Late recurrences and the necessity for long-term follow-up in corneal and conjunctival intraepithelial neoplasia

New combined treatments, surgery and high-dose-rate interventional radiotherapy (brachytherapy), in advanced ocular surface and eyelid cancers

PURPOSE

To evaluate the clinicopathological characteristics and the effectiveness of post-operative high-dose-rate (HDR) interventional radiotherapy (IRT - brachytherapy) in managing advanced ocular surface squamous neoplasia (OSSN) and eyelid tumors.

METHODS

Nineteen patients with advanced malignancies affecting the ocular surface (stage ≥ T2) and eyelids (staging ≥ T3) were enrolled. Post-operative HDR-IRT treatment followed surgery after multidisciplinary discussion. In our series a total dose of 49 Gy was administered in 14 fractions of 3.5 Gy each, 2 doses per day. Local disease control is the study's main outcome. Death rate, total survival, disease-free survival, and toxicity are secondary outcomes.

RESULTS

Local recurrence was observed in 4 cases, 2 were conjunctival melanomas and 2 were conjunctival squamous cell carcinoma. The median OS was 56.3 months. The 12, 24 and 36 months survival rate was respectively 100.00% (IQR: 100.00% - 100.00%), 100.00% (IQR: 100.00% - 100.00%), 100.00% (IQR: 100.00% - 100.00%) respectively . The median DFS was 56.3 months. The 12, 24 and 36 months disease survival rate was respectively 85.71% (IQR: 69.21% - 100.00%), 68.57% (IQR: 42.11% - 100.00%), 68.57% (IQR: 42.11% - 100.00%) respectively. In eyelid tumors, madarosis and eyelid abnormalities are the main side effects, while in OSSNs, dry eye symptoms are frequently reported.

CONCLUSION

Postoperative HDR-IRT has been effective in advanced eyelid cancers control. More challenging appears instead an effective treatment of advanced OSSNs, particularly conjunctival melanomas. Multicenter studies are needed to get a larger patient sample and to evaluate different radiotherapy dosages by different histologic and T types of tumors.

Punctal and Canalicular Stenosis Following Topical 1% 5-Fluorouracil Eye Drop Therapy for Ocular Surface Squamous Neoplasia

PURPOSE

To present the first known cases of punctal and canalicular stenosis following topical 5-fluorouracil (5-FU) eye drops for ocular surface squamous neoplasia (OSSN).

METHODS

A retrospective chart review of patients with OSSN receiving topical 1% 5-FU eye drops as a primary or adjuvant treatment between 2013 and 2021 was performed. Individuals diagnosed with punctal or canalicular stenosis during or after topical 5-FU use were included in this study. Four individuals met these criteria; we report clinical findings and treatment course for each patient.

RESULTS

We reviewed 303 patients (316 eyes) with OSSN. All patients were treated with topical 1% 5-FU eye drops in cycles, given 4 times daily for 1 week with 3 weeks off. Four patients (5 eyes) developed punctal stenosis, for a frequency of 1.3%. The mean age at 5-FU initiation in the 4 individuals was 61 years (range 53-69). Most individuals were male (75%), White (75%), and non-Hispanic (100%). The most common presenting symptom of stenosis was epiphora, noted 4.6 ± 3 months after initiating topical 5-FU (after 4.9 ± 2.0 cycles). This occurred in 4 eyes while on therapy (3, 2, 4, and 4 months since 5-FU initiation) and in 1 eye after stopping therapy (10.3 months since 5-FU initiation). In 1 eye, punctal stenosis and epiphora resolved spontaneously after stopping 5-FU. Punctal dilation led to symptom resolution in 2 eyes. Surgical intervention (punctoplasty and external dacryocystorhinostomy) was needed in 2 eyes for punctal and canalicular stenosis, respectively.

CONCLUSIONS

Punctal or canalicular stenosis is a rare and previously unreported adverse effect of topical 5-FU that may require surgical treatment.

Excision combined with ocular surface reconstruction followed by topical chemotherapy for ocular surface squamous neoplasia

PURPOSE

To investigate the visual prognosis of ocular surface squamous neoplasia (OSSN) after tumor resection and ocular surface reconstruction, and clarify factors that influence recurrence.

STUDY DESIGN

Retrospective cohort study.

METHODS

Medical records of all patients who underwent surgical treatment for OSSN at our hospital between January 1996 and December 2019 were reviewed. Tumor size/location, histological classification, surgical procedure, intraoperative mitomycin-C use, and postoperative topical 5-fluorouracil (5-FU) administration were examined, and pre and postoperative visual acuity (VA) were compared to elucidate factors that influence disease recurrence.

RESULTS

Tumor excision was performed in 70 eyes of 70 cases (43 men, 27 women; average age: 71.6 ± 12.6 years) with dysplasia (8 eyes), carcinoma in situ (26 eyes), and invasive squamous cell carcinoma (36 eyes). Tumors were found in the limbus (N = 59 eyes), palpebral conjunctiva (N = 8 eyes), and from the bulbar to palpebral conjunctiva (N = 3 eyes). Surgical procedures performed were limbal transplantation/keratoepithelioplasty (N = 29 eyes), cultivated oral mucosal epithelial transplantation (N = 3 eyes), and auto-conjunctival epithelium transplantation (N = 2 eyes). Ocular surface was reconstructed using amniotic membrane, donor cornea, or cultivated epithelial sheet. The mean follow-up was 38.6 ± 38.6 months (range, 2 months to 13.8 years). VA postoperatively improved in 25 (61.0%) cases. Recurrence occurred in 19 (27.1%) cases at from 2 to 50 months (median: 12.5 months) postoperative. Uni- and multivariate analyses revealed that presurgical tumor size and postoperative administration of 5-FU were significantly related to recurrence.

