Epidemiology of ocular surface squamous neoplasia in Africa

The clinical presentation and treatment of an invasive conjunctival squamous spindle cell carcinoma

Ocular surface squamous neoplasia represents neoplastic epithelial abnormalities of conjunctiva and cornea, ranging from squamous dysplasia to invasive squamous cell carcinoma and is both sight- and life-threatening. Squamous spindle cell carcinoma (SSCC) of conjunctiva is a rare variant with distinct behavior which is thought to be more locally aggressive. We describe an 83-year-old woman with a progressively enlarging huge SSCC in her right eye over the past 2 years. The tumor bulged out with local invasion into intraocular and orbital cavities. Wide excision of the tumor with frozen section control was performed. After surgery, topical 0.03% mitomycin C was given as adjuvant therapy. At 40-month follow-up, the lesion site showed no evidence of local recurrence. This case provides a valuable and complete experience of the clinical presentation for the progression and treatment of this rare disease.

Long-Term Efficacy and Safety of Subconjunctival/Perilesional 5-Fluorouracil Injections for Ocular Surface Squamous Neoplasia

Purpose

To investigate the effectiveness and safety of subconjunctival/perilesional 5-fluorouracil injections on ocular surface squamous neoplasia (OSSN) during a 3-year follow-up period.

Patients and Methods

We followed up six patients with intraepithelial OSSN (in one eye each) that had regressed after subconjunctival/perilesional 5-fluorouracil injections. Conjunctival fluorescein angiography (FA) and indocyanine green angiography (ICGA), as well as anterior segment optical coherence tomography (AS-OCT), were performed to evaluate the OSSN status 3 years after initiation of treatment.

Results

The mean age of patients (five males, one female) at baseline was 62.3±11.6 years. The mean number of 5-fluorouracil injections was 17.0±8.6, with a mean treatment duration of 13.0±7.4 weeks. At the final visit, both intratumoral and conjunctival feeding vessels had disappeared on ICGA and FA, with no neovascularization-related leakage, in accordance with the results of AS-OCT. The period from complete tumor regression to final visit according to AS-OCT was 32.5±4.2 months, which was longer than that according to ICGA (31.3±3.2 months, p=0.034). The final best-corrected visual acuity was similar to that at baseline (p=0.128). No side effects were observed in any of the eyes.

Conclusion

Subconjunctival/perilesional 5-fluorouracil injections are an effective and safe treatment for OSSN. Future studies with a larger sample size are warranted for confirmation of our findings, as well as investigation into the reasons for residual areas of non-perfusion in the conjunctiva.

Diagnosis and staging of ocular surface squamous neoplasia

Background: Ocular surface squamous neoplasia (OSSN) is the most common ocular tumour. The diagnosis of OSSN is based on clinical suspicion and confirmed by various diagnostic modalities, of which histology is the gold standard. With the move to less invasive management options such as topical chemo- or immunotherapy, less invasive diagnostic options have come to the fore.Aim: The purpose of this article was to review the current staging and diagnostic modalities for OSSN with a focus on less invasive modalities.Method: A literature review was performed for publications on ocular surface neoplasia and diagnostic modalities.Results: Histology is the gold standard for diagnosing OSSN. Cytology has been shown to be a simple, repeatable and minimally invasive diagnostic modality, which also allows for additional testing such as polymerase chain reaction. Anterior segment optical coherence tomography provides a non-contact method of evaluating the ocular surface, with OSSN showing a thickened hyper-reflective epithelium, abrupt transition zone and demarcation line. Vital dyes are used less commonly with high sensitivity, but lower specificity for OSSN. Finally, confocal microscopy provides en-face images of the ocular surface, with OSSN showing a classic ‘starry night’ appearance.Conclusion: Histology remains the gold standard for diagnosis; however, with the increasing use of topical therapy for OSSN, there has been an increase in the uptake of less invasive diagnostic modalities.

Detection of a large spectrum of viral infections in conjunctival premalignant and malignant lesions

To study the interaction between HIV and other carcinogenic infections in conjunctival squamous cell carcinoma (SCC), we evaluated the presence of a broad spectrum of human viruses in conjunctiva specimens. Beta Human papillomavirus (HPV; n = 46), gamma HPV (n = 52), polyomaviruses (n = 12) and herpes viruses (n = 3) was determined in DNA extracted from 67 neoplastic and 55 non-neoplastic conjunctival tissues of HIV-positive and HIV negative subjects by Luminex-based assays. Next-generation sequencing (NGS) was also used to further characterize the presence of cutaneous HPVs. Detection of beta-2 HPV infections was associated with the risk of neoplasia (adjusted odds ratio [aOR] 3.0; 95% confidence interval [CI] 1.3-6.8), regardless of HIV status (HIV positive, aOR 2.6, 95% CI 0.9-7.7; HIV negative, aOR 3.5, 95% CI 0.9-14.4). EBV was strongly associated with the risk of neoplasia (aOR 12.0, 95% CI 4.3-33.5; P < .01) mainly in HIV individuals (HIV positive, aOR 57.5; 95% CI: 10.1-327.1; HIV negative aOR 2.6; 95% CI: 0.2-34.7). NGS allowed to identify 13 putative novel HPVs in cases and controls. Our findings suggest a role of beta HPV types and EBV, in conjunctival SCC. However, additional studies of viral expression in tumor tissue are required to confirm the causal association.

Proton beam radiotherapy of locally advanced or recurrent conjunctival squamous cell carcinoma: experience of the CATANA Centre

Aim:

Conjunctival squamous cell carcinoma (SCC) is a rare tumour of the ocular region and microscopic radical surgical is difficult. There are no single guidelines for therapeutic management and the role of radiation therapy is not clearly defined although conventionally photon or electron beams are used. Proton beam radiotherapy (PBRT) is a new option for a conservative approach and allows good sparing of the organs at risk.

Materials and methods:

After surgical resection, we collected 15 cases treated at our institution with PBRT. The dose delivered was between 48 and 60 Gy relative biological effectiveness (RBE), with fractions of 12–15 Gy RBE.

Results:

After an average period of 48 months, the patients achieved excellent disease control (overall survival and disease-free survival: 86·6%), with minimal acute and late toxicity.

Findings:

In this work, we present our experience on the use of PBRT technique in SCC treatment. A larger sample of patients is needed to draw conclusions about the impact of this treatment on disease recurrence and overall survival.

Cost-effective treatment of ocular surface squamous neoplasia for an undocumented and uninsured New York City patient: a case report

Background

New York City has a heterogeneous population with many undocumented and uninsured immigrants from equatorial areas who have a higher incidence of ocular surface squamous neoplasia. To the best of our knowledge, this is the first documented selection of this cost-effective treatment of ocular surface squamous neoplasia (the use of absolute ethanol along the corneal margin, primary excision, double freeze-thaw cryopexy, and primary conjunctival closure) for an undocumented and uninsured New York City patient.

Case presentation

A 35-year-old man from Ecuador presented to a New York City emergency department due to worsening discomfort of a long-standing left eye pterygium. A slit-lamp examination of the left eye demonstrated a nasally located conjunctival mass measuring 6 × 8 mm extending onto the cornea (3 mm superiorly and 6 mm inferiorly on the cornea). Histological diagnosis confirmed squamous cell carcinoma in situ arising from the pterygium. Surgical excision with adjunctive absolute alcohol with additive double freeze-thaw cryopexy was performed. Our patient has remained free of tumor recurrence at year 2 postoperative visit.

