Ocular Tumors Located at the Level of the Conjunctiva

Review Article | DOI: https://doi.org/10.31579/2690-1919/562

Ocular Tumors Located at the Level of the Conjunctiva

  • Marieta Dumitrache 1*
  • M. Burcea 1
  • M. Manea 2
  • M.L. Cioboată 2

1Department of Ophthalmology ‚UMF’ Carol Davila, Bucharest, Romania.

2UMF’ Carol Davila, Bucharest, Romania.

*Corresponding Author: Marieta Dumitrache, Department of Ophthalmology ‚UMF’ Carol Davila, Bucharest, Romania.

Citation: Marieta Dumitrache, M. Burcea, M. Manea, M.L. Cioboată, (2025), Ocular Tumors Located at the Level of the Conjunctiva, J Clinical Research and Reports, 20(5); DOI:10.31579/2690-1919/562

Copyright: © 2025, Marieta Dumitrache. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received: 09 July 2025 | Accepted: 22 July 2025 | Published: 04 August 2025

Keywords: benign; malignant conjunctival tumors; pterygium; papilloma; squamous carcinoma; hemangioma; malignant melanoma

Abstract

The conjunctiva comprises a heterogeneous set of tumors, mostly benign 52%, precancerous tumor lesions 18% and malignant tumors 30%. Conjunctival tumors can be congenital or acquired and from a histological point of view are: epithelial, stromal, melanocytic. The clinical examination highlights the location, size, mobility, pigmentation, extension of the tumor and must be correlated with complementary examinations - optical coherence tomography of the anterior pole, ultrasonic biomicroscopy), ultrasound, biopsy with histological analysis of the sample. Benign tumors of the conjunctiva can be: degenerative, inflammatory, epithelial, histocytic, xanthoma, vascular tumors. Precancerous lesions can develop at the conjunctiva level. Malignant tumors of the conjunctiva represented by primary malignant melanoma – MMP require complete surgical excision followed by cryotherapy, radiotherapy, and in tumor extension exenteration. Secondary tumors in the conjunctiva extend from the eye, orbit, eyelid. Metastatic tumors of the uni or bilateral conjunctiva are very rare.

Introduction

● The conjunctiva is a mucous membrane that covers the posterior surface of the eyelids and the anterior surface of the eyeball; inserting at the level of the sclerocorneal limbus.

Conjunctival tumors comprise a heterogeneous set of lesions; mostly benign (52%); precancerous tumor lesions (18%); and malignant conjunctival tumors (30%).[1;2]

Conjunctival tumors are congenital and acquired; and from a histological point of view they are: epithelial; stromal; melanotic.

The conjunctiva and subconjunctival tissue are composed of various anatomical structures; each structural element of the conjunctiva can be a tumor starting point(1)

  • epithelium – epithelial cysts; benign hyperplasia; dysplasia; carcinomas
  • conjunctival tissue – inflammatory tumors
  • blood vessels – telangiectasias; hemangioma
  • lymphatic – lymphangioma
  • nerves – neuroma; neurofibroma
  • melanocytes – nevus; melanosis; melanoma

At the level of the sclerocorneal limbus; the conjunctival stroma is thick and contains vascular arches.

The conjunctiva can be examined directly in daylight; highlighting the presence of a tumor; the location; size; extension; mobility; and pigmentation of the tumor.

Sometimes complementary examinations are necessary - optical coherence tomography of the anterior pole; ultrasonic biomicroscopy; biopsy with histological analysis of the collected sample; exfoliative conjunctival cytology useful in evaluating adjacent inflammatory and/or infectious lesions.

  • Predisposing risk factors for the development of malignant tumors are: [2;3]
  • genetic factors
  • prolonged sun exposure (ultraviolet light)
  • viral immunodeficiency – HIV; papillomavirus HPV which can favor the development of bilateral; invasive tumors
  • immune disorders: organ transplant; immunosuppression
  • eczema; atopy; pemphigoid scars
  • autoimmune diseases
  • The symptoms of conjunctival tumors are nonspecific; they appear late in development: [3]
  • sensation of visual discomfort due to dry eyes
  • foreign body sensation
  • the appearance and expansion of a whitish/pinkish/protruding + pigmented formation
  • over time; as the tumor expands; vision decreases

Clinical Forms Of Conjunctival Tumors [3;4;5;6]

  • Benign conjunctival tumors with cell proliferation are clinically evident by the presence of a flat; clear-edged tumor formation – papilloma; nevus; angioma without life-threatening risk.
  • Precancerous conjunctival tumors are capable of transforming into malignant lesions – actinic keratosis; PAM intraepithelial neoplasia.
  • Malignant tumors have a risk of extension in surface and depth and have a risk of loco-regional recurrence and distant spread through metastasis; which can even carry a life-threatening reserved prognosis.

Benign tumors [1;3;4;5]

Degenerative conjunctive diseases [4;6]

Pinguela

  • Yellowish-white; round lesion located at the medial limbus; present in people chronically exposed to the sun
  • More common in older people
  • It shows elastic and collagen changes
  • A histologically similar lesion that extends to the cornea is Pterygium in which the epithelium may be normal; thinned; hyperplastic; dysplastic.

Pterygium

  • triangular subepithelial fibrovascular lesion due to proliferation of degenerated tissue of the bulbar conjunctiva; may grow beyond the limbus and insert onto the cornea
  • at the head of the pterygium; at the level of the anterior corneal epithelium; there may be iron deposits – Stocker's line
  • complications: chronic irritation; astigmatism; decreased visual acuity if the pterygium extends beyond the center of the cornea

Surgical treatment:

  • simple excision; accompanied by recurrences
  • excision followed by closure of the conjunctival defect with amniotic membrane or conjunctival autograft

Warehouse injuries [3;4]

They are a deposit of exogenous materials or abnormal metabolites in the conjunctiva.