CONCLUSION

Combined surgical excision and postoperative topical 5-FU administration effectively prevented OSSN recurrence, and ocular surface reconstruction contributed to improvement of VA.

Limbal Stem Cell Deficiency After Treatment of Ocular Surface Squamous Neoplasia

PURPOSE

To investigate limbal stem cell deficiency (LSCD) in patients surgically treated for ocular surface squamous neoplasia (OSSN).

METHODS

This retrospective case-control study investigated clinical and histological data from patients with OSSN surgically treated in a referral center.

RESULTS

The study included 98 patients (58 male, 40 female) with a mean age of 61.1 (23-86) years. Less than 3 clock hours were involved by OSSN in 48 eyes (49.0%), 3-6 clock hours in 32 eyes (32.7%), 6-9 clock hours in 12 eyes (12.2%), and more than 9 clock hours in 6 eyes (6.1%). Limbal stem cell deficiency was identified in 36 patients (36.7%) after surgery. The severity of LSCD was mild in 17 eyes, moderate in 11, and severe in 8. The prevalence of LSCD increased significantly in groups with 6 clock hours or more of OSSN involvement (p < 0.001). The affected limbal side (superior, inferior, nasal, or temporal) had no significant association with the prevalence of LSCD (p = 0.869). Patients with recurrent OSSN had a higher LSCD prevalence (p = 0.003). The higher the tumor stage, the more likely it was to develop LSCD (p < 0.001). Patients with corneal involvement were also more likely to develop LSCD (p = 0.021). The prevalence of LSCD was raised with increasing histopathological grade (p = 0.019). Furthermore, solely the number of clock hours affected by OSSN was an independent risk factor in multivariate analyses (p < 0.001).

CONCLUSIONS

The size and severity of OSSN and the presence of recurrent OSSN are associated with an increased likelihood of developing LSCD. Furthermore, the extent of the limbal area involved by the OSSN is identified as an independent risk factor of the development of LSCD.

Ocular Surface Squamous Neoplasia: Changes in the Standard of Care 2003 to 2022

PURPOSE

The aim of this review was to elucidate treatment preferences for ocular surface squamous neoplasia and to examine the changes in treatment modalities over the past 2 decades.

METHODS

An electronic survey was distributed to members of The Cornea Society, Ocular Microbiology and Immunology Group, and 4 international corneal specialist listservs. Questions examined medical and surgical treatment preferences, and results were compared with surveys administered in 2003 and 2012.

RESULTS

A total of 285 individuals responded to the survey; 90% of respondents were self-classified as corneal specialists. Seventy-three percent reported using primary topical monotherapy to treat ocular surface squamous neoplasia as compared with 58% in 2012 ( P = 0.008). Compared with 2003, the percentage use of topical interferon significantly increased ( P < 0.0001) from 14% to 55%, 5-fluorouracil increased ( P < 0.0001) from 5% to 23%, and mitomycin C decreased ( P < 0.0001) from 76% to 19% as a primary monotherapy. The frequency of performing excision without the use of postoperative adjunctive medical therapy decreased significantly ( P < 0.0001), from 66% to 26% for lesions <2 mm, 64% to 12% for lesions between 2 and 8 mm, and 47% to 5% for lesions >8 mm from 2003 to 2022. More clinicians initiated topical immuno/chemotherapy without performing a biopsy as compared to 2003 (31% vs. 11%, P < 0.0001).

CONCLUSIONS

These results demonstrate a paradigm shift in the management of ocular surface squamous neoplasia. The use of primary medical therapy as a first approach has significantly increased, with a reduction in the frequency of performing surgical excision alone.

Cytomorphological Spectrum of Ocular Surface Squamous Neoplasia in Elderly Age Group and Its Clinicopathological Correlation

Background

Ocular surface squamous neoplasia (OSSN) encompasses a range of dysplastic changes from mild dysplasia to invasive carcinoma. This research aims to elucidate the cytomorphological spectrum of OSSN in the elderly age group and correlate these findings with clinical and pathological features.

Methods

A retrospective analysis was conducted on elderly patients (>60 years) diagnosed with OSSN over a 5 year period. Cytological and histopathological findings were analyzed and correlated with clinical data.

Results

The cytomorphological spectrum of OSSN in the elderly age group exhibited a broad range of cellular changes, from mild dysplasia to invasive squamous cell carcinoma. The predominant cytological features included increased nuclear-cytoplasmic ratio, pleomorphism, and abnormal mitotic figures. Clinically, OSSN presented most commonly as a unilateral conjunctival mass with a history of chronic irritation. Histopathologically, there was a significant correlation between the degree of dysplasia and the depth of invasion (P < 0.05).

Conclusion

This research highlights the diverse cytomorphological spectrum of OSSN in the elderly age groups and emphasizes the importance of comprehensive clinicopathological correlation for accurate diagnosis and management. The predominant cytological features observed, including increased nuclear-cytoplasmic ratio, pleomorphism, and abnormal mitotic figures, reflect the underlying dysplastic alterations and provide valuable insights into the diagnosis and the classification of OSSN. Further studies are warranted to explore the potential role of impression cytology in the diagnosis and management of OSSN and to evaluate the efficacy of different treatment modalities in the elderly age group.

Efficacy of topical 5-Fluorouracil in the management of ocular surface squamous neoplasia: a study of 101 eyes

OBJECTIVE

To study the efficacy and side-effect profile of topical 5-Fluorouracil (5-FU) in the treatment of ocular surface squamous neoplasia (OSSN).

METHODS

Retrospective study of 101 eyes of 100 patients treated with 5-FU with one week on and 3 weeks off regimen.