Conclusions

Our case highlights the need to choose a cost-effective treatment for ocular surface squamous neoplasia in an at-risk population among undocumented and uninsured patients. Areas in the world with similar types of populations or treatment challenges may need to consider this approach as a primary treatment option.

Observational study of ocular surface squamous neoplasia: Risk factors, diagnosis, management and outcomes at a tertiary eye hospital in South Africa

BACKGROUND

Ocular surface squamous neoplasia (OSSN) is the most common ocular surface tumour. Diagnosis and management have traditionally been by excision biopsy. Recently there has been success with the use of topical chemo or immunotherapy, which has resulted in a move from invasive diagnosis by histology to an array of non-invasive diagnostic tests.

METHODS

This observational study aims to describe the characteristics of patients with OSSN at St John Eye Hospital in Johannesburg, South Africa. Non-invasive diagnostic tests (impression cytology, anterior segment-OCT, methylene blue staining) will be compared to the gold standard, histology. Treatment success, recurrence and adverse events will be documented between three treatment options that include: surgical excision, topical 5-Fluorouracil (5FU) chemotherapy, and topical 5FU with retinoic acid therapy.

DISCUSSION

There is a trend to the use of less invasive diagnosis and management for OSSN. Minimally invasive diagnostic tests include cytology, anterior-segment OCT and methylene blue staining. The study will compare these to the gold standard histology, thereby providing evidence for their use in clinical practice. Interferon alpha 2b is commonly used as immunotherapy for OSSN. The cost of this medication is prohibitive to its adoption in a developing country. We therefore decided to use 5FU as the chemotherapeutic agent of choice in this study. The success, adverse events and recurrence rates with this agent may provide additional evidence for its use in the management of OSSN. Overall, if diagnosis and management can be implemented with good success in the outpatient environment, care can be improved for this condition in a developing country.

[Diagnosis and Therapy of Benign and Malignant Tumors of the Conjunctiva]

The aim of this paper is to give an overview of different benign and malignant epibulbar tumors. Categories can be made of the age of manifestation (paediatric tumors versus tumors of adults), the originating cell types (squamous cell tumors, melanocytic tumors, lymphomas or germ cell tumors) or genesis (proliferative, infectious or degenerating tumors). Most epibulbar tumors show lesions on the conjunctiva or the cornea. These can be flesh coloured or pigmented efflorescences with leucoplakias or hyperkeratosis. Especially malignant tumors show atypical growth of blood vessels, are often prominent and can have ulcerations or bleeding. In case of tumor growth, change in pigmentations or atypical bleedings a malign tumor can be suspected. The diagnosis should be confirmed using histopathological evaluation after an incisional or excisional biopsy. Molecular pathologic techniques extend the diagnostic tools and have an implication on the therapy of metastatic tumors. Therapeutic options of the malignant tumors (apart from lymphomas) are chirurgical excision preferably with a no touch technique and afterwards an adjuvant therapy consisting of radiation or cryotherapy. A topical chemotherapy with Mitomycin C, 5-Fluorouracil or Interferon α2b can be effective to reduce persisting precancerosis and reduce recurrences. In case of a suspected malignant tumor it is advisable to refer the patient to an ophthalmo-oncologic center to plan and ensure interdisciplinary therapy.

Benigne und maligne Bindehauttumoren in Diagnostik und Therapie

Bindehauttumoren betreffen in Diagnostik und Therapie alle Bereiche der augenärztlichen Praxis. Das beginnt mit der klinischen Kontrolle von Bindehautnävi und anderen benignen Tumoren, der Einschätzung von entzündlichen Pseudotumoren und ihrer Abgrenzung zu Präkanzerosen oder vernarbenden Erkrankungen und mündet in der hochspezialisierten und interdisziplinären Führung onkologischer Patienten mit Lymphomen, hochmalignen Melanomen oder invasiven Plattenepithelkarzinomen.

Ocular surface squamous neoplasia: Population demographics, pathogenesis and risk factors

Background: Ocular surface squamous neoplasia (OSSN) is a unifying term used to describe conjunctival intra-epithelial neoplasia, squamous cell carcinoma in situ and invasive squamous cell carcinoma.Aim: The aim of this article was to describe the demographics, clinical features, pathogenesis and risk factors of OSSN.Method: A literature search was conducted using the search criteria ‘ocular surface squamous neoplasia’, ‘diagnosis’, ‘epidemiology’, ‘pathogenesis’ and ‘risk factors’.Results: Ocular surface squamous neoplasia is the most common ocular tumour, with incidence rates ranging from 0.01 to 3.4 per 100 000 persons/year. There are two main patterns  of disease presentation: older white males in temperate climates where human immunodeficiency virus (HIV) and human papilloma virus (HPV) are not associated; and a younger patient population in tropical climates where HIV and HPV are more prevalent. The pathogenesis primarily revolves around ultraviolet B exposure and HPV infection that cause genetic mutations and uncontrolled cellular proliferation, whilst HIV infection and vitamin A impair tumour surveillance mechanisms. Ocular surface squamous neoplasia is first suspected clinically before formal confirmation of the diagnosis. Morphologically, it can be divided into three groups: placoid, nodular and diffuse. Placoid lesions can further be sub-divided into gelatinous, leukoplakic and papilliform lesions. Nodular lesions have the poorest prognosis, with the highest risk of metastasis and recurrence.Conclusion: Ocular surface squamous neoplasia is a common ocular tumour associated with ultraviolet radiation, HPV and HIV infection. The pathogenesis revolves around acquired genetic mutations, unregulated cellular proliferation and impaired tumour surveillance mechanisms.

The Changing Global Epidemic of HIV and Ocular Disease

Purpose: Overview of the evolving epidemiology of human immunodeficiency virus (HIV)-related ocular disease over time. Method: Narrative review. Results: HIV enhances susceptibility to opportunistic eye infections, has direct pathogenic effects, and places patients at risk of immune recovery inflammatory syndromes in previously infected eyes after starting highly-active antiretroviral therapy (HAART). Widespread availability of HAART has resulted in a decrease of infectious ocular conditions such as cytomegalovirus retinitis, toxoplasmic retinitis, squamous cell carcinoma of the conjunctiva, and microvascular retinopathy. However, large coexisting burdens of tuberculosis, herpesvirus infection and syphilis (among others) continue to contribute to the burden of ocular disease, especially in low-resource settings. Growing risks of cataract, retinopathy and retinal nerve fiber thinning can affect patients with chronic HIV on HAART; thought due to chronic inflammation and immune activation. Conclusion: The changing epidemic of ocular disease in HIV-infected patients warrants close monitoring and identification of interventions that can help reduce the imminent burden of disease.

OCULAR SURFACE SQUAMOUS CELL NEOPLASIA IN A 25 YEARS MAN FROM D.I.KHAN, PAKISTAN

Ocular surface squamous neoplasia (OSSN) is a term that describes the spectrum of abnormal growth of atypical squamous epithelial cells of the conjunctiva, cornea, and sclera. It is more common in people working for long in sun-exposed areas. It resembles other common ocular surface conditions such as pterygium, pinguecula, atopic conjunctivitis, diffuse episcleritis, chronic blepharoconjunctivitis which may result in the wrong diagnosis of the entity. Here we report a case of OSSN in a 25 years old man which was referred to us as a case of pterygium. An excisional biopsy revealed clusters of dysplastic squamous epithelial cells.

