Clinical features predictive of orbital exenteration for conjunctival melanoma

Purpose: Conjunctival malignant melanoma can sometimes be difficult to cont rol locally, and orbital exenteration may be necessary. To our knowledge, t he risk factors that portend exenteration have not been previously identifi ed. The purpose of this study was to review patients who underwent orbital exenteration for advanced disease and to identify retrospectively the clini cal factors predictive of ultimate exenteration. Methods: The records of patients with conjunctival melanoma who were manage d on the Oncology Service at Wills Eye Hospital from 1974 to 1997 were revi ewed. Factors predictive of orbital exenteration were analyzed using Cox pr oportional hazards regression models. Results: Of 151 consecutive patients with conjunctival melanoma, 20 (13%) r equired orbital exenteration for advanced disease. The number of melanoma e xcisions performed before referral ranged from 0 to 11, with a mean of 2. T he clinical factors predictive of orbital exenteration on multivariable ana lysis were visual acuity of 20/200 or worse, lack of tumor pigmentation, an d extralimbal tumor location. All exenterations were performed using an eye lid-sparing technique. At mean follow-up of 51 months after exenteration, 4 patients (20%) had died of metastasis, 3 (15%) were alive with metastasis, and 13 (65%) had not developed metastasis. Conclusions: Conjunctival melanoma can show aggressive local behavior, and orbital exenteration is necessary in up to 13% of cases at a tertiary refer ral center. Patients with risk factors such as poor visual acuity, amelanot ic tumor, and extralimbal tumor location may require wider excision and rad iation therapy to control the tumor and avoid orbital exenteration. It is h oped that modern surgical approaches will decrease the need for orbital exe nteration.