RESULTS

Of the 100 patients (101 eyes), the mean age at diagnosis of OSSN was 49 (median, 52 years; range, 11-87 years). History of prior intervention was noted in 6 (6%) eyes. Tumor epicenter included bulbar conjunctiva (n = 54; 53%), limbus (n = 27; 27%), and cornea (n = 20;20%). Mean number of cycles of topical 5-FU administered was 3 (median, 3; range, 1-8). Complete tumor regression was achieved with topical 5-FU in 89 (88%) eyes with a mean number of 2 cycles (median, 2; range, 1-6) of 5-FU. The remaining 12 (12%) lesions underwent additional treatment including excisional biopsy (n = 7), extended enucleation (n = 3), and topical Interferon alpha 2b (n = 2) for complete tumor control. Over a mean follow-up period of 6 months (median, 5 months; range, 1-36 months) following treatment, tumor recurrence was noted in 2 (2%) patients, and side-effects were noted in 7 (7%) eyes including conjunctival hyperemia (n = 1), punctal stenosis (n = 1), sterile keratitis (n = 4), and limbal stem cell deficiency (n = 1).

CONCLUSION

Topical 5-FU is an effective non-invasive therapy for OSSN with a minimal side-effect profile.

Novel automated non-invasive detection of ocular surface squamous neoplasia using artificial intelligence

Ocular surface squamous neoplasia (OSSN) is a common eye surface tumour, characterized by the growth of abnormal cells on the ocular surface. OSSN includes invasive squamous cell carcinoma (SCC), in which tumour cells penetrate the basement membrane and infiltrate the stroma, as well as non-invasive conjunctival intraepithelial neoplasia, dysplasia, and SCC in-situ thereby presenting a challenge in early detection and diagnosis. Early identification and precise demarcation of the OSSN border leads to straightforward and curative treatments, such as topical medicines, whereas advanced invasive lesions may need orbital exenteration, which carries a risk of death. Artificial intelligence (AI) has emerged as a promising tool in the field of eye care and holds potential for its application in OSSN management. AI algorithms trained on large datasets can analyze ocular surface images to identify suspicious lesions associated with OSSN, aiding ophthalmologists in early detection and diagnosis. AI can also track and monitor lesion progression over time, providing objective measurements to guide treatment decisions. Furthermore, AI can assist in treatment planning by offering personalized recommendations based on patient data and predicting the treatment response. This manuscript highlights the role of AI in OSSN, specifically focusing on its contributions in early detection and diagnosis, assessment of lesion progression, treatment planning, telemedicine and remote monitoring, and research and data analysis.

Clinicopathological Correlates of Ocular Surface Squamous Neoplasia

Introduction

This study examined the distribution of histopathological disease severity amongst a cohort of patients treated for clinically suspected ocular surface squamous neoplasia and evaluated the relationship between various patient and clinical factors and the severity of pathological grade as well as treatment outcomes.

Methods

A retrospective cohort study of demographic and clinicopathological factors of 150 patients clinically diagnosed with suspected ocular surface squamous neoplasia who underwent excision of lesion with histopathological diagnosis.

Results

The study included 125 cases; the mean age at diagnosis was 64 years (SD = 11.26). 74% of cases were histologically confirmed as ocular surface squamous neoplasia. Pathological distribution was conjunctival intraepithelial neoplasia I (13.6%), conjunctival intraepithelial neoplasia II (16.8%), conjunctival intraepithelial neoplasia III (21.6%), carcinoma in situ (21.6%), and squamous cell carcinoma (2.4%). Lesion appearance was leukoplakic (18%), gelatinous (15%), dysplastic (11%), vascular (6%), papilliform (2%), nodular (2%). Lesion location was nasal (43%), temporal (42%), and superior or inferior (14%). Recurrence occurred in 7 cases (5.6%). A significant association was found between presence of leukoplakia and pathological grade (p = 0.05).

Conclusions

Ocular surface squamous neoplasia is most frequently diagnosed in conjunctival intraepithelial neoplasia III and carcinoma in situ stages, and treatment outcomes are usually favourable.

Periocular and ocular surface nonmelanoma skin cancer

Periocular and ocular surface nonmelanoma malignancies, including basal cell carcinoma (BCC), squamous cell carcinomas (SCC), and ocular surface squamous neoplasia (OSSN), are rare, but their management requires special considerations. The most common periocular malignancy is BCC, which constitutes 80% to 96% of tumors, followed by SCC, which represents 5% to 10% of tumors. OSSN represents a spectrum of diseases that encompass dysplastic alteration to the squamous epithelium of the eye. OSSN ranges from squamous dysplasia to conjunctival intraepithelial neoplasia/carcinoma in situ to invasive SCC, which is the most common ocular malignancy. These tumors can be staged using the eighth edition of the American Joint Committee on Cancer categorization system. The standard of care for periocular malignancies is Mohs micrographic surgery, while medical management with 5-fluorouracil (5-FU), interferon alfa-2b (INF), and mitomycin C (MMC) or "no touch" surgical excision are options for OSSN. Systemic therapies, including sonic hedgehog inhibitors for BCC and epidermal growth factor inhibitors and immune-checkpoint inhibitors for SCC, can be utilized for advanced disease. Recurrence rates are higher for periorbital and ocular malignancies than their respective cutaneous counterparts. These carcinomas and their respective treatments have unique side effects and considerations in an effort to preserve visual function.

Clinic-pathological agreement in the diagnosis of conjunctival tumours: Analysis of 195 cases

PURPOSE

The present study aims to assess the agreement between clinical and pathological diagnosis in conjunctival tumours in a specialist ocular oncology unit.

METHODS

retrospective study of consecutive patients with conjunctival tumours diagnosed at the Ocular Oncology Unit of the University Hospital of Valladolid was performed from 1992 to 2017. Tumours were classified according to their origin (epithelial, melanocytic, lymphoid and others) and degree of malignancy (benign, premalignant, malignant). A biopsy was performed in cases of symptomatic or growing lesions. Cohen´s kappa (κ) statistics was used as an indicator of agreement between clinical and pathological diagnosis.