High resolution anterior segment optical coherence tomography for differential diagnosis between corneo-conjunctival intraepithelial neoplasia and pterygium

OBJECTIVE

To assess if anterior segment optical coherence tomography (AS-OCT) is a noninvasive diagnostic method suitable to differentiate benign corneo-conjunctival lesions (pterygium) from premalignant lesions (corneo-conjunctival intraepithelial neoplasia, CIN).

MATERIAL AND METHODS

An observational, analytical and cross-sectional study was conducted in 22 eyes with conjunctival lesions clinically suspicious for pterygium and CIN during two years. Morphological differences between both lesions were studied with AS-OCT; epithelial thicknesses (EE) and extension length on corneal surface (GIC) were compared between both groups. A surgical excision of the lesion was performed for histopathological diagnosis.

RESULTS

Mean age of patients with pterygium (n=18) was 52.67±15 y.o and 74±12 y.o in subjects with CIN (n=4) (p<0.021). In pterygia, AS-OCT showed typical features (normal, thinning or slightly thickened EE; 77.4±26μm), in addition to an increase in wedge-shaped subepithelial tissue. Patients with CIN had a mean thickened EE (262.5±124μm) and strongly hyperreflective, with abrupt transition between normal and pathological epithelium. Analysis of EE between subjects with pterygium and CIN revealed statistically significant differences (p<0.002). ROC curve revealed a 100% sensitivity and specificity of OCT-SA in differentiation between CIN and pterygium, using 141μm as cutoff point of EE.

CONCLUSION

AS-OCT is a useful tool for the differentiation between pterygium and CIN able to provide typical morphological characteristics. An EE greater than 141μm in AS-OCT suggests a sensitivity and specificity of 100% for the diagnosis of CIN.

Survey of 138 Conjunctival Tumors in the Dominican Republic

PURPOSE

To report the frequency of conjunctival tumors in the Dominican Republic.

METHODS

Retrospective noninterventional case series. One hundred thirty-eight consecutive patients with a conjunctival mass evaluated at two tertiary referral centers from 2010 to 2018. Main outcome measures were frequency of tumors by diagnosis and distribution of tumors relative to patients' age and gender.

RESULTS

The mean age at presentation was 41.2 years (median, 42 years; range 10 days - 91 years). There were 83 male patients (60%) and 55 female patients (40%). The three most common specific diagnoses were junctional, compound, and subepithelial naevi (47 [34%]), squamous cell carcinoma (SCC) (26 [19%]) and conjunctival squamous intraepithelial neoplasia (CIN) (17 [12%]). The mean age at detection was 36.5 years for non-malignant tumors and 56.3 years for malignant tumors (p < .001), with a mean difference of 19.8 years at time of diagnosis (95% CI, 10.7-28.8). Benign tumors were more common in children and young adults; malignant and premalignant tumors were more common in mid and older adults (p = .009). Malignant tumors were more common in males (73%) than in females (27%) (p = .04).

CONCLUSION

In the Dominican Republic, conjunctival tumors are benign (63%), premalignant (13%) and malignant (24%). Malignant tumors are more common in older adults and men.

Clinical Management of Squamous Cell Carcinoma of the Conjunctiva

Patient: Female, 33-year-old

Final Diagnosis: Conjunctival squamous cell carcinoma

Symptoms: Tumorous lesion on the nasal bulbar conjunctiva • red eye

Medication: —

Clinical Procedure: The conjunctival tumor was excised. The histopathological diagnosis suggested a conjunctival squamous cell carcinoma. A treatment with topical MMC was admistered

Specialty: Ophthalmology

The role of infectious agents in cancer of the ocular region

The purpose of the study was to investigate the association between infectious agents and the development of cancer in the ocular adnexa. A comprehensive literary study was carried out, reviewing and summarizing previous reports on the topic. A broad range of malignancies of the ocular adnexa are associated with infectious agents. A strong association and possible causal relationship between the infectious agent and the development of ocular adnexal cancer are seen in Merkel cell carcinoma (Merkel cell polyomavirus), Burkitt lymphoma (Epstein-Barr virus) and Kaposi sarcoma (human herpesvirus 8). Infection with Chlamydia psittaci has been associated with the development of extranodal marginal zone B-cell lymphoma in Italy. Human papillomavirus infection has been associated with the development of squamous cell carcinomas of the ocular adnexa, although with a highly variable reported prevalence. By exploring the role of infectious agents in the ocular adnexa and the mechanism by which they contribute to oncogenesis, the diagnostics, management and prevention of these malignancies may also improve. Antibiotic treatment and vaccines against infectious agents may be valuable in future treatment. Additionally, the presence of infectious agents within the tumours may have a prognostic or predictive value.

Epidemiology of invasive ocular surface squamous neoplasia in Canada during 1992-2010

BACKGROUND

Ocular surface squamous neoplasia (OSSN) is the most common non-pigmented ocular surface malignancy. It is classified as invasive OSNN (IOSSN) when the underlying stroma are infiltrated by dysplastic squamous epithelial cells through the basement membrane. Here, we present the descriptive epidemiology and geographical distribution of IOSSN in Canada.

METHODS

We determined the incidence and geographical distribution of IOSSN cases diagnosed between 1992 and 2010 using two independent population-based cancer registries: the Canadian Cancer Registry and Le Registre Québécois du Cancer.

RESULTS

The mean annual age-standardised incidence rate (WHO 2000-2025) of IOSSN for 1992-2010 was 0.45 cases per million individuals per year with an average annual percent increase in incidence of 4.5%. IOSSN localisation to the conjunctiva was documented in at least 57% of the reported cases. IOSSN exhibited a male predilection ratio of 3.3:1.0 with a mean age at diagnosis of 69 years. Incidence rates of IOSSN across Canadian provinces and cities showed no significant differences from the crude national average.

CONCLUSIONS

Our results, particularly concerning IOSSN patient age and male predilection, corroborate with data reported from the USA. Additional studies are needed to determine whether the observed increase in incidence rate over the study period (1992-2010) is significant.

Human papillomavirus type 16 causes a defined subset of conjunctival in situ squamous cell carcinomas

Squamous cell carcinoma of the conjunctiva is associated with a number of risk factors, including HIV infection, iatrogenic immunosuppression and atopy. In addition, several studies have suggested an involvement of HPV, based on the presence of viral DNA, but did not establish whether there was active infection or evidence of causal disease association. In this manuscript, 31 cases of conjunctival in situ squamous cell carcinoma were classified as HPV DNA-positive or -negative, before being analysed by immunohistochemistry to establish the distribution of viral and cellular biomarkers of HPV gene expression. Our panel included p16INK4a, TP53 and MCM, but also the virally encoded E4 gene product, which is abundantly expressed during productive infection. Subsequent in situ detection of HPV mRNA using an RNAscope approach confirmed that early HPV gene expression was occurring in the majority of cases of HPV DNA-positive conjunctival in situ squamous cell carcinoma, with all of these cases occurring in the atopic group. Viral gene expression correlated with TP53 loss, p16INK4a elevation, and extensive MCM expression, in line with our general understanding of E6 and E7's role during transforming infection at other epithelial sites. A characteristic E4 expression pattern was detected in only one case. HPV mRNA was not detected in lower grades of dysplasia, and was not observed in cases that were HPV DNA-negative. Our study demonstrates an active involvement of HPV in the development of a subset of conjunctival in situ squamous cell carcinoma. No high-risk HPV types were detected other than HPV16. It appears that the conjunctiva is a vulnerable epithelial site for HPV-associated transformation. These cancers are defined by their pattern of viral gene expression, and by the distribution of surrogate markers of HPV infection.

