Scleral depression saves lives
Conjunctival lymphomas comprise a large proportion (25%) of all periocular lymphoma. However, initial presentation by prolapsing a lesion during scleral depression has not been previously reported. By far the majority of conjunctival lymphomas are B-cell non-Hodgkin lymphomas.

Here presents an interesting case of a 44-year-old man with no past medical history presented for retinal evaluation due to the new onset floater of the left eye. His slit lamp exam was unremarkable including the lids, lashes and conjunctiva. Bilateral dilated fundus exam was unremarkable. When scleral depression was performed on the left eye, a salmon colored tongue-like conjunctival mass appeared from the superior fornix prolapsing each time the lid was indented with the depressor, and receding when pressure was removed. The lesion was biopsied, which disclosed B-cell large cell (DLBCL) intermediate grade non-Hodgkin's lymphoma. Staging examination including bone marrow biopsy determined that the lymphoma was confined solely to the conjunctiva. Patient was treated with 38 gray total external beam radiation to the orbit as well as chemotherapy with cyclophosphamide, doxorubicin, and vincristine (CHOP) with complete remission of disease.

On routine follow-up, 10 years after his initial radiation treatment, he was noted to have a small area of telangiectasia adjacent to the fovea in the left eye consistent with mild radiation retinopathy. At present, nearly 20 years from initial diagnosis, he has had no recurrence of his lymphoma, his visual acuity remains 20/20, and his radiation retinopathy has not progressed.

In conclusion, scleral depression may lead to incidental diagnoses of life-threatening conditions due to prolapse and exposure of forniceal tumors. Early diagnosis of DLBCL in this case led to an atypical outstanding outcome