RESULTS

Of 462 consecutive patients, a biopsy was required in 195 (42.2%). The agreement with the pathological diagnosis was successful in 154 (79.0%) cases. Analysis according to the grade of malignancy showed the lowest rate of agreement among benign (n = 83; 91.6%) and premalignant (n = 62; 90.3%) lesions, with a total agreement in malignant lesions (n = 50; 100%); the Cohen´s kappa coefficient (κ) was 0.90. The highest rates of concordance were found in epithelial, melanocytic and soft tissue lesions with κ values of 1, 0.8 and 1 respectively. The worst rate of concordance was found in lymphoid lesions with a κ value of 0.3.

CONCLUSION

Most of the conjunctival tumours were correctly identified clinically; benign and malignant lesions showed the highest rate of accuracy; however, premalignant tumours can hide micro-invasive diseases that can go unnoticed on clinical examination. The biopsy is essential for accurate diagnosis and treatment.

Local ocular safety of the subconjunctival injection of cetuximab in rabbits

BACKGROUND

To evaluate the safety of different doses of subconjunctival cetuximab in rabbits.

METHODS

After general anesthesia rabbits received a subconjunctival injection of 2.5 mg in 0.5 ml, 5 mg in 1 ml, and 10 mg in 2 ml of cetuximab in their right eyes (two rabbits in each group). A similar volume of normal saline solution was injected subconjunctivally in the left eyes. The histopathologic changes were evaluated after enucleation with the aid of H&E staining.

RESULTS

No significant difference were observed between the treated and control eyes in terms of conjunctival inflammation, goblet cell density, or limbal blood vessel density for all administered doses of cetuximab.

CONCLUSION

Subconjunctival injection of cetuximab with the administrated doses in rabbit eyes are safe.

Clinicopathological profile, management and clinical outcomes in recurrent cases of ocular surface squamous neoplasia at a tertiary care centre

PURPOSE

This study was taken up to look into the various causes of recurrence, clinicopathological profile and final outcomes in recurrent cases of ocular surface squamous neoplasia (OSSN).

METHODOLOGY

A prospective cohort study was conducted and total 18 patients were recruited. All patients were subjected to detailed history, comprehensive eye examination and imaging studies. A treatment plan was formulated based on the size and extent of the lesion. The primary outcome measure was complete response to treatment with no evidence of recurrence after12 months and secondary outcome measure was complication associated with each treatment modality.

RESULTS

The common cause of recurrence in our study was misdiagnosis of the lesion as in 15 cases it was diagnosed as pterygium and in 03 cases it was actinic keratosis. Excision Biopsy with adjunctive cryotherapy was the preferred treatment modality followed by topical interferon-alpha 2b drop-in our study. We could achieve good outcomes in terms of complete response to the treatment in 16 cases. The complication associated with this treatment was minimal in our study as few patients complained redness and irritation which subsided after application of topical lubricants. There was no sign of recurrence even at 12 months of follow-up in all 18 cases.

CONCLUSION

The current study provided clinicopathological characteristics and treatment outcomes in recurrent cases of OSSN. In our study, adopting appropriate treatment strategy, regular follow-up to assess the response to treatment and change over to new treatment plan in cases with inadequate response helped in achieving good outcomes in recurrent cases of OSSN.

Topical 1% 5-fluorouracil eye drops as primary treatment for ocular surface squamous neoplasia: Long-term follow-up study

PURPOSE

To determine the efficacy and safety of topical 1% 5-fluorouracil (5FU) eye drops as primary treatment of ocular surface squamous neoplasia (OSSN).

METHODS

Patients were diagnosed with OSSN based on slit-lamp examination and anterior segment optical coherence tomography (AS-OCT). In ambiguous cases an incisional biopsy was performed. All were treated with 5FU eye drops as primary therapy and retrospectively reviewed. Data on demographics, tumor characteristics, treatment outcome, and side effects were collected. The primary outcome measures were resolution frequency and recurrence rate of OSSN. Secondary outcomes were risk factors for resolution and recurrence, and side effects of treatment.

RESULTS

The mean age of 251 subjects (258 eyes) was 67.5 ± 11.7 years, 182 were male. Patients were followed up on average for 752 ± 580 days. Overall, 87% of patients experienced complete tumor resolution. Multivariable analysis revealed that superior tumor location (HR: 0.62, 95% CI: 0.41-0.93, p = 0.02) and leukoplakia (HR: 0.65, 95% CI: 0.41-0.93, p = 0.02), decreased the likelihood of tumor resolution. The recurrence rate was 4% at six months, 8% at one year, and 19% at two years. Larger tumor area increased chances of tumor recurrence (HR: 1.01, 95% CI: 1.00-1.02 p = 0.03). The most common side effects of 5-FU were mild hyperemia and pain, which occurred in 26% and 23% of patients, respectively. Among the sight-threatening side effects, limbal stem cell deficiency occurred in only 3% of patients.

CONCLUSIONS

Topical 1% 5FU eye drops are a safe and effective medication for OSSN. Superior tumor location and leukoplakia decreased the chance of tumor resolution.

Pegylated Interferon Alpha 2a for the Treatment of Ocular Surface Squamous Neoplasia

PURPOSE

The purpose of this study was to introduce the initial experience in the use of topical pegylated interferon alpha 2a (PegIFN-α-2a) for ocular surface squamous neoplasia (OSSN).

METHODS

A retrospective medical record review of 8 eyes of 8 patients diagnosed with OSSN and treated with PegIFN-α-2a was performed. All cases were diagnosed of noninvasive OSSN both clinically and histologically. The pegIFN-α-2a was prescribed at a concentration of 20 μg/mL and applied 4 times a day for at least 3 months.

RESULTS

In all 8 cases, topical PegIFN-α-2a was well-tolerated and did not lead to discomfort or any adverse side effects. It resulted in reduction in lesion size and extent in all cases and complete resolution of the lesions.