[Conjunctival malignancies]

Conjunctival malignancies are rare. However, some of these tumors are among the most aggressive malignancies in ophthalmology and require radical forms of therapy that may lead to blindness or loss of the ipsilateral eye and tumor-associated death. The most relevant primary conjunctival malignancies for oncologists are squamous cell carcinoma, malignant melanoma and malignant lymphoma. Surgical therapy is the primary treatment for squamous cell carcinoma and malignant melanoma. An adjuvant therapy in the form of topical chemotherapy or radiation is necessary in most cases. The isolated malignant lymphoma of the conjunctiva is biopsied excisionally if possible. However, if an incisional biopsy was unavoidable, additional irradiation should be performed; malignant lymphoma generally responds very well to relatively low irradiation doses with a good prognosis quad vitam. More aggressive forms, such as diffuse large cell B‑cell lymphoma or mantle cell lymphoma, must also be treated systemically at an early stage.

Conjunctival intraepithelial neoplasia and carcinoma: distinct clinical and histological features in relation to human papilloma virus status

AIMS

Human papillomavirus (HPV) is considered a causative agent for the development of a broad range of human carcinomas. The role of HPV in the development of conjunctival intraepithelial neoplasia (CIN) and carcinoma (cSCC) remains unclear. The purpose of the present study was to investigate the HPV prevalence in a nationwide cohort and to describe clinical and histopathological features in relation to HPV status.

METHODS

All cases of CIN and cSCC in Denmark from 1980 to 2016 were included. We combined p16 immunohistochemistry (IHC), RNA in situ hybridisation (RNA ISH) and HPV DNA PCR to detect HPV. The results were correlated to clinical and histopathological parameters.

RESULTS

One hundred twelve primary tumours and 33 recurrent tumours were included for HPV analysis. Twenty-four (21%) of the primary tumours were HPV positive by PCR. Eighteen of out 19 HPV-positive tumours were positive by RNA ISH. HPV16 was the most prevalent genotype (n=18, 75%). The patients with HPV-positive tumours were significantly younger (mean difference 11.5 years, 95% CI 5.2 to 17.9, p=0.0005) and had a higher recurrence compared with patients with HPV-negative tumours (HR 2.30, 95% CI 1.02 to 5.21, p=0.046). The HPV-positive tumours were associated with a positive p16 IHC and a non-keratinising morphology.

CONCLUSION

We describe distinct clinical and histopathological features associated with HPV status in cSCC. The finding of transcriptionally active HPV in this material lends support to a causal role of HPV in a subset of cSCC.

PD-L1/PD1 Expression, Composition of Tumor-Associated Immune Infiltrate, and HPV Status in Conjunctival Squamous Cell Carcinoma

Purpose

Conjunctival squamous cell carcinoma (SCC), a type of ocular surface neoplasia, is primarily treated by surgical resection and topical immuno- or chemotherapy. Metastatic disease may be treated with systemic chemo- or immunotherapy, albeit with variable response. The purpose of this study was to determine whether immune checkpoint blockade might be considered in the management of conjunctival SCC.

Methods

In this retrospective study, we evaluated tumor programmed death-ligand 1 (PD-L1) expression, high-risk human papillomavirus (HPV) status, and immunohistochemical expression of cluster of differentiation 3 (CD3), cluster of differentiation 8 (CD8), and programmed death 1 (PD1) in tumor-associated immune infiltrate in a series of 31 conjunctival SCCs.

Results

PD-L1 expression in ≥1% of tumor cells was noted in 14 conjunctival SCCs (47%) and was more prevalent in invasive than in situ SCC and among tumors with higher American Joint Committee on Cancer (AJCC) T category (≥T3 versus ≤T2). The density of CD3-positive T cells was higher in primary than recurrent tumors and higher in invasive than in situ tumors. Density of CD3-positive and CD8-positive T cells was higher in higher AJCC stage tumors. Density of CD8-positive T cells was higher in HPV-positive than HPV-negative tumors. PD-L1 expression correlated with a higher density of CD3-, CD8-, and PD1-positive cells in the tumor-associated immune infiltrate but not with HPV status.

Conclusions

Our findings demonstrate that PD-L1 is expressed in almost half of conjunctival SCCs. The density of tumor-associated immune cells correlated with invasive SCC, stage, and HPV status in conjunctival SCC. Our findings support further studies to establish the potential application of immune checkpoint blockade in the management of conjunctival SCC.

Update on pharmacotherapy for ocular surface squamous neoplasia

The most frequently encountered non-pigmented tumor of the ocular surface is ocular surface squamous neoplasia (OSSN). Over the past two decades, the pharmacological management of OSSN has grown, with topical 5-fluorouracil, mitomycin, and interferon alpha 2b all being successfully used to treat this disease. Other agents, such as anti-vascular endothelial growth factor (VEGF), retinoic acid, cidofovir and Aloe vera, have less frequently been used in the treatment of OSSN. This review will discuss these pharmacologic agents, summarizing available data and presenting the approach to the treatment of these tumors.

The burden of squamous cell carcinoma of the conjunctiva in Africa

Squamous cell carcinoma of the conjunctiva (SCCC) is a relatively common cancer in Africa, although its precise incidence and geographic distribution have not been previously systematically studied.

METHODS

Using the methods employed to produce national estimates of cancer incidence for the "Globocan" series of the International Agency for Research on Cancer, along with detailed information on cancer incidence by histological subtype from cancer registries in Africa, we estimate the numbers and rates of incidence by sex, age group, country and region of Africa.

RESULTS

We estimate that the number of new cases occurring in 2018 to be about 6 200, with all but about 50 in sub Saharan Africa, and 55% in females. On a national basis, the geographic distribution of incidence rates resembles that of the prevalence of infection with HIV, with a strong correlation between them, especially in males.

CONCLUSIONS

We estimate that about one third of the total cases of SCCC occurring in Africa are HIV-related.

Epidemiology of ocular surface squamous neoplasia in veterans: a retrospective case-control study

Background

A number of risk factors have been evaluated in ocular surface squamous neoplasia, but few studies have assessed risk factors specific to the armed forces veteran population.

Methods

We conducted a retrospective case-control study on 55 patients and 55 age-matched controls with biopsy-proven ocular surface squamous neoplasia from the Miami Veterans Administration Hospital Eye Clinic to investigate potential risk factors encountered by veterans, including service-specific exposures. Veteran-specific risk factors included ionizing radiation exposure, Agent Orange exposure, deployment to Southwest Asia, and exposure to the series of biochemical warfare tests known as Project Shipboard Hazard and Defense. Data was analyzed with SPSS (SPSS Inc., Chicago, IL) using t-tests, chi-squared, and logistic regression analysis, with a p-value of < 0.05 considered statistically significant.

