Ocular adnexal lymphoma presenting as incidental tarsal foll
A 43-year-old healthy woman with no medical or ocular history presented for her annual routine eye examination and was incidentally found to have giant follicles in the left eye inferior fornix extending onto the nasal palpebral conjunctiva (Fig. 1). Lymphadenopathy was absent. The follicles did not resolve with topical antibiotics, topical steroids or oral doxycycline. Chlamydia, Herpes Simplex Virus and bacterial swabs were negative. Conjunctival biopsy was performed. A formalin-fixed sample stained with hematoxylin-eosin showed lymphomatous infiltration on light microscopy.

Immunohistochemical staining of a fresh tissue specimen revealed infiltrating cells expressing CD20 and BCL2 with lambda light chain restriction; BCL6 and Cyclin D1 were negative. These findings confirmed a diagnosis of ocular adnexal mucosa-associated lymphoid tissue (MALT) lymphoma. She underwent external beam radiation therapy (EBRT) to the inferior fornix (25.2 Gy) and nasal palpebral conjunctiva (29.2 Gy), resulting in complete resolution of the follicles. She remained recurrence-free over the ensuing twelve years.

This case is a reminder of the variation in presentations of conjunctival MALT lymphoma and the importance of a thorough slit lamp examination, including eyelid eversion and examination of the fornices, even in seemingly low-risk asymptomatic patients. Awareness of atypical presentations may help expedite diagnosis and avoid delayed treatment.