  • localized lesions within systemic diseases – Fabry; ochronosis;
  • crystalline deposits in: cystinosis; oxalosis gout; dysproteinemias
  • deposits that occur through the use of topical medications: epinephrine or systemically: tetracycline

Amyloidosis

Primary

  • is present in young; healthy adults evidenced by acellular eosinophilic deposits in the stroma; with nodular or diffuse thickening of the conjunctiva
  • if amyloid deposits are in the conjunctiva; they suggest a localized lesion; if they are present in the eyelid; they suspect their existence within a systemic condition

Secondary – within a hereditary disease or after chronic inflammation.

Tumorous Dysgenesis Conjunctival Abnormalities [1;7]

Epibulbar limbic dermoid

  • tumor present in a child in the form of a yellowish-white subconjunctival mass located at the level of the inferotemporal limbus
  • single or multiple small; round; shiny ivory-white tumor
  • the tumor may be accompanied by deep vascularization that can invade the cornea
  • can produce significant astigmatism depending on location
  • may contain cartilaginous formations; hair follicles; sebaceous and sweat glands; then constituting a complex choristoma
  • may be isolated or present in patients with Goldenhar syndrome where there are bilateral limbic dermoid or dermolipoma
  • ocular may be associated with: palpebral coloboma; amyridia; microphthalmia
  • systemic can be associated with Goldenhar; Treacher; Collins; Franceschetti syndrome

Treatment

  • excision if visual function impairment occurs due to induced astigmatism; cataracts or chronic ocular irritation
  • Excision is relatively easy for small tumors; for large perilimbic tumors lamellar keratectomy is sometimes necessary; associated or not with lamellar keratoplasty.

Dermolipoma

is a dermoid that contains adipose tissue

  • the tumor is pinkish-yellow in color; is located in the supero-temporal part of the bulbar conjunctiva behind the orbital septum with possible extension towards the orbit; then accompanied by proptosis
  • sometimes the tumor can be located in the orbit with subconjunctival extension
  • the tumor is adherent to the conjunctiva; but mobile relative to the sclera

Surgical treatment

  • excision of the tumor without damaging neighboring anatomical structures (muscles; lacrimal gland)
  • conjunctival graft if needed

Conjunctival cyst

  • present in the conjunctival sac bottoms in the form of a translucent; mobile; round or oval tubular tumor
  • may be:
  • inclusion cyst – posttraumatic (accidental; surgical)
  • accessory lacrimal gland cyst
  • cyst involving lymphatic channels

Embryonic Tumors [1;6]

Rhabdomyosarcoma

  • rare tumor; located on the conjunctiva; in the bottom of the supero-nasal conjunctival sac; sometimes secondary to orbital extension
  • presents as a pedunculated; reddish; soft; rapidly growing mass
  • the diagnosis must be established quickly because in the absence of treatment with radiotherapy and chemotherapy the local and even lifelong prognosis can be fatal

Nerve Tumors [4]

neuroma

  • they are rare tumors
  • may be present in Recklinghausen neurofibromatosis

Histiocytic And Xanthomatous Tumors

Fibrosarcoma of the conjunctiva

  • tumor located in the vicinity of the limbus
  • the tumor is small; yellowish and composed of histocytes; sometimes swirled; and large xanthomatous cells loaded with fat
  • may be present in Hans Schuler Christian disease

Juvenile xanthogranuloma

  • tumor present in the child
  • can be isolated or associated with skin lesions of the same nature
  • it presents as a yellowish or pinkish; thick mass; located juxtalimbically
  • requires corticosteroid therapy

Inflammatory Tumors [3]

  • are diffuse or localized granulomatous inflammatory reactions generated by: bacteria (mycobacteria); foreign bodies; parasites; collagen diseases
  • have a relatively sudden onset with ocular pain and discomfort
  • the clinical appearance is similar to lymphomas
  • clinical diagnosis is confirmed by biopsy

Kaposi Sarcoma

  • slow-growing; low-grade tumor that occurs in HIV patients
  • presents as diffuse; well-vascularized nodules or plaques (sometimes they can mimic subconjunctival hemorrhage)
  • treatment is palliative; being indicated in infection; bleeding and consists of radiotherapy and excision followed by cryotherapy

Epithelial Tumors Of The Conjunctivus [4;5;6]

Conjunctival papilloma

It comes in two forms

  • multiple pedunculated or sessile lesions with smooth; non-keratinized surface
  • present in children and young adults
  • can be induced by human papillomavirus infection (HPV type 6; 11)
  • uni; occasionally bilateral; is located in the conjunctival sac bottoms; on the tarsal conjunctiva; caruncle; limbus
  • small lesions do not require treatment because they can resolve spontaneously
  • large lesions require biopsy excision and cryotherapy
  • Recurrent lesions are indicated for intralesional; subconjunctival injections with interferon alpha; local applications with mitomycin C
  • non-infectious sessile papilloma; located at or near the limbus
  • may extend to the cornea or bulbar conjunctiva
  • has an irregular surface and is present in adults
  • these tumors are benign; but can also be precancerous and require complete excision

Molluscum contagiosum

  • rare tumor of the conjunctiva; more commonly located on the eyelid

Keratoacanthoma – Pseudoepitheliomatous hyperplasia

  • rare tumors; more commonly located on the eyelids; with the presence of inflammatory lesions

Limb leukokeratosis

  • is the abnormal keratinization of the conjunctiva located especially at the level of the temporal limbus
  • histologically it is a leukoplakia
  • It appears as small; dense; avascular leukoplakic plaques with smooth edges and a white; dry surface.
  • rarely undergoes malignant transformation in case of incomplete excisions

Vascular Tumors [7;8]

Telangiectasia 

  • dilation of pre-existing vessels
  • nonspecific by local irritation or prolonged inflammation; which can lead to irreversible dilation of the vessels
  • may be present in:
  • Rendu-Osler-Weber disease – hemorrhagic telangiectasia affecting the skin; mucous membranes of the nose; mouth; lungs; gastrointestinal tract; conjunctiva
  • thyroid ophthalmopathy may present with telangiectasias near the insertion of the rectus