Results

The strongest risk factor for ocular surface squamous neoplasia was lifetime sun exposure both directly assessed via historical quantification of exposure by dermatology practitioners (Odds Ratio (OR) 5.4, 95% Confidence Interval (CI) 2.27–12.847, p < 0.005), and using the surrogate markers of basal cell carcinoma (OR 3.157, 95% CI 1.286–7.748, p = 0.010) and pingueculae (OR 5.267, 95% CI 2.104–13.186, p < 0.005). Of the veteran-specific risk factors, Agent Orange exposure and Southwest Asia deployment were not associated with an increased risk of ocular surface squamous neoplasia. Exposure to ionizing radiation and involvement in Project Shipboard Hazard and Defense were not documented among any cases or controls.

Conclusions

The results of our study are consistent with prior established risk factors, namely highlighting the important role of sun exposure in ocular surface squamous neoplasia among veterans.

Ocular surface squamous neoplasia: angiographic characteristics and response to subconjunctival/perilesional 5-fluorouracil injections

Introduction: To investigate the angiographic characteristics of ocular surface squamous neoplasia (OSSN) and to evaluate the efficacy of subconjunctival/perilesional 5-fluorouracil injections in OSSN cases.

Materials and methods: Six eyes of six patients with primary OSSN, received perilesional, subconjunctival, 25-mg/mL 5-fluorouracil injections at certain intervals. Anterior segment digital photography images, anterior segment optical coherence tomography (AS-OCT), and conjunctival indocyanine green angiography (ICGA) were obtained simultaneously with fluorescein angiography.

Results: The mean best-corrected vision acuity significantly improved after treatment. At baseline, the median of the largest thickness of OSSN was 905.0 (interquartile range: 492.0–1592.5) μm based on AS-OCT data. There was an abrupt transition between normal and abnormal epithelium, a thickened hyper-reflective epithelium, and a sharp plane of cleavage between the lesion and underlying tissue, all indicative of OSSN. The angiographic characteristics of OSSN included focal or seafan-shaped intratumoral and conjunctival feeding vessels visible via ICGA, and abnormal vascular leakage visible with fluorescein angiography. The median time to tumor regression after treatment was 35.0 (interquartile range: 32.0–45.5) days in five eyes without recurrence, and OSSN in one eye regressed partially 40 days after treatment.

Conclusion: This is the first report of the angiographic characteristics of OSSN and its response to subconjunctival/perilesional 5-fluorouracil injections by simultaneous conjunctival angiography and AS-OCT. The improved subconjunctival/perilesional 5-fluorouracil injection was an effective therapy for OSSN in both best-corrected vision acuity gain and anatomic outcomes.

Novel automated non invasive detection of ocular surface squamous neoplasia using multispectral autofluorescence imaging

PURPOSE

Diagnosing Ocular surface squamous neoplasia (OSSN) using newly designed multispectral imaging technique.

METHODS

Eighteen patients with histopathological diagnosis of Ocular Surface Squamous Neoplasia (OSSN) were recruited. Their previously collected biopsy specimens of OSSN were reprocessed without staining to obtain auto fluorescence multispectral microscopy images. This technique involved a custom-built spectral imaging system with 38 spectral channels. Inter and intra-patient frameworks were deployed to automatically detect and delineate OSSN using machine learning methods. Different machine learning methods were evaluated, with K nearest neighbor and Support Vector Machine chosen as preferred classifiers for intra- and inter-patient frameworks, respectively. The performance of the technique was evaluated against a pathological assessment.

RESULTS

Quantitative analysis of the spectral images provided a strong multispectral signature of a relative difference between neoplastic and normal tissue both within each patient (at p < 0.0005) and between patients (at p < 0.001). Our fully automated diagnostic method based on machine learning produces maps of the relatively well circumscribed neoplastic-non neoplastic interface. Such maps can be rapidly generated in quasi-real time and used for intraoperative assessment. Generally, OSSN could be detected using multispectral analysis in all patients investigated here. The cancer margins detected by multispectral analysis were in close and reasonable agreement with the margins observed in the H&E sections in intra- and inter-patient classification, respectively.

CONCLUSIONS

This study shows the feasibility of using multispectral auto-fluorescence imaging to detect and find the boundary of human OSSN. Fully automated analysis of multispectral images based on machine learning methods provides a promising diagnostic tool for OSSN which can be translated to future clinical applications.

Human papillomavirus infection and ocular surface disease (Review)

Human papillomavirus (HPV) infection has been implicated as a primary cause of lesions in the anogenital region, skin, oropharynx and respiratory tract. Additionally, the role of HPV in the pathogenesis of ocular surface disease has also been extensively studied. Conjunctival papilloma development has been strongly associated with the HPV infection of certain subtypes. On the other hand, the role of HPV in conjunctival pterygium, conjunctival intraepithelial neoplasia (CIN) and ocular surface squamous neoplasia (OSSN) remains controversial. Genetic predisposition and environmental factor is important in HPV hosts as regards the pathogenesis of ocular surface disease. Several studies have indicate a synergic role of HPV with ultraviolet radiation in pterygium establishment. A higher recurrence risk rate and more aggressive disease of ophthalmic pterygium is observed in cases of HPV infection. The purpose of this review was to provide a systematic review of the literature and to assist in a better understanding of the role of HPV in ocular surface disease.

Human health in relation to exposure to solar ultraviolet radiation under changing stratospheric ozone and climate

The Montreal Protocol has limited increases in the UV-B (280-315 nm) radiation reaching the Earth's surface as a result of depletion of stratospheric ozone. Nevertheless, the incidence of skin cancers continues to increase in most light-skinned populations, probably due mainly to risky sun exposure behaviour. In locations with strong sun protection programs of long duration, incidence is now reducing in younger age groups. Changes in the epidemiology of UV-induced eye diseases are less clear, due to a lack of data. Exposure to UV radiation plays a role in the development of cataracts, pterygium and possibly age-related macular degeneration; these are major causes of visual impairment world-wide. Photodermatoses and phototoxic reactions to drugs are not uncommon; management of the latter includes recognition of the risks by the prescribing physician. Exposure to UV radiation has benefits for health through the production of vitamin D in the skin and modulation of immune function. The latter has benefits for skin diseases such as psoriasis and possibly for systemic autoimmune diseases such as multiple sclerosis. The health risks of sun exposure can be mitigated through appropriate sun protection, such as clothing with both good UV-blocking characteristics and adequate skin coverage, sunglasses, shade, and sunscreen. New sunscreen preparations provide protection against a broader spectrum of solar radiation, but it is not clear that this has benefits for health. Gaps in knowledge make it difficult to derive evidence-based sun protection advice that balances the risks and benefits of sun exposure.

Predictors of Ocular Surface Squamous Neoplasia and Conjunctival Squamous Cell Carcinoma among Ugandan Patients: A Hospital-based Study

AIM

The aim of the study was to assess the predictors of ocular surface squamous neoplasia (OSSN) and conjunctival squamous cell carcinoma (SCC) among Ugandan patients.

MATERIALS AND METHODS

Patients presenting for removal of ocular surface lesions received human immunodeficiency virus (HIV) testing, completed questionnaires about demographic, behavioral, and historical potential risk factors for conjunctival neoplasia, and had lesions examined for interpalpebral versus other locations, rough versus smooth texture, and number of feeder vessels. Biopsies were classified pathologically using standard definitions classified OSSN and SCC. HIV rates were calculated for patients: with OSSN, SCC, and benign lesions. Potential risk factors and gross findings were tested for abilities to predict OSSN and SCC.