CONCLUSIONS

Topical PegIFN-α-2a might be an effective and safe treatment option for noninvasive OSSN.

Ocular Surface Squamous Neoplasia: A 12-Month Prospective Evaluation of Incidence in Waikato, New Zealand

Ocular surface squamous neoplasia (OSSN) has a high incidence in the southern hemisphere. This prospective study evaluated the incidence of OSSN in the Waikato region of New Zealand. All patients presenting with pterygium or conjunctival lesions in the Waikato region in 2020 were included. All surgeons in the region were asked to send all conjunctival and corneal specimens excised for histopathologic examination. The primary outcome measure was the incidence of OSSN. Eighty-eight percent of all excised specimens were sent for histopathologic examination. Of the 185 excised lesions sent for histopathological assessment, 18 (10%) were reported as OSSN. Patients were on average 69.4 years of age (standard deviation, SD = 6.9), predominantly male (78%), and of New Zealand-European ethnicity (89%). The OSSN annual incidence was 3.67/100,000/year. Histology grades included conjunctival intraepithelial neoplasia (CIN)-I (25%), CIN-II (25%), CIN-III (12.5%), carcinoma in situ (25%), and invasive squamous cell carcinoma (SCC) (12.5%). One patient with invasive SCC required exenteration. This study identified a high incidence rate of OSSN and is the first prospective study to analyze OSSN epidemiology in New Zealand.

Racial and socioeconomic disparities in ocular surface squamous neoplasia: a National Cancer Database analysis

PURPOSE

A retrospective population-based study to investigate racial and socioeconomic disparities in patients diagnosed with ocular surface squamous neoplasia (OSSN).

METHODS

To explore racial disparity, we selected OSSN patients with known age, insurance, gender and zip code-level income and education from the National Cancer Database (NCDB). Comparisons of clinical and socioeconomic variables stratified by race were made with the chi-square or Mann-Whitney tests. Survival outcome was examined a Cox regression model.

RESULTS

Of the 2,402 identified patients from 2004 to 2015, 117 were black. Unadjusted differences were found between groups in regard to age, histology, insurance, income, and education. Black patients in comparison to white patients were younger (mean age: 62 years vs. 70 years; p < .001), represented a higher proportion of Medicaid use (10.3% vs. 3.2%; p < .001) or uninsured (10.3% vs. 2.7%; p < .001), and were more likely to reside in areas of low educational attainment (32.5% vs. 16.1% of whites; p < .001). Multivariate analysis found significantly higher risk of death in patients who were male (HR: 1.66, 95% CI 1.37-2.01) or black (HR: 1.57, 95% CI 1.03-2.38).

CONCLUSION

Disparities in socioeconomic factors were observed in black patients with OSSN. OSSN occurred earlier in blacks, who were also socioeconomically disadvantaged and faced higher risk of death.

Ocular surface squamous neoplasia in Northern Thailand: a 16-year review

Purpose

To evaluate clinical characteristics, treatments, and outcomes in patients with ocular surface squamous neoplasia (OSSN) at a tertiary center in Northern Thailand.

Methods

Patients diagnosed with either corneal-conjunctival intraepithelial neoplasia (CIN) or squamous cell carcinoma (SCC) from May 2000 to December 2015, were recruited. The patients’ demographics, symptoms, clinical characteristics, cytopathology, treatments, and outcomes were reviewed.

Results

Overall 171 eyes from 168 patients, 92 eyes were CIN and 79 eyes were SCC. Males were affected in 65.5%. The mean age was 58.8 ± 16.8 (29–99) years. In most cases (60.3%), the tumors were located at the limbus. The most common clinical characteristic was papilliform appearance (46.2%). Human immunodeficiency virus (HIV) infection was found in 37 (22.0%) patients with a mean age of 40.5 ± 7.7 years. The treatments and outcomes were evaluated in 136 eyes whose main initial treatment was wide excision with adjunctive cryotherapy (47.8%), followed by topical mitomycin C (30.9%). The mean follow-up time after treatment was 20.8 ± 2.2 (3–110) months and the recurrence occurred in 18 eyes (13.2%) during the follow-up period. The mean recurrence-free time (months) for CIN was significantly longer than that of SCC (81.3 ± 10.0 [95%CI 61.5 – 101.1] vs 33.2 ± 4.6 [95%CI 24.0 – 42.3], p = 0.030). SCC was the only significant risk factor that influences the recurrence of the tumors with the adjusted hazard ratio of 5.69 (p = 0.005).

Conclusion

OSSN in Northern Thailand usually involved a limbal area and presented as a papilliform mass. HIV infection should be suspected in young patients. CIN had better outcomes after treatments than invasive SCC.

Histopathological Rate of Ocular Surface Squamous Neoplasia in Clinically Suspected Pterygium Specimens: 10-Year Results

PURPOSE

The aim of this study was to evaluate the prevalence of histopathologically confirmed ocular surface squamous neoplasia (OSSN) in clinically diagnosed pterygium samples at a tertiary center in Northern California, over a 10-year period (2009-2019).

METHODS

A retrospective chart review of patients older than 18 years with clinically diagnosed benign pterygium requiring excision was conducted. Clinically suspected pterygia were excised using standard techniques and routinely submitted to the University of California Davis for pathologic evaluation. Demographic, clinical, surgical, and pathological information were recorded and analyzed. The prevalence rate of OSSN was calculated.

RESULTS

A total of 348 consecutive specimens were evaluated. The mean (±SD) age of the patients was 58 ± 12 years, with a near equal sex representation. A total of 57 (16%) pterygia were recurrent at initial presentation. Histopathologic results demonstrated a single case of OSSN. This patient did not have a documented history of carcinoma in other organs or any history of herpes virus, human papilloma virus, or human immunodeficiency virus infection.