Hemangioma– proliferation of new blood vessels

Pyogenic granuloma

  • it is improperly called so because the lesion does not induce pus; it is not granulomatous
  • it is formed by granulation tissue with multiple capillaries and inflammatory cells with a "fleshy" appearance; after trauma; post-surgery or after a chalazion that partially drains at the tarsal surface level

Capillary hemangioma– eyelid; orbit may involve the palpebral conjunctiva

  • appear early; can grow rapidly; and sometimes regress spontaneously before the age of 5
  • crying causes tumor growth
  • amblyopia may occur in 50% of cases secondary to anisometropia

Treatment requires:

  • clinical follow-up for possible spontaneous regression
  • for large tumors corticosteroid injections

Cavernous hemangioma

  • is located deeper
  • the growth rate is slower
  • may be accompanied by exophthalmos

Lymphangioma

  • benign; slowly progressive tumors affecting the orbit; eyelid; conjunctiva
  • may coexist with lymphangioma of the face; nasal cavity; paranasal sinuses; palate
  • treatment is surgical; difficult with partial; repeated resections

Precancerous Lesions [3;5;6] –potentially malignant

Conjunctival and corneal intraepithelial neoplasia (CCIN)includes: [9]

  • Benign conjunctival dysplasia
  • benign; progressive; unilateral lesions with discrete malignant potential; located in the deep layers of the epithelium
  • small "fleshy" whitish pinkish; papillary; gelatinous tumors with fine vascular tuberosities on the surface
  • the epithelium is thickened with marked dyskeratosis and clear cellular atypia limited by normal cells with intact basement membrane
  • when cellular atypia and dyskeratosis are important; Bowen's disease of the conjunctiva develops
  • can extend laterally towards the cornea from which it detaches leaving the Bowman's membrane intact
  • if the basement membrane ruptures; carcinoma in situ or invasive squamous cell carcinoma occurs
  • Carcinoma in situ – malignant [10;11]
  • the lesions are malignant; more common in adults and the elderly; with men being more frequently affected than women
  • The risk factors are:
  • prolonged UV exposure
  • HPV infection; HIV

Clinical forms of CCIN are:

  • plaque-shaped lesions
  • are initially located at the limbus with extension into the interpalpebral fissure
  • unilateral; unifocal; with a white/gray gelatinous appearance
  • papillomatous lesions
  • diffuse form with conjunctival thinning

The differential diagnosis of CCIN is made with:

  • atypical conjunctival papilloma
  • pterygium
  • pseudoepitheliomatous hyperplasia
  • chronic unilateral conjunctivitis
  • amelanotic melanoma

A positive diagnosis of CCIN type is made ONLY on pathological examination because malignant and benign lesions have the same appearance.

Treatment

  • localized forms – excision with cryotherapy
  • diffuse forms
  • excision may be difficult because the tumor boundaries are imprecise
  • frequently the excision remains incomplete and involves recurrences
  • if necessary; to reduce recurrences; applications of Mitomycin C; 5 Fluorouracil; Interferon alpha will be made

Hereditary benign intraepithelial dyskeratosis [5;6]

  • rare; bilateral with abnormal keratinization
  • may be associated with oral lesions on the ventral side of the tongue; labial mucosa in the form of white; spongy masses
  • AD transmission
  • lesions present in the first year of life
  • It presents as prominent; grayish-white nasal or temporal semicircular conjunctival plaques with a dry surface; clear edges and intensely vascularized.
  • isolated limbic nodules may coexist
  • rarely the cornea is affected with deep; vascularized corneal opacities
  • being a precancerous lesion; careful clinical follow-up of the patient is necessary.

Actinic keratosis

  • can develop in the epithelium producing pinguecula or pterygium
  • limbic tumor; whitish; clearly keratinized (resembles leukokeratosis); but is vascularized
  • structural disorganization and cytological abnormalities are highlighted
  • the excision must be done completely because it can generate carcinoma

Xeroderma pigmentosum

  • conjunctival localization is common and serious
  • is present in patients exposed to solar radiation
  • initially edema appears followed by pigmentation; atrophy and tumor
  • some forms can cause rapidly invasive conjunctival carcinoma

Malignant Tumors [1;4;5;7;11]

Squamous conjunctival carcinoma

  • rare tumor with slow growth rate and low malignant potential that can develop from CCIN or occur per primam
  • may develop in patients with xeroderma pigmentosum or HIV infection
  • is located juxtalimbically on the palpebral conjunctiva or on the cornea
  • it presents as a vegetative; papillary; lobulated; whitish; vascularized tumor (each lobe being centered on a capillary)
  • progression outside of treatment is flat; the tumor spreading into the surface of the conjunctiva and cornea; invasion of the deep layers being exceptional
  • It has a tendency to invade nearby lymph nodes; which requires radical; broad treatment that encompasses the entire lesion.

Treatment requires:

  • complete excision and cryotherapy of the margins
  • for early cases or recurrences; chemotherapy; Mitomycin C; 5 Fluorouracil can be used
  • tumors involving 50% of the limb have a more reserved prognosis; and limbic stem cell transplant is indicated
  • in ocular invasion; enucleation is indicated; and in those with orbital involvement; exenteration

Mucoepidermoid or dyskeratotic cell carcinoma

  • associates with mucinous cells
  • has a tendency to invade deeply into the corneal stroma and inside the eyeball

Glandular Tumors Of The Conjunctivia [5;8]

It develops from the sebaceous glands in the caruncle and the semilunar fold.

Sebaceous adenoma of the caruncle– formed by well-defined sebaceous nodules.