RESULTS

One hundred and ninety-five patients presented with 212 lesions in 203 eyes. Nearly 34% of the patients were more than 60 years old, 67% were peasants, 88% spent more than 20 h/week outdoors, and only 10% wore sun protection. No potential risk factors predicted neoplasia. HIV prevalence was 17.1% among patients with OSSN compared to 11.1% among those without OSSN; 42.9% among SCC patients compared to 12.0% among those without SCC. Rough tumor surface (adjusted odds ratio [aOR] = 4.4 and 95% confidence interval [CI]: 2.2-9.1), six or more feeder vessels (aOR = 2.6, 95% CI: 1.3-5.2), and interpalpebral tumor location (aOR = 3.3, 95% CI: 1.5-7.1) predicted OSSN. Only a rough tumor surface (aOR = 34.6, 95% CI: 7.8-153.4) predicted SCC.

CONCLUSION

HIV infection remained a risk factor for OSSN and particularly, SCC, but less so than in the past. Lesions' rough surface, six or more feeder vessels, and interpalpebral location increased OSSN risk. Only a rough tumor surface increased risk for SCC.

Clinical characteristics, HIV status, and molecular biomarkers in squamous cell carcinoma of the conjunctiva in Ghana

BACKGROUND AND AIMS

Conjunctival squamous cell carcinoma (CSCC) varies in incidence geographically from 0 to 1 case per 100 000 per year globally. Additionally, the incidence of CSCC is known to increase 49% for every 10° decrease in latitude. Since the onset of the AIDS epidemic, there has been a trend of increasing incidence of CSCC in Africa, and despite relatively stable levels of ultraviolet (UV) exposure, there is an observed 12 times greater risk of developing CSCC when individuals are infected with HIV. In this study, we aim to analyze the clinical characteristics and biomarkers of CSCC in Ghana.

METHODS

In this study, a registry review of patients from January 2011 to May 2016 with CSCC at Komfo-Anokye Teaching Hospital in Kumasi, Ghana, was performed (n = 64). Tumor blocks of the CSCC were analyzed for the expression of various biomarkers.

RESULTS

In this study, the median age of onset of CSCC is 46.5 years old (range of 20-90 y old). Fifty one and a half percent (n = 33) of the cohort is female. There is a low rate of smoking and alcohol use in our CSCC cohort. Thirty-nine percent (n = 12) of Ghanaian men with CSCC are HIV-, while only 12% (n = 4) of women are HIV-. Fifteen patients had metastasis to lymph nodes or other tissues, and we observed a statistically significant relationship between HIV infection and metastasis (P = 0.027, chi-squared test). We observed no statistically significant relationship between known prognostic CSCC biomarkers and HIV status, age, or tumor stage.

CONCLUSION

Better characterization of CSCC could have a profound impact on the prevention, early identification, and treatment of CSCC in Africa. A retrospective chart analysis and collection of tumor samples can be challenging in this region due to methods of record keeping and stigma attached to clinical data such as HIV testing and smoking and alcohol use. As a result, in this study, data were often incomplete leading to inconclusive results and analysis that should be interpreted with caution. Future studies should consider a prospective study design that gathers clinical data in a standardized format and ensures fresh tissue from CSCC tumors.

Human papillomavirus DNA detected in fingertip, oral and bathroom samples from unvaccinated adolescent girls in Tanzania

OBJECTIVE

Human papillomavirus (HPV) DNA has been detected in vaginal samples from adolescent girls who report no previous sex and, in high-income settings, from fingertips, raising the possibility of non-sexual transmission. No such studies originate from East Africa which bears among the highest cervical cancer incidence and HPV prevalence worldwide. HPV-related oral cancer incidence is increasing, but oral HPV prevalence data from East Africa are limited. We aimed to describe the HPV DNA prevalence in genital and non-genital sites and in the bathroom of unvaccinated adolescent girls, and examine genotype concordance between sites.

METHODS

We nested a cross-sectional study of HPV in genital and extragenital sites within a cohort study of vaginal HPV acquisition. Unvaccinated girls age 16-18 years in Tanzania, who reported ever having had sex, were consented, enrolled and tested for the presence of HPV DNA in vaginal samples collected using self-administered swabs, oral samples collected using an oral rinse, and on fingertips and bathroom surfaces collected using a cytobrush.

RESULTS

Overall, 65 girls were enrolled and 23 (35%, 95% CI 23% to 47%) had detectable vaginal HPV. Adequate (β-globin positive) samples were collected from 36 girls' fingertips and HPV was detected in 7 (19%, 95% CI 6% to 33%). 63 girls provided adequate oral samples, 4 (6%, 95% CI 0% to 13%) of which had HPV DNA detected. In bathroom samples from 58 girls, 4 (7%, 95% CI 0% to 14%) had detectable HPV DNA. Of the 11 girls with extragenital HPV, six had the same genotype in >1 site.

CONCLUSION

We found a high prevalence of HPV in non-genital sites in adolescent girls and in their bathrooms, in this region with a high cervical cancer incidence. Concordance of genotypes between sites supports the possibility of autoinoculation.

A prospective study of the incidence, associations and outcomes of ocular surface squamous neoplasia in the United Kingdom

PURPOSE

To describe the incidence, associations and outcomes of ocular surface squamous neoplasia (OSSN) in the United Kingdom.

METHODS

Prospective, observational study of every new case of OSSN reported via the British Ophthalmological Surveillance Unit reporting scheme over a 12-month period. Cases were followed up for 12 months.

RESULTS

The reported incidence of OSSN was 0.53 cases/million/year (conjunctival intraepithelial neoplasia: 0.43 cases/million/year; squamous cell carcinoma: 0.08 cases/million/year). Eighty-five per cent of affected patients were male, 97% were Caucasian, and the mean age at presentation was 67.9 (±12.8) years. Information on potential underlying risk factors was frequently unknown. The most commonly affected sites were the limbus and the nasal and temporal bulbar conjunctivae. Most patients presented with a visual acuity of 6/9 or better, without symptoms of pain or visual loss. Excision (with or without additional treatment) was the most common first-line treatment and interferon (with or without additional treatment) was the most common second-line treatment, although management varied widely. Complications of treatment were rare but occasionally severe. Recurrence within 12 months of follow-up occurred in at least 6% of patients.

CONCLUSION

Although subject to reporting bias, these data suggest that there has not been a significant change in the incidence of OSSN in the United Kingdom, or its demographic profile, since 1996. The broad range of management approaches identified in this study reflect a lack of consensus as to the optimal referral and treatment pathways.

Lack of relationship between cigarette smoking and alcohol use with dysplasia grade in ocular surface squamous neoplasia

Objective

To evaluate smoking and alcohol use as risk factors for higher-grade dysplasia in a population of patients with histopathologically proven ocular surface squamous neoplasia.

Materials and methods

This is a retrospective chart review of data extracted from a database comprising demographic information and medical diagnosis information based on International Classification of Disease codes. Outcome measures were analyzed using the Wilcoxon two-sided test, a non-parametric t-test.

Results

Database review yielded 35 patients with ocular surface squamous neoplasia lesions proven by histopathologic analysis. The mean age was 64.51 years with SD 17.54 years. Patients were 28.57% female and 71.43% male. Nearly all patients were White (88.57%), and 5.71% were African American, 2.86% Hispanic, and 2.86% Other. There was no significant difference in dysplasia grade between smokers and non-smokers (P=0.7044), those who used alcohol vs did not use alcohol (P=0.2470), those who used tobacco and alcohol vs those who did not (P=0.5117), and those who used either tobacco or alcohol vs those who did not (P=0.8259).