CONCLUSIONS

The prevalence of histopathological OSSN in clinically suspected pterygia within our sample was approximately 0.3%. Because of shared clinical characteristics of pterygia and OSSN, a high index of suspicion and judicious use of anterior segment optical coherence tomography enable for effective preoperative diagnosis of OSSN. However, in the absence of clinical expertise or high-resolution optical coherence tomography, routine tissue pathologic examination may be warranted.

EYE DISEASE IN KIDNEY TRANSPLANTATION: CLINICAL CHALLENGES IN A UNIQUE PATIENT POPULATION

Eye disease is common among kidney transplant recipients and their management is challenging. Chronic kidney disease is associated with ocular complications, both independently and in the context of various systemic disorders. In addition, chronic immunosuppression predisposes kidney transplant recipients to an array of long-term ocular issues. This may be broadly categorized into infections, malignancies, and other immunosuppression-specific side effects. The interdependence of kidney disease, transplant pharmacotherapy and ocular health therefore requires a multispecialty approach. Although the kidney transplant population has grown along with the burden of associated oculopathies, systematic guidelines targeting this patient group are lacking. This evidenced-based narrative review summarizes the pertinent issues that may present in the ophthalmic and optometric clinical settings, with emphasis on collaborative management and directions for future research.

Update on the Management of Ocular Surface Squamous Neoplasia

Purpose of review

To review and update the latest findings in diagnosis and management of ocular surface squamous neoplasia (OSSN).

Recent findings

OSSN is the most common anterior segment neoplastic disease process. Several ocular surface imaging techniques have been developed for the early diagnosis and management of clinical and subclinical ocular surface squamous neoplasia, including high-resolution optical coherence tomography (HR-OCT), in vivo confocal microscopy, and ultrasound biomicroscopy. Treatment modalities include both surgical and medical management, with a recent trend towards primary and adjunctive pharmacotherapy.

Summary

There is increasing use of HR-OCT for the diagnosis and monitoring of clinical and subclinical OSSN lesions. Topical pharmacotherapy agents, including interferon α-2b, 5-fluorouracil, and mitomycin C, have demonstrable efficacy in the treatment of OSSN and their use may be dictated based upon tumor factors, patient factors, cost, and side effect profile. Both surgical excision and adjunctive topical medications have excellent success, with the favored treatment method trending towards topical pharmacotherapy as primary therapy.

Genomic Alterations in Human Papillomavirus-Positive and -Negative Conjunctival Squamous Cell Carcinomas

Purpose

The genomic alterations contributing to the pathogenesis of conjunctival squamous cell carcinomas (SCCs) and their precursor lesions are poorly understood and hamper our ability to develop molecular therapies to reduce the recurrence rates and treatment-related morbidities of this disease. We aimed to characterize the somatic DNA alterations in human papillomavirus (HPV)-positive and HPV-negative conjunctival SCC.

Methods

Patients diagnosed with conjunctival SCC in situ or SCC treated in ocular oncology referral centers in Denmark were included. HPV detection (HPV DNA PCR, p16 immunohistochemistry, and mRNA in situ hybridization) and targeted capture-based next-generation sequencing of 523 genes frequently involved in cancer were performed to describe the mutational profile based on HPV status.

Results

Tumor tissue was available in 33 cases (n = 8 conjunctival SCCs in situ, n = 25 conjunctival SCCs), constituting 25 male and 8 female patients. Nine cases were HPV positive. The HPV-positive SCCs in situ and SCCs were characterized by transcriptionally active high-risk HPV (types 16 and 39) within the tumor cells, frequent mutations in PIK3CA (n = 5/9), and wild-type TP53, CDKN2A, and RB1, while the HPV-negative counterparts harbored frequent mutations in TP53 (n = 21/24), CDKN2A (n = 7/24), and RB1 (n = 6/24).

Conclusions

Our findings have delineated two potentially distinct distributions of somatic mutations in conjunctival SCC based on HPV status-pointing to different biological mechanisms of carcinogenesis. The present findings support a causal role of HPV in a subset of conjunctival SCC.

Corneal Epithelial Stem Cells-Physiology, Pathophysiology and Therapeutic Options

In the human cornea, regeneration of the epithelium is regulated by the stem cell reservoir of the limbus, which is the marginal region of the cornea representing the anatomical and functional border between the corneal and conjunctival epithelium. In support of this concept, extensive limbal damage, e.g., by chemical or thermal injury, inflammation, or surgery, may induce limbal stem cell deficiency (LSCD) leading to vascularization and opacification of the cornea and eventually vision loss. These acquired forms of limbal stem cell deficiency may occur uni- or bilaterally, which is important for the choice of treatment. Moreover, a variety of inherited diseases, such as congenital aniridia or dyskeratosis congenita, are characterized by LSCD typically occurring bilaterally. Several techniques of autologous and allogenic stem cell transplantation have been established. The limbus can be restored by transplantation of whole limbal grafts, small limbal biopsies or by ex vivo-expanded limbal cells. In this review, the physiology of the corneal epithelium, the pathophysiology of LSCD, and the therapeutic options will be presented.

Human Papillomavirus Related Neoplasia of the Ocular Adnexa

Human papillomaviruses (HPV) are a large group of DNA viruses that infect the basal cells of the stratified epithelium at different anatomic locations. In the ocular adnexal region, the mucosa of the conjunctiva and the lacrimal drainage system, as well as the eyelid skin, are potential locations for HPV-related neoplasia. The role of HPV in squamous cell neoplasia of the ocular adnexa has been debated for several decades. Due to the rarity of all these tumors, large studies are not available in the scientific literature, thereby hampering the precision of the HPV prevalence estimates and the ability to conclude. Nevertheless, increasing evidence supports that defined subsets of conjunctival papillomas, intraepithelial neoplasia, and carcinomas develop in an HPV-dependent pathway. The role of HPV in squamous cell tumors arising in the lacrimal drainage system and the eyelid is still uncertain. Further, the potential of HPV status as a diagnostic, prognostic, or predictive biomarker in these diseases is a topic for future research.