Oncocytoma or oxyphytic cell adenoma

  • rarely; they are small; benign tumors composed of small; acidophilic granular cells – oncocytes z – with a pseudogranular appearance
  • may be derived from ectopic tear tissue

Sebaceous gland carcinoma

  • can mimic a chalazion; blepharitis
  • affects the Zeiss; Meibomian glands and conjunctiva in 40-80%
  • intraepithelial malignant cells appear individually grouped or arranged throughout the thickness of the conjunctival epithelium
  • have a high degree of malignancy
  • signs of conjunctival inflammation may be present requiring differential diagnosis with: conjunctivitis; blepharitis; meibomitis; limbic keratitis
  • treatment consists of surgical excision; occasionally exenteration

Lymphoid Lesions [3;5;7]

  • Benign and malignant lesions are salmon pink in color; frequently located in the bottom of the conjunctival sac; rarely being present in the case of a systemic disease
  • are relatively flat with a smooth surface and soft consistency

Conjunctival lymphoid lesions associated with systemic manifestations

Conjunctival non-Hodgkin's lymphoma; large B-cell

  • 10% have systemic manifestations
  • have an insidious onset; painless
  • are homogeneously colored; light pink lesions located at the bulbar conjunctiva of the fundus of the scrotum; oval in shape; slightly raised; similar to fish roe
  • Clinically they may resemble inflammatory pseudotumors; but they have a sudden onset; are painful and are associated with systemic vasculitis or collagen diseases.
  • early stages are difficult to differentiate from reactive lymphoid hyperplasia
  • biopsy is necessary to determine malignant potential

Possible effective treatment:

  • radiotherapy (low dose for polyclonal tumors; higher doses for monoclonal ones)
  • if necessary chemotherapy; excision; cryotherapy; local interferon injections

Burkitt's lymphoma

  • is one of the most common malignant tumors in African children
  • association with Epstein-Barr virus has been proven

Conjunctival localization of Hodgkin's disease– is rare

Granulocytic sarcoma

  • It is the anterior extension of an orbital tumor (Chloroma) and may be preceded by several months by the onset of lymphoid leukemia.

Pigmented Tumors Of The Conjunctivia [1;4;5;6;7]

Benign Tumors [3;6;7]

Moles

  • the most common form of conjunctival tumor
  • are congenital lesions; well demarcated; mobile on the underlying planes; located on the juxtalimbic bulbar conjunctiva; caruncle; semilunar fold; eyelid margin
  • 20-30% remain unpigmented; but by age 20-30 they become more pigmented and enlarge.
  • must be differentiated from acquired melanosis which occurs later
  • signs of malignant potential
  • extension into the fundus of the sac; palpebral; corneal
  • pigmentation change +/-
  • vascular development except during puberty

There are five types of nevi:

  • junctional in the conjunctival epithelium
  • compounds – in the epithelium and its own substance
  • Spitz nevus or juvenile melanoma – rare; made up of spindle and/or epithelial cells
  • blue nevus which has intensely pigmented; fusiform or dendritic melanocytes located deep in the substance itself

Treatment

excision is indicated when the lesion is unsightly or there is suspicion of malignant transformation

Epithelial melanosis (racial)

Congenital ocular melanocytosis [5]

It is a melanocytic hyperplasia with three clinical forms

Ocular melanocytosis– located only in the eyes

  • is unilateral; present at the level of the uvea; sclera; episclera; conjunctival epithelium
  • multifocal gray subconjunctival pigmentation

Dermal melanosis– only affects facial skin with hyperpigmentation

Oculodermal melanocytosis– Ota's nephew

  • It involves the eye and facial skin in the territory of the trigeminal nerve; branches 1 and 2; and is a hyperpigmentation of the eyelid skin associated with conjunctival melanosis.
  • is the most common form of congenital ocular melanocytosis
  • unilateral present in black and Asian populations
  • Abnormal melanocytes are deposited in the deep layers of the dermis; sclera; episcleral tissues; uvea; orbit; brain; palate; nasopharynx with pigment visible from birth; but skin pigmentation appears later
  • hyperpigmentation of the facial skin in the trigeminal area – branches one and two; of the oral and nasal mucosa
  • location in the uvea; orbit; brain is associated with an increased risk of ipsilateral uveal malignant melanoma; especially in whites
  • possible associations
  • hyperchromic iris
  • iris with thinned; papillary areas present in neurofibromatosis I; Axenfeld; Rieger; Peters anomalies
  • Pigmented FO
  • melanoma of the uveal tract; orbit; optic disc; brain
  • glaucoma associated with trabecular hyperpigmentation 10%

Primary acquired melanosis – PAM [6;7] 

Histologically there are two forms of PAM

  • to differentiate these forms; histopathological examination of material collected through multiple biopsies from different sites is necessary
  • PAM without cellular atypia
  • where melanocytes are located in the basal membrane region of the epithelium and have a dendritic shape
  • have low malignant potential
  • PAM with cellular atypia
  • containing epithelioid cells that evolve towards the superficial epithelium in a pagetoid pattern
  • have a high risk of malignant transformation 50% in the first 5 years
  • PAM with atypia with precancerous lesions; with risk of malignant transformation within 5 years with areas of brown; irregular; uni/multifocal pigmentation; predominantly on the bilateral limb in melanodermal individuals.

Treatment requires excision of small lesions and cryotherapy or topical mitomycin in large lesions.

Precancerous Lesions [1;5;12]

Primary acquired melanosis (PAM) – Reese precancerous melanosis

  • adults 40-50 years old; Caucasians with unilateral; diffuse; inhomogeneous; brownish-brown pigmentation
  • unlike nevi; they can be located on the conjunctiva in any part (conjunctival sac; tarsal conjunctiva; cornea); corneal invasion suggesting a proliferative process
  • they may regress spontaneously; until complete disappearance; or areas of regression and areas of lesion progression may coexist.

It must be differentiated from

  • racial melanosis
  • bilateral; asymmetrical
  • occurs in pigmented people
  • does not invade the cornea
  • low malignant potential
  • secondary melanosisin
  • Addison's disease; pregnancy
  • medications: chlorpromazine; topical epinephrine
  • diseases with chronic inflammation and scarring – trachoma.

