute and chronic inf lammatory cells are found within these fronds.The epithelium is acanthotic, nonkeratinized stratif ied squamous epithelium without atypia. Numerous goblet cells are seen along with acute inf lammatory cells. Koilocytosis is exhibited. The basement membrane is intact.
治疗
Management
◎ 较小的病变可以不治疗，密切随诊观察。
◎ Small lesions with asymptome can be left untreated with close follow-up.
◎ 较大的病灶，尤其是老年患者，首选的治疗方法是完全切除并进行活检或联合冷冻治疗。
◎ Complete excision with biopsy and combined with cryotherapy the margin are the preferred treatments for large lesions, especially in elder patients.
◎ 结膜下干扰素-α、二氧化碳激光汽化、局部丝裂霉素C、免疫抑制剂和口服西咪替丁对于复发病例和降低复发率有一定帮助。
◎ Subconjunctival interferon-α, carbon dioxide laser vaporization, topical mitomycin C, immunosuppressants and oral cimetidine are helpful in recurrent cases and in reducing the recurrence rate.
患者教育和预后
Patient Education & Prognosis
◎ 结膜乳头状瘤是一种预后较好的良性肿瘤，与人乳头状瘤病毒感染密切相关，尤其是6型和11型。
◎ Most conjunctival papilloma is a benign tumor with good prognosis and strongly associated with human papillomavirus infection, especially types 6 and 11.
◎ 本病具有一定的自发消退倾向，手术切除术后复发率高，总体癌变概率很小，但应警惕老年人中的无蒂型结膜乳头状瘤有较高的恶变风险，故定期随访尤为重要。
◎ Regular follow-up is important because of their tendency for spontaneous resolution, high rate of recurrence after surgical excision and small chance of cancerization. However,there is a higher risk of malignant transformation in the elderly with a sessile lesion.
◎ 应教育患者避免揉眼。
◎ Patients should be educated to avoid eye rubbing.