Management of ocular surface squamous neoplasia: Bowman Club Lecture 2021

The gold-standard treatment for ocular surface squamous neoplasia (OSSN) has traditionally been surgical excision with wide margins and a no-touch technique. However, surgery may be associated with several unfavourable sequelae, as well as significant recurrence rates if margins are positive. In recent years, topical chemotherapy with 5-fluorouracil, interferon α-2b and mitomycin C have emerged as valuable agents capable of effectively treating OSSN with varying adverse effects. These medical treatment options usually present additional costs to the patient but can allow patients to avoid surgery with fewer long-term effects. Anterior segment high-resolution optical coherence tomography is an excellent tool for diagnosing and monitoring OSSN and can be a useful aid for both surgical and medical treatments of OSSN.

Ocular surface squamous neoplasia in New Zealand: a ten-year review of incidence in the Waikato region

BACKGROUND

Ocular surface squamous neoplasia (OSSN) is a relatively rare disease with a low mortality and highly variable incidence. Despite a high incidence of OSSN in the Southern hemisphere, there is limited epidemiological data for New Zealand. The current study aims to assess the incidence, demographics, and histological grade of OSSN in the Waikato region of New Zealand, home to ~10% of the population of New Zealand.

METHODS

Non-interventional retrospective cohort study. All conjunctival biopsy histology reports from 2010 to 2019 in the Waikato region of New Zealand were analysed. Age, sex, and ethnicity were analysed and the incidence of OSSN was calculated. Main outcome measures included histological grade, rate of recurrence, and incidence of OSSN.

RESULTS

A total of 386 patients underwent conjunctival biopsy with histology during the study period. Eighty-three lesions (22%) involving 80 patients (21%) were reported positive for OSSN. Patients with OSSN had a mean age of 68.9 years (SD = 13.2), were predominantly male (76%), and of New Zealand-European ethnicity (53%). Conjunctival intraepithelial neoplasia-1 (30%) was the most frequent diagnosis. Three patients (4%) had recurrent lesions requiring repeat biopsy. The peak annual OSSN incidence rate was 3.81/100,000 population in 2019. The overall ten-year incidence was 2.13/100,000 population/year.

CONCLUSION

This is the largest study to investigate OSSN incidence in New Zealand. The incidence rate of OSSN is one of the highest rates reported in the literature.

Ocular surface squamous neoplasia: management and outcomes

Ocular surface squamous neoplasia (OSSN) is the most common ocular tumour with an incidence ranging from 0.03 to 1.9 per 100,000 persons/year. The diagnosis is made on clinical suspicion and confirmed with anterior-segment optical coherence tomography (AS-OCT), cytology, or histology. The purpose of this review is to provide an overview of the management options available for OSSN and review their success and recurrence rates. Surgery is the gold standard for the management of small OSSN lesions. With the increased use of less invasive diagnostic modalities such as AS-OCT and cytology, there has been a move to use topical therapies for the management of OSSN. The most commonly used agents are interferon-α2b (IFN), mitomycin-C (MMC) and 5-fluorouracil (5FU). They have been shown to have similar resolution and recurrence rates but differ in cost and side effect profile. IFN has the lowest side effect profile, but is also the most expensive, whereas MMC has the greatest surface toxicity and is priced midway between the three. 5FU is the cheapest of the three topical agents with less surface toxicity than MMC. Radiotherapy is mostly employed as adjuvant therapy. Newer novel therapies are available but have not been widely adopted as mainstream therapy due to cost and lack of clinical evidence. OSSN has the benefit of many management options. No single modality has been shown to superior and some patients will need the use of combination therapy to achieve an optimal clinical outcome.

Bilateral ocular surface squamous neoplasia: A study of 25 patients and review of literature

PURPOSE

To describe the risk factors, clinical presentation, management, and outcomes of patients with bilateral ocular surface squamous neoplasia (OSSN).

METHODS

Retrospective case series.

RESULTS

Of the 25 patients with bilateral OSSN, the mean age at diagnosis of OSSN was 31 years (median, 24 years; range, 2-60 years). Risk factors for bilateral OSSN included xeroderma pigmentosum (n = 15, 60%), human immunodeficiency virus infection (n = 3, 12%), conjunctival xerosis (n = 1, 4%), and topical steroid use (n = 1, 4%). There were no identifiable ocular or systemic risk factors in 7 (28%) patients. Presentation was synchronous in 14 (56%) and metachronous in 11 (44%) patients. Tumor morphology was bilaterally similar in 12 (48%) patients. Histopathological examination (n = 36) revealed conjunctival intraepithelial neoplasia (CIN) grade 1 in 4 (8%); grade 2 in 7 (14%); carcinoma in situ in 5 (10%), and invasive carcinoma in 20 (40%). Primary management of OSSN (n = 49) included excisional biopsy (n = 31, 62%), topical immunotherapy (IFN α2B) (n = 11; 22%), topical Mitomycin C (MMC) (n = 3, 6%), enucleation (n = 1, 2%), orbital exenteration (n = 2, 4%), and plaque brachytherapy (PBT) (n = 1, 2%). One patient was lost to follow-up after detection of tumor in the second eye. Recurrent tumors were noted in 16 (32%) eyes and binocular globe salvage was achieved in 16 (64%) patients at a mean follow up of 41 months (median 30 months; range, 1-164 months).

CONCLUSION

OSSN occurrence can be synchronous or metachronous. Meticulous examination of the fellow eye is important for an early diagnosis of OSSN.