Treatment

  • for small lesions – biopsy and excision
  • the presence of atypia requires complete excision of the lesions followed by cryotherapy
  • Very large injuries require:
  • abscission
  • cryotherapy
  • topical application of mitomycin C
  • periodic re-examination at -6 months

Malignant Tumors [3;4;12;13]

Primary malignant melanoma (PMN) [7;11;12;13]

  • represents 2% of ocular malignancy
  • is present in Caucasians 50-55 years old
  • exceptional in blacks and under 20 years old
  • located on the bulbar conjunctiva the lesion is nodular; sessile or pediculated; pigmented; well vascularized and fixed to the episclera
  • rarely the tumor is amelanotic; which can cause diagnostic confusion

MMP can develop from:

  • primary acquired melanosis (PAM) – 75%
  • Malignant transformation of PAM is suggested by nodular thickening of a previously smooth pigmented area
  • MMPs are well vascularized and fixed to the underlying tissues; while PAM is mobile on them
  • through the degeneration of a pre-existing nevus; which increases in volume; becomes pigmented; and is accompanied by an inflammatory reaction
  • by spontaneous "de novo" occurrence in apparently intact conjunctiva
  • nipple-shaped; blackish; rarely achromatic; highly vascularized formation that bleeds easily and tends to develop on the surface
  • dissemination occurs through local extension or lymphatic spread
  • The evolution is rapid and serious with invasion of the conjunctiva; cornea; preauricular and submandibular lymph nodes and metastases in the lungs; liver; and brain.

The differential diagnosis of MMP clinically and through anatomical-oatological examination can be made with:

  • large nevus that grows at puberty but does not affect the cornea
  • melanocytoma – rare; congenital pigmented lesion; with a slow growth rate fixed to the underlying tissue
  • pigmented conjunctival carcinoma
  • ciliary body or uveal melanoma extending to the sclera
  • metastases of malignant melanoma from elsewhere

The treatment of MMP is:

  • complete surgical excision followed by
  • cryotherapy at the base of the lesion and on its edges
  • periodic re-examination every 6-12 months
  • for diffuse MMP; excision of the nodules; cryotherapy; mitomycin C are performed
  • for invasive tumors in the orbit – exenteration; radiotherapy
  • exenteration does not improve the overall prognosis; but will only be applied in extensive and aggressive forms of disease that cannot be otherwise controlled
  • lymph node involvement requires radiotherapy
  • the presence of metastases requires palliative chemotherapy.

The mortality rate in MMP is 12% at 5 years and 25% at 10 years. In forms developed from PAM with pagetoid pattern; mortality reaches 44%.

Factors indicating a reserved prognosis:

  • multifocal tumors
  • tumor extension into the tarsal conjunctiva; sac bottoms; caruncle
  • tumor with a thickness greater than or equal to 2mm; gives a reserved prognosis
  • lymphatic dissemination; orbital
  • relapse
  • cellular atypia
  • development from WFP
  • The prognosis depends on the histopathological appearance of the primary acquired melanosis from the tumor composition; in which the presence of the pagetoid growth pattern offers a reserved evolutionary prognosis.
  • The depth of invasion gives a more reserved prognosis than the thickness.

Carunculus Tumors [8]

Benign

  • papilloma – 3-%
  • snow – 25%
  • inclusion cyst
  • sebaceous hyperplasia
  • sebaceous adenoma
  • pyogenic granuloma
  • oncocytoma

Malignant – 5%

  • squamous cell carcinoma
  • malignant melanoma
  • sebaceous adenocarcinoma

Secondary Tumors of the Conjunctivus [1;7;11]

  • are malignant neoplasms originating from the eye; orbit; eyelids that reach the conjunctiva by direct extension
  • The most important tumor that extends to the conjunctiva is orbital rhabdomyosarcoma in children.
  • retinoblastoma; medullary epithelioma in children may extend anteriorly to the episclera
  • in adults; uveal melanoma can extend to the conjunctiva
  • Squamous carcinoma; malignant eyelid tumors; can occasionally extend conjunctivally.

Metastatic Tumors of the Conjunctivus [5;6]

  • Uni or bilateral metastases can be uni or multifocal conjunctival lesions extremely rarely
  • There may be leukemic infiltrates of the conjunctiva in the form of pale pink; uni-; rarely bilateral subepithelial masses that require systemic chemotherapy and local radiotherapy.

Conjunctival tumors are congenital; acquired. Benign tumors have a favorable prognosis; precancerous lesions must be followed periodically; malignant tumors must be quickly diagnosed and appropriate treatment must be applied; and the patient monitored.

Conclusion

Congenital or acquired conjunctival tumors are benign clinically evident by the presence of precancerous or malignant tumors that can recur; metastasize; and may even have a vital prognosis. Benign tumors can be: degenerative; dysgenic; embryonal; inflammatory; histiocytic; epithelial; vascular. Conjunctival precancerous lesions are benign tumors with malignant potential. Malignant tumors of the conjunctiva are squamous conjunctival carcinoma. Pigmented tumors of the conjunctiva are benign tumors. Precancerous lesions are primary acquired melanosis with atypia – PAM. Malignant tumors of the conjunctiva are primary malignant melanoma MMP. Treatment of MMP is surgical excision; cryotherapy; exenteration in extension. Secondary tumors of the conjunctiva start from the orbit; eyelids (rhabdomyosarcoma; uveal melanoma). Conjunctival metastases are extremely rare and require chemotherapy and radiotherapy. Benign tumors of the conjunctiva have a favorable prognosis; precancerous lesions must be followed periodically; malignant tumors must be quickly diagnosed and treatment appropriate to the stage of evolution must be applied; and the patient monitored

References

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Orlando Villarreal

Dr. Katarzyna Byczkowska My testimonial covering: "The peer review process is quick and effective. The support from the editorial office is very professional and friendly. Quality of the Clinical Cardiology and Cardiovascular Interventions is scientific and publishes ground-breaking research on cardiology that is useful for other professionals in the field.

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Katarzyna Byczkowska

Thank you most sincerely, with regard to the support you have given in relation to the reviewing process and the processing of my article entitled "Large Cell Neuroendocrine Carcinoma of The Prostate Gland: A Review and Update" for publication in your esteemed Journal, Journal of Cancer Research and Cellular Therapeutics". The editorial team has been very supportive.