Conclusion

No statistically significant relationship was found between high-grade dysplasia and cigarette smoking, alcohol use, or both cigarette smoking and alcohol use.

[Topical cyclosporine A and risk of ocular surface neoplasia]

INTRODUCTION

Cyclosporine A (CsA) has well-known cutaneous carcinogenic effects when administered systemically. In ophthalmology, it is increasingly used in the form of eye drops since its indication for moderate to severe eye dry eye. The goal of this review of the literature is to evaluate a possible link between topical ocular CsA use and the occurrence of ocular surface neoplasia.

MATERIALS AND METHODS

A literature review was performed. Publications evaluating the safety and efficacy of topical CsA as well as studies on the epidemiology and risk factors for conjunctival neoplasia and cases of conjunctival neoplasia were analyzed. Finally, post-market surveillance data from commercially available CsA eye drops were also evaluated.

RESULTS

Five cases of conjunctival neoplasia in patients treated with systemic and/or topical CsA have been described in the literature, three with systemic administration alone, another with combined systemic and local administration, and one case of local administration alone. In these cases, no direct link with the administration of ocular topical CsA could be determined. Among the numerous prospective studies evaluating the safety and efficacy of topical CsA as well as the case-control studies evaluating the risk factors for developing conjunctival neoplasia, no relationship between the occurrence of conjunctival neoplasia and the use of topical ocular CsA was observed.

CONCLUSION

Despite plausible pathophysiologic mechanisms, to date there is no evidence of an increased risk of ocular surface neoplasia with the use of topical ocular CsA. Further studies specifically addressing this question and with a longer duration are needed in order to precisely evaluate this theoretical risk.

Clinical Management of Ocular Surface Squamous Neoplasia: A Review of the Current Evidence

Ocular surface squamous neoplasia (OSSN) is the most common non-pigmented malignancy of the ocular surface and is represented in a wide range of histologic diagnoses, ranging from mild epithelial dysplasia to invasive squamous carcinoma. Although surgical excision is still the gold standard for OSSN treatment, interest in conservative medical approaches is steadily growing. We have reviewed all of the literature on OSSN published in English in the MEDLINE database up to May 2018, using the keywords “ocular surface squamous neoplasia,” “squamous conjunctival carcinoma,” and “conjunctival carcinoma in situ,” with the aim to provide a comprehensive review of the most recent evidence on this distinct clinical entity.

Characteristics, management, and outcome of squamous carcinoma of the conjunctiva in a single tertiary cancer center in Jordan

AIM

To evaluate the features and outcome of management of malignant conjunctival squamous tumors in King Hussein Cancer Center (a referral tertiary cancer center in the Middle East).

METHODS

Retrospective case series of 31 eyes for 31 patients with conjunctival squamous neoplasia. Main outcome measures included: age, gender, laterality, tumor location, pathological features, tumor stage, treatment modality, and outcome.

RESULTS

Twenty (65%) patients were males and median age was 58y. Twenty-two (71%) eyes had the tumor in the nasal quadrant. Tumor invasion to nearby structures was seen in 19 (61%) eyes, including the cornea, fornix, eyelid, and orbit in 17 (55%), 1 (3%), 2 (6%), and 3 (10%) eyes, respectively. Eye salvage was achieved by surgical excision with cryotherapy followed by topical chemotherapy in 28 (90%) eyes, and orbital exenteration was necessary in 3 (10%) eyes due to orbital tumor invasion. Tumor recurrence was seen in 7 (23%) eyes, and the significant predictive factors for recurrence were tumor extension onto the nearby structures (P=0.04), tumor invasiveness (P=0.038), and tumor TNM stage (P=0.031). No significant change in visual acuity was seen, and disease related mortality was 6% (2 patients, both had orbital invasion by invasive squamous carcinoma).

CONCLUSION

Conjunctival squamous carcinoma is more common in males. Advanced American Joint Committee on Cancer (AJCC) T-stage, tumor local invasion, more pathologically aggressive tumors, and surgical treatment alone (without adjuvant therapy) are associated with higher risk for recurrence, and orbital invasion is the most important poor prognostic factor for metastasis and death. Treatment strategies should be affected by tumor characteristics at presentation.

Treatment and Pathology of an Unusual Large Carcinoma of the Conjunctiva

Carcinoma of the conjunctiva is a malignant tumor which is mostly detected and surgically treated at an early stage because of medical or cosmetic problems. Exceptions of this rule may occur in developing countries, where patients do not have access to standard medical care systems. We report the case of a conjunctival carcinoma in an African patient with an unusually late presentation. Because of local medical shortcomings, and considering the severe, transmural inflammation of anterior ocular structures, an exenteration was performed although the orbit was not deeply involved with the tumor. The strong nuclear expression of p53 indicates a major role of UV exposure in this case. A total of 16-month follow-up in this patient and larger published series suggest that the risk of metastasis is rather low under those circumstances, even with invasive tumors.

Telomerase promoter mutations in human immunodeficiency virus-related conjunctiva neoplasia

BACKGROUND

Squamous cell carcinoma (SCC) of the conjunctiva is a common cancer in Africa mainly associated with solar ultraviolet (UV) exposure and human immunodeficiency virus (HIV) infection. We analyzed the role of HIV on the occurrence of telomerase reverse transcriptase (TERT) promoter mutations among a cohort of conjunctiva neoplasia Ugandan patients.

METHODS

Telomerase reverse transcriptase promoter mutations were searched in 72 conjunctiva neoplasia cases, comprising SCC and intraepithelial neoplasia grade 1-3 (CIN1-3), as well as in 53 conjunctiva normal tissues and in 24 HIV-related Kaposi sarcoma.

RESULTS

The average prevalence of TERT promoter mutations in conjunctiva neoplasia was 31.9%. The mutation rates were significantly higher in HIV-positive (31.8% of CIN1 and CIN2, 46.2% of CIN3 and SCC,) than HIV-negative patients (22.2% of CIN1 and CIN2, 13.3% of CIN3 and SCC). Such mutations were rarely identified among HIV-positive conjunctiva controls (3.6%) and never in Kaposi sarcoma lesions. The most frequent variations were the hot spots - 124G>A and - 146G>A and tandem transitions - 124_125GG>AA and - 138_139GG>AA.

CONCLUSIONS

Telomerase reverse transcriptase promoter mutations are early events in conjunctival neoplasia and could be used for timely diagnosis of conjunctiva tumours. The high frequency of UV-signatures in HIV-positive conjunctiva lesions suggests an additive effect of the virus to UV-related mutagenesis.

