title: Malignant melanoma of the lacrimal drainage apparatus complicating conjunctival melanoma.
abstract: OBJECTIVE
  Melanoma of the conjunctiva may occasionally involve the lacrimal drainage apparatus (LDA). This makes clinical management difficult. The authors describe 5 cases of conjunctival melanoma with LDA disease and make recommendations about its management.
  
  
  METHODS
  Retrospective review of case notes and histopathology reports.
  
  
  RESULTS
  Five cases of LDA melanoma arising in patients with conjunctival melanoma are described. All 5 had orbital exenteration as part of their treatment. Melanoma of the LDA was clinically present at the time of exenteration in 1 case, found unexpectedly in 2 cases, and developed subsequent to exenteration in 2 cases. One patient died within 8 months of exenteration from metastatic melanoma. Two patients were disease free 3 and 5 years after exenteration. One patient developed metastasis in the parotid gland 4 years after exenteration but remained disease free 7 years after exenteration. One more patient has had a local recurrence in the maxilla and lateral nasal wall 4 years after exenteration, and after resection of that lesion and radiotherapy is disease free after 18 months. Seventeen patients underwent orbital exenteration for conjunctival melanoma over the period 1996-2013 at the authors'institution, with 5 having or developing LDA disease (29%). In the same period, there were 52 patients with conjunctival melanoma overall, with LDA involvement occurring in 5 of 52 patients (9.6%).
  
  
  CONCLUSIONS
  Melanoma of the LDA may complicate conjunctival melanoma in a significant percentage of cases having orbital exenteration. The surgical technique for orbital exenteration in patients with conjunctival melanoma should take this into account by intentionally removing the lacrimal sac and upper nasolacrimal duct as well as the lacrimal canaliculi. If melanoma is found in the LDA, consideration should be given to wider en bloc excision of the LDA.
authors.affiliation: *Orbital Plastic and Lacrimal Clinic, Royal Victorian Eye and Ear Hospital; †Department of Anatomical Pathology, St Vincent's Hospital; ‡Centre for Eye Research Australia, Department of Ophthalmology, University of Melbourne; and §Centre for Eye Research Australia, Department of Surgery, University of Melbourne, Melbourne, Australia.
authors.forename: Khami
authors.initials: K
authors.lastname: Satchi
authors.forename: Penny
authors.initials: P
authors.lastname: McKelvie
authors.forename: Alan A
authors.initials: AA
authors.lastname: McNab
mesh_terms: D000328:Adult; D000369:Aged, 80 and over; D003230:Conjunctival Neoplasms / Q000473:pathology* / Q000628:therapy; D005134:Eye Neoplasms / Q000556:secondary* / Q000628:therapy; D005260:Female; D006801:Humans; D007766:Lacrimal Apparatus Diseases / Q000473:pathology* / Q000628:therapy; D008279:Magnetic Resonance Imaging; D008297:Male; D008545:Melanoma / Q000556:secondary* / Q000628:therapy; D008875:Middle Aged; D009915:Orbit / Q000601:surgery; D049268:Positron-Emission Tomography; D018714:Radiotherapy, Adjuvant; D012189:Retrospective Studies; D014057:Tomography, X-Ray Computed