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Anthony Kodzo-Grey Venyo

Testimony of Journal of Clinical Otorhinolaryngology: work with your Reviews has been a educational and constructive experience. The editorial office were very helpful and supportive. It was a pleasure to contribute to your Journal.

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Pedro Marques Gomes

Dr. Bernard Terkimbi Utoo, I am happy to publish my scientific work in Journal of Women Health Care and Issues (JWHCI). The manuscript submission was seamless and peer review process was top notch. I was amazed that 4 reviewers worked on the manuscript which made it a highly technical, standard and excellent quality paper. I appreciate the format and consideration for the APC as well as the speed of publication. It is my pleasure to continue with this scientific relationship with the esteem JWHCI.

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Bernard Terkimbi Utoo

This is an acknowledgment for peer reviewers, editorial board of Journal of Clinical Research and Reports. They show a lot of consideration for us as publishers for our research article “Evaluation of the different factors associated with side effects of COVID-19 vaccination on medical students, Mutah university, Al-Karak, Jordan”, in a very professional and easy way. This journal is one of outstanding medical journal.

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Prof Sherif W Mansour

Dear Hao Jiang, to Journal of Nutrition and Food Processing We greatly appreciate the efficient, professional and rapid processing of our paper by your team. If there is anything else we should do, please do not hesitate to let us know. On behalf of my co-authors, we would like to express our great appreciation to editor and reviewers.

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Hao Jiang

As an author who has recently published in the journal "Brain and Neurological Disorders". I am delighted to provide a testimonial on the peer review process, editorial office support, and the overall quality of the journal. The peer review process at Brain and Neurological Disorders is rigorous and meticulous, ensuring that only high-quality, evidence-based research is published. The reviewers are experts in their fields, and their comments and suggestions were constructive and helped improve the quality of my manuscript. The review process was timely and efficient, with clear communication from the editorial office at each stage. The support from the editorial office was exceptional throughout the entire process. The editorial staff was responsive, professional, and always willing to help. They provided valuable guidance on formatting, structure, and ethical considerations, making the submission process seamless. Moreover, they kept me informed about the status of my manuscript and provided timely updates, which made the process less stressful. The journal Brain and Neurological Disorders is of the highest quality, with a strong focus on publishing cutting-edge research in the field of neurology. The articles published in this journal are well-researched, rigorously peer-reviewed, and written by experts in the field. The journal maintains high standards, ensuring that readers are provided with the most up-to-date and reliable information on brain and neurological disorders. In conclusion, I had a wonderful experience publishing in Brain and Neurological Disorders. The peer review process was thorough, the editorial office provided exceptional support, and the journal's quality is second to none. I would highly recommend this journal to any researcher working in the field of neurology and brain disorders.

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Dr Shiming Tang

Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.

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Raed Mualem

International Journal of Clinical Case Reports and Reviews. I strongly recommend to consider submitting your work to this high-quality journal. The support and availability of the Editorial staff is outstanding and the review process was both efficient and rigorous.

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Andreas Filippaios

Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.

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Dr Suramya Dhamija

Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.

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Bruno Chauffert

I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!

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Baheci Selen

"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".

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Jesus Simal-Gandara

I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.

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Douglas Miyazaki

We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.

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Dr Griffith

I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.

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Dr Tong Ming Liu

I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.

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Husain Taha Radhi

I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.

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S Munshi

Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.

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Tania Munoz

“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.

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George Varvatsoulias

Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.

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Rui Tao

Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.

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Khurram Arshad

Clinical Cardiology and Cardiovascular Interventions, we deeply appreciate the interest shown in our work and its publication. It has been a true pleasure to collaborate with you. The peer review process, as well as the support provided by the editorial office, have been exceptional, and the quality of the journal is very high, which was a determining factor in our decision to publish with you.

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Gomez Barriga Maria Dolores

The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews journal clinically in the future time.

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Lin Shaw Chin

Clinical Cardiology and Cardiovascular Interventions, I would like to express my sincerest gratitude for the trust placed in our team for the publication in your journal. It has been a true pleasure to collaborate with you on this project. I am pleased to inform you that both the peer review process and the attention from the editorial coordination have been excellent. Your team has worked with dedication and professionalism to ensure that your publication meets the highest standards of quality. We are confident that this collaboration will result in mutual success, and we are eager to see the fruits of this shared effort.

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Maria Dolores Gomez Barriga

Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, I hope this message finds you well. I want to express my utmost gratitude for your excellent work and for the dedication and speed in the publication process of my article titled "Navigating Innovation: Qualitative Insights on Using Technology for Health Education in Acute Coronary Syndrome Patients." I am very satisfied with the peer review process, the support from the editorial office, and the quality of the journal. I hope we can maintain our scientific relationship in the long term.

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Dr Maria Dolores Gomez Barriga

Dear Monica Gissare, - Editorial Coordinator of Nutrition and Food Processing. ¨My testimony with you is truly professional, with a positive response regarding the follow-up of the article and its review, you took into account my qualities and the importance of the topic¨.

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Dr Maria Regina Penchyna Nieto

Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, The review process for the article “The Handling of Anti-aggregants and Anticoagulants in the Oncologic Heart Patient Submitted to Surgery” was extremely rigorous and detailed. From the initial submission to the final acceptance, the editorial team at the “Journal of Clinical Cardiology and Cardiovascular Interventions” demonstrated a high level of professionalism and dedication. The reviewers provided constructive and detailed feedback, which was essential for improving the quality of our work. Communication was always clear and efficient, ensuring that all our questions were promptly addressed. The quality of the “Journal of Clinical Cardiology and Cardiovascular Interventions” is undeniable. It is a peer-reviewed, open-access publication dedicated exclusively to disseminating high-quality research in the field of clinical cardiology and cardiovascular interventions. The journal's impact factor is currently under evaluation, and it is indexed in reputable databases, which further reinforces its credibility and relevance in the scientific field. I highly recommend this journal to researchers looking for a reputable platform to publish their studies.