Ocular surface squamous neoplasia in HIV-infected patients: current perspectives

Ocular surface squamous neoplasia (OSSN) refers to a spectrum of conjunctival and corneal epithelial tumors including dysplasia, carcinoma in situ, and invasive carcinoma. In this article, we discuss the current perspectives of OSSN associated with HIV infection, focusing mainly on the epidemiology, pathophysiology, clinical manifestations, diagnosis, and treatment of these tumors in patients with HIV. Upsurge in the incidence of OSSN with the HIV pandemic most severely affected sub-Saharan Africa, due to associated risk factors, such as human papilloma virus and solar ultraviolet exposure. OSSN has been reported as the first presenting sign of HIV/AIDS in 26%-86% cases, and seropositivity is noted in 38%-92% OSSN patients. Mean age at presentation of OSSN has dropped to the third to fourth decade in HIV-positive patients in developing countries. HIV-infected patients reveal large aggressive tumors, higher-grade malignancy, higher incidence of corneal, scleral, and orbital invasion, advanced-stage T4 tumors, higher need for extended enucleation/exenteration, and increased risk of tumor recurrence. Current management of OSSN in HIV-positive individuals is based on standard treatment guidelines described for OSSN in the general population, as there is little information available about various treatment modalities or their outcomes in patients with HIV. OSSN can occur at any time in the disease course of HIV/AIDS, and no significant trend has been discovered between CD4 count and grade of OSSN. Furthermore, the effect of highly active antiretroviral therapy on OSSN is controversial. The current recommendation is to conduct HIV screening in all cases presenting with OSSN to rule out undiagnosed HIV infection. Patient counseling is crucial, with emphasis on regular follow-up to address high recurrence rates and early presentation to an ophthalmologist for of any symptoms in the unaffected eye. Effective evidence-based interventions are needed to allow early diagnosis and treatment, as well as prevention of the disease.

Conjunctival Squamous Cell Carcinoma with Corneal Stromal Invasion in Presumed Pterygia: A Case Series

Aim

To describe 4 cases of conjunctival squamous cell carcinoma (SCC) with corneal stromal invasion.

Methods

Retrospective, clinicopathologic case series.

Results

All patients had prior resections of presumed pterygia. The degree of corneal involvement dictated the extent of surgical management. One eye with localized invasion was treated with lamellar keratoplasty and plaque brachytherapy. Another case with widespread invasion warranted penetrating keratoplasty and eventual enucleation. Two cases were treated medically prior to surgical intervention: one with localized invasion was treated with topical interferon and retinoic acid; another with significant inflammation was treated with doxycycline and fluorometholone. The patient who underwent keratoplasty and brachytherapy had no recurrence after 7 years of follow-up. Those initially treated medically had resections of recurrence but ultimately required enucleation. Histologically, specimens demonstrated SCC invading the deep corneal stroma, with 2 tumors of the mucoepidermoid type.

Conclusions

This series demonstrates the importance of maintaining clinical suspicion of conjunctival squamous neoplasia in pterygia. We recommend that all excised pterygia be submitted for histopathologic evaluation and be carefully evaluated for dysplasia and variants of SCC associated with increased risk of intraocular invasion. Undetected ocular surface squamous neoplasia may give rise to potentially vision- and eye-threatening invasive corneal SCC.

Clinicodemographic profile and treatment outcome in patients of ocular surface squamous neoplasia

Purpose:

The aim is to study the clinicodemographic profile and treatment outcome of ocular surface squamous neoplasia (OSSN).

Methods:

This was a retrospective observational study of 57 eyes (56 cases) with clinically diagnosed OSSN, presenting in our center over the past year.

Results:

The median age of presentation was 55 years with male:female ratio being 4.5:1. Systemic predisposing conditions were xeroderma pigmentosa (1) postkidney transplant immunosuppression (1), and human immunodeficiency virus infection (1). Patients with predisposing conditions had a younger median age of onset (33 years). The majority of tumors were nodular (61.4%), gelatinous (61.4%), and had limbal involvement (96%). On ultrasound biomicroscopy (UBM), mean tumor height was 2.93 ± 1.02 mm, and intraocular extension was evident in seven eyes. OSSN with intraocular extension had a mean tumor height of 4.3 ± 1.32 mm. Nodal metastasis was seen in one case at presentation. As per American Joint Committee for Cancer Classification seventh edition staging-two cases were T1, one was T2, 46 were T3 and eight were T4. Treatment advised included conservative therapy for 39; wide local excision (4 mm margin clearance) with cryotherapy for seven; enucleation in four; and exenteration in four eyes. Overall, complete regression was achieved in 88% of cases during a mean follow-up of 13.5 ± 4.6 months. Recurrence was seen in three cases, which were treated with exenteration, radical neck dissection, and palliative chemo-radiotherapy, respectively.

Conclusion:

Although associated with old age, earlier onset of OSSN is seen in patients with systemic predisposing conditions. Thicker tumors in the setting of a previous surgery or immunocompromised status should be considered high-risk features for intraocular extension and should be evaluated on UBM.

Challenging Treatment of Ocular Surface Squamous Neoplasia in Patients with Atopic Disease

PURPOSE

Few studies have described ocular surface squamous neoplasia (OSSN) and its association with atopic diseases and there is no consensus on the course of OSSN in atopic patients. We thereby report three patients with atopy and OSSN.

METHODS

Retrospective case series.

RESULTS

Three male patients with mean age of 73 presented with OSSN and history of atopy treated with immunosuppressant therapy. Their histories included atopic dermatitis and keratoconjunctivitis. All patients had treatment complicated by multiple surgeries, recurrences, or advanced disease. The patients initially received medical treatment with topical interferon-alpha-2b (IFNα2b). However, all the patients had recurrences and required modification of treatment including topical 5-fluorouracil (5-FU).

CONCLUSION

We report on three patients with a history of atopy whose OSSN presentation and course was challenging. Overall, our cases responded better to topical 5-fluorouracil compared to topical interferon-alpha-2b, but recurrences were common. These patients may benefit from more aggressive and long-term treatment.

Delay along the care-seeking journey of patients with ocular surface squamous neoplasia in Kenya

Background

In Africa, accessing eye health services is a major challenge. Ocular surface squamous neoplasia (OSSN) is a substantial ocular health problem in Africa related to solar UV light exposure and HIV infection among other risk factors. The disease causes visual loss and even death in advanced cases. This study was conducted to assess referral pathway and treatment delay for patients with OSSN in Kenya.

Methods

Adults with conjunctival lesions presenting to four eye centres were asked about their occupations, when they noticed the growth, health facilities visited in seeking care, cost of consultation, surgery, medicines and histopathology and dates at each step. The time-to-presentation was divided into quartiles and correlates analysed using ordinal logistic regression.

Results

We evaluated 158 first-time presenters with OSSN. Most were women (102 [65%]), living with HIV (78/110 tested [71%]), with low to medium income (127 [80%]). Most of the HIV patients (49/78 [63%]) were in antiretroviral care programs. About half (88/158, [56%]) presented directly to the study centres while the rest were referred. Indirect presenters sought care earlier than direct presenters (median 2.0 months vs 5.5 months) and travelled a shorter distance to the first health facility (median 20 km vs 30 km) but had surgery later (median 12.5 months vs 5.5 months). Visits beyond the first health facility for indirect presenters markedly increased delay (median 7.3, 29.0, 37.9, and 32.0 months for 1–4 facilities, respectively). Delay was associated with number of health facilities visited (adjusted ordered OR = 9.12; 95%CI 2.83–29.4, p < 0.001) and being female (adjusted ordered OR = 2.42; 95%CI 1.32–4.44, p = 0.004). At the time of presentation at the study centres for surgery the median tumour diameter in both directly and indirectly presenting patients was 6 mm (p = 0.52) and the histological spectrum of OSSN was similar between the groups (p = 0.87).

Conclusions

Referral delays definitive treatment for OSSN. Women were more likely to experience delay. Despite regular contact with the health system for those with known HIV infection, delays occurred. Early detection and referral of OSSN in the HIV service might reduce delays, but reassuringly delay did not give rise to a larger proportion with more advanced grade of OSSN.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2428-4) contains supplementary material, which is available to authorized users.