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Dr Marcelo Flavio Gomes Jardim Filho

Dear Editorial Coordinator of the Journal of Nutrition and Food Processing! "I would like to thank the Journal of Nutrition and Food Processing for including and publishing my article. The peer review process was very quick, movement and precise. The Editorial Board has done an extremely conscientious job with much help, valuable comments and advices. I find the journal very valuable from a professional point of view, thank you very much for allowing me to be part of it and I would like to participate in the future!”

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Zsuzsanna Bene

Dealing with The Journal of Neurology and Neurological Surgery was very smooth and comprehensive. The office staff took time to address my needs and the response from editors and the office was prompt and fair. I certainly hope to publish with this journal again.Their professionalism is apparent and more than satisfactory. Susan Weiner

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Dr Susan Weiner

My Testimonial Covering as fellowing: Lin-Show Chin. The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews.

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Lin-Show Chin

My experience publishing in Psychology and Mental Health Care was exceptional. The peer review process was rigorous and constructive, with reviewers providing valuable insights that helped enhance the quality of our work. The editorial team was highly supportive and responsive, making the submission process smooth and efficient. The journal's commitment to high standards and academic rigor makes it a respected platform for quality research. I am grateful for the opportunity to publish in such a reputable journal.

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Sonila Qirko

My experience publishing in International Journal of Clinical Case Reports and Reviews was exceptional. I Come forth to Provide a Testimonial Covering the Peer Review Process and the editorial office for the Professional and Impartial Evaluation of the Manuscript.

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Luiz Sellmann

I would like to offer my testimony in the support. I have received through the peer review process and support the editorial office where they are to support young authors like me, encourage them to publish their work in your esteemed journals, and globalize and share knowledge globally. I really appreciate your journal, peer review, and editorial office.

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Zhao Jia

Dear Agrippa Hilda- Editorial Coordinator of Journal of Neuroscience and Neurological Surgery, "The peer review process was very quick and of high quality, which can also be seen in the articles in the journal. The collaboration with the editorial office was very good."

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Thomas Urban

I would like to express my sincere gratitude for the support and efficiency provided by the editorial office throughout the publication process of my article, “Delayed Vulvar Metastases from Rectal Carcinoma: A Case Report.” I greatly appreciate the assistance and guidance I received from your team, which made the entire process smooth and efficient. The peer review process was thorough and constructive, contributing to the overall quality of the final article. I am very grateful for the high level of professionalism and commitment shown by the editorial staff, and I look forward to maintaining a long-term collaboration with the International Journal of Clinical Case Reports and Reviews.

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Cristina Berriozabal

To Dear Erin Aust, I would like to express my heartfelt appreciation for the opportunity to have my work published in this esteemed journal. The entire publication process was smooth and well-organized, and I am extremely satisfied with the final result. The Editorial Team demonstrated the utmost professionalism, providing prompt and insightful feedback throughout the review process. Their clear communication and constructive suggestions were invaluable in enhancing my manuscript, and their meticulous attention to detail and dedication to quality are truly commendable. Additionally, the support from the Editorial Office was exceptional. From the initial submission to the final publication, I was guided through every step of the process with great care and professionalism. The team's responsiveness and assistance made the entire experience both easy and stress-free. I am also deeply impressed by the quality and reputation of the journal. It is an honor to have my research featured in such a respected publication, and I am confident that it will make a meaningful contribution to the field.

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Dr Tewodros Kassahun Tarekegn

"I am grateful for the opportunity of contributing to [International Journal of Clinical Case Reports and Reviews] and for the rigorous review process that enhances the quality of research published in your esteemed journal. I sincerely appreciate the time and effort of your team who have dedicatedly helped me in improvising changes and modifying my manuscript. The insightful comments and constructive feedback provided have been invaluable in refining and strengthening my work".

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Dr Shweta Tiwari

I thank the ‘Journal of Clinical Research and Reports’ for accepting this article for publication. This is a rigorously peer reviewed journal which is on all major global scientific data bases. I note the review process was prompt, thorough and professionally critical. It gave us an insight into a number of important scientific/statistical issues. The review prompted us to review the relevant literature again and look at the limitations of the study. The peer reviewers were open, clear in the instructions and the editorial team was very prompt in their communication. This journal certainly publishes quality research articles. I would recommend the journal for any future publications.

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Dr Farooq Wandroo

Dear Jessica Magne, with gratitude for the joint work. Fast process of receiving and processing the submitted scientific materials in “Clinical Cardiology and Cardiovascular Interventions”. High level of competence of the editors with clear and correct recommendations and ideas for enriching the article.

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Dr Anyuta Ivanova

We found the peer review process quick and positive in its input. The support from the editorial officer has been very agile, always with the intention of improving the article and taking into account our subsequent corrections.

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Dr David Vinyes

My article, titled 'No Way Out of the Smartphone Epidemic Without Considering the Insights of Brain Research,' has been republished in the International Journal of Clinical Case Reports and Reviews. The review process was seamless and professional, with the editors being both friendly and supportive. I am deeply grateful for their efforts.

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Gertraud Teuchert-Noodt

To Dear Erin Aust – Editorial Coordinator of Journal of General Medicine and Clinical Practice! I declare that I am absolutely satisfied with your work carried out with great competence in following the manuscript during the various stages from its receipt, during the revision process to the final acceptance for publication. Thank Prof. Elvira Farina

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Dr Elvira Farina

Dear Jessica, and the super professional team of the ‘Clinical Cardiology and Cardiovascular Interventions’ I am sincerely grateful to the coordinated work of the journal team for the no problem with the submission of my manuscript: “Cardiometabolic Disorders in A Pregnant Woman with Severe Preeclampsia on the Background of Morbid Obesity (Case Report).” The review process by 5 experts was fast, and the comments were professional, which made it more specific and academic, and the process of publication and presentation of the article was excellent. I recommend that my colleagues publish articles in this journal, and I am interested in further scientific cooperation. Sincerely and best wishes, Dr. Oleg Golyanovskiy.

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Dr Oleg Golyanovski

Dear Ashley Rosa, Editorial Coordinator of the journal - Psychology and Mental Health Care. " The process of obtaining publication of my article in the Psychology and Mental Health Journal was positive in all areas. The peer review process resulted in a number of valuable comments, the editorial process was collaborative and timely, and the quality of this journal has been quickly noticed, resulting in alternative journals contacting me to publish with them." Warm regards, Susan Anne Smith, PhD. Australian Breastfeeding Association.

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Dr Susan Anne Smith

Dear Jessica Magne, Editorial Coordinator, Clinical Cardiology and Cardiovascular Interventions, Auctores Publishing LLC. I appreciate the journal (JCCI) editorial office support, the entire team leads were always ready to help, not only on technical front but also on thorough process. Also, I should thank dear reviewers’ attention to detail and creative approach to teach me and bring new insights by their comments. Surely, more discussions and introduction of other hemodynamic devices would provide better prevention and management of shock states. Your efforts and dedication in presenting educational materials in this journal are commendable. Best wishes from, Farahnaz Fallahian.

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Dr Farahnaz Fallahian

Dear Maria Emerson, Editorial Coordinator, International Journal of Clinical Case Reports and Reviews, Auctores Publishing LLC. I am delighted to have published our manuscript, "Acute Colonic Pseudo-Obstruction (ACPO): A rare but serious complication following caesarean section." I want to thank the editorial team, especially Maria Emerson, for their prompt review of the manuscript, quick responses to queries, and overall support. Yours sincerely Dr. Victor Olagundoye.

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Dr Victor Olagundoye

Dear Ashley Rosa, Editorial Coordinator, International Journal of Clinical Case Reports and Reviews. Many thanks for publishing this manuscript after I lost confidence the editors were most helpful, more than other journals Best wishes from, Susan Anne Smith, PhD. Australian Breastfeeding Association.

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Dr Susan Anne Smith

Dear Agrippa Hilda, Editorial Coordinator, Journal of Neuroscience and Neurological Surgery. The entire process including article submission, review, revision, and publication was extremely easy. The journal editor was prompt and helpful, and the reviewers contributed to the quality of the paper. Thank you so much! Eric Nussbaum, MD

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Dr Eric S Nussbaum

Dr Hala Al Shaikh This is to acknowledge that the peer review process for the article ’ A Novel Gnrh1 Gene Mutation in Four Omani Male Siblings, Presentation and Management ’ sent to the International Journal of Clinical Case Reports and Reviews was quick and smooth. The editorial office was prompt with easy communication.

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Hala Al Shaikh

Dear Erin Aust, Editorial Coordinator, Journal of General Medicine and Clinical Practice. We are pleased to share our experience with the “Journal of General Medicine and Clinical Practice”, following the successful publication of our article. The peer review process was thorough and constructive, helping to improve the clarity and quality of the manuscript. We are especially thankful to Ms. Erin Aust, the Editorial Coordinator, for her prompt communication and continuous support throughout the process. Her professionalism ensured a smooth and efficient publication experience. The journal upholds high editorial standards, and we highly recommend it to fellow researchers seeking a credible platform for their work. Best wishes By, Dr. Rakhi Mishra.

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Dr Rakhi Mishra

Dear Jessica Magne, Editorial Coordinator, Clinical Cardiology and Cardiovascular Interventions, Auctores Publishing LLC. The peer review process of the journal of Clinical Cardiology and Cardiovascular Interventions was excellent and fast, as was the support of the editorial office and the quality of the journal. Kind regards Walter F. Riesen Prof. Dr. Dr. h.c. Walter F. Riesen.

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Dr Walter F Riesen

Dear Ashley Rosa, Editorial Coordinator, International Journal of Clinical Case Reports and Reviews, Auctores Publishing LLC. Thank you for publishing our article, Exploring Clozapine's Efficacy in Managing Aggression: A Multiple Single-Case Study in Forensic Psychiatry in the international journal of clinical case reports and reviews. We found the peer review process very professional and efficient. The comments were constructive, and the whole process was efficient. On behalf of the co-authors, I would like to thank you for publishing this article. With regards, Dr. Jelle R. Lettinga.

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Dr Jelle Lettinga

Dear Clarissa Eric, Editorial Coordinator, Journal of Clinical Case Reports and Studies, I would like to express my deep admiration for the exceptional professionalism demonstrated by your journal. I am thoroughly impressed by the speed of the editorial process, the substantive and insightful reviews, and the meticulous preparation of the manuscript for publication. Additionally, I greatly appreciate the courteous and immediate responses from your editorial office to all my inquiries. Best Regards, Dariusz Ziora

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Dariusz Ziora

Dear Chrystine Mejia, Editorial Coordinator, Journal of Neurodegeneration and Neurorehabilitation, Auctores Publishing LLC, We would like to thank the editorial team for the smooth and high-quality communication leading up to the publication of our article in the Journal of Neurodegeneration and Neurorehabilitation. The reviewers have extensive knowledge in the field, and their relevant questions helped to add value to our publication. Kind regards, Dr. Ravi Shrivastava.

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Dr Ravi Shrivastava

Dear Clarissa Eric, Editorial Coordinator, Journal of Clinical Case Reports and Studies, Auctores Publishing LLC, USA Office: +1-(302)-520-2644. I would like to express my sincere appreciation for the efficient and professional handling of my case report by the ‘Journal of Clinical Case Reports and Studies’. The peer review process was not only fast but also highly constructive—the reviewers’ comments were clear, relevant, and greatly helped me improve the quality and clarity of my manuscript. I also received excellent support from the editorial office throughout the process. Communication was smooth and timely, and I felt well guided at every stage, from submission to publication. The overall quality and rigor of the journal are truly commendable. I am pleased to have published my work with Journal of Clinical Case Reports and Studies, and I look forward to future opportunities for collaboration. Sincerely, Aline Tollet, UCLouvain.

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Dr Aline Tollet