Single-Fraction Adjuvant Electronic Brachytherapy after Resection of Conjunctival Carcinoma

Simple Summary

A centralized distribution of specialized oncologic facilities is a widely repeated situation in many latitudes around the globe, limiting the patient’s access options to specialized treatments. Strategies to alleviate the overpassed attention capacities in low- and middle-income countries, such as Peru, have driven the attention of practitioners towards hypofractionated treatments. In order to shorten treatment times and hospital visits, treating ocular conjunctival carcinoma with a single-fraction electronic brachytherapy approach arises as a novel option, which further increases the current therapeutic arsenal against this entity. We aim to report the clinical findings of this treatment modality, in terms of feasibility, oncological outcomes and toxicity profile, while opening a new possibility of diminishing patient- and health care-related financial impact.

Abstract

A retrospective study was performed to assess the outcomes of a single-fraction adjuvant electronic brachytherapy (e-BT) approach for patients with squamous cell conjunctival carcinoma (SCCC). Forty-seven patients with T1–T3 SCCC were included. All patients underwent surgery followed by a single-fraction adjuvant e-BT with a porTable 50-kV device. Depending on margins, e-BT doses ranged between 18 to 22 Gy prescribed at 2 mm depth, resembling equivalent doses in 2 Gy (EQD2) per fraction of 46–66 Gy (α/β ratio of 8–10 Gy and a relative biological effect (RBE) of 1.3). The median age was 69 (29–87) years. Most tumors were T1 (40.4%) or T2 (57.5%) with a median size of 7 mm (1.5–20). Margins were positive in 40.4% of cases. The median time from surgery to e-BT was nine weeks (0–37). After a median follow-up of 24 (17–40) months, recurrence occurred in only two patients (6 and 7 months after e-BT), yielding a median disease-free survival (DFS) of 24 (6–40) months and DFS at two years of 95.7%. Acute grade 2 conjunctivitis occurred in 25.5%. E-BT is a safe and effective for SCCC treatment, with clinical and logistic advantages compared to classical methods. Longer follow-up and prospective assessment are warranted.

Ocular surface squamous neoplasia: outcomes following primary excision with 2 mm margin and cryotherapy

PURPOSE

To assess margins and the rate of local recurrence of ocular surface squamous neoplasia after excision with a 2 mm margin and cryotherapy at a single ophthalmic oncology center.

OUTCOME MEASURES

(1) Conjunctival margin were assessed as positive, negative, or indeterminate margins. (2) Feasibility of repair without a graft. (3) Local recurrence.

METHODS

Retrospective chart review of histologically proven conjunctival intraepithelial neoplasia and invasive squamous cell carcinoma cases that underwent excision with a 2 mm margin and cryotherapy.

RESULTS

Eighty cases met inclusion criteria for the quantitative analysis. The margin was positive in six cases (7.5%), four of which were treated with post-op topical immunotherapy/chemotherapy. Of the six positive margin cases, there was one recurrence which occurred in the patient who did not receive post-op topical adjuvant therapy, however resolved after starting topical treatment. Conjunctival repair without use of a graft was feasible in 74 (93%) cases with a mean basal diameter of 6.4 mm. Total number of local recurrence was seen in three cases (4%), which were successfully treated with adjuvant topical treatment (one positive margin case, one indeterminate margin case) or repeat resection followed by episcleral plaque brachytherapy (one negative margin case).

CONCLUSION

Excision with 2 mm margin of OSSN is not associated with high rates of positive surgical margins. Even those with positive margins, when treated with adjuvant topical therapy did not develop recurrence. While achieving low rates of local recurrence, the conjunctiva is conserved, thereby minimizing the need for amniotic membrane or free conjunctival grafts for conjunctival repair.

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.

Kasuistik: Management eines limbalen Carcinoma in situ der Bindehaut

Das Carcinoma in situ (CIS) der Bindehaut stellt einen der häufigsten okulären Tumoren dar. Neben der klassischen chirurgischen Therapie besteht die Möglichkeit der Anwendung von Chemotherapeutika adjuvant oder als Monotherapie. Wir behandelten einen Patienten mit einem limbalen CIS ausschließlich konservativ mittels Applikation von Mitomycin(MMC)-Augentropfen. Drei Monate nach Abschluss zeigte sich kein Hinweis auf Dysplasien oder Malignität, und auch nach 12 Monaten ergab sich kein klinischer Hinweis auf ein Rezidiv. Bei der Therapie steht zwar weiterhin die chirurgische Sanierung im Vordergrund, in den letzten 15 Jahren zeigt sich jedoch ein Trend zu topischen Chemotherapeutika primär oder adjuvant bei einer Resektion nicht im Gesunden. Das Nebenwirkungspotenzial sowie der infrastrukturelle Aufwand sollten dabei stets berücksichtigt werden.

An Unexpected Incidence of Ocular Surface Neoplasia on Pterygium Surgery. A Retrospective Clinical and Histopathological Report

PURPOSE

To report the unexpected finding of ocular surface neoplasia (OSSN) on conjunctival tissue removed during pterygium surgery and subjected to histopathology analysis.

METHODS

This is an observational, descriptive retrospective study in which all the samples removed during surgery between 1997 and 2020 with a clinical diagnosis of pterygium were sent for histopathology analysis in which an unexpected OSSN was found.

RESULTS

There were 461 cases with a preoperative diagnosis of pterygium, with a mean age of 30.14 ± 10.6 years. In this group, there was an unexpected finding of OSSN in 69 cases (14.96%) of the surgical samples, with a mean age of 46 ± 8.2 years (31.86 ± 12.13).

CONCLUSIONS

The unexpected coincidence of pterygium and OSSN is frequent, although varies depending on the geographical location. We recommend performing a histopathology analysis on every pterygium removed.

Management of ocular surface squamous neoplasia extending up to a filtering trabeculectomy bleb

A 73-year-old-gentleman was referred for ocular surface squamous neoplasia (OSSN) in his right eye (RE). He had history of combined cataract with trabeculectomy in RE and was maintaining his intraocular pressure (IOP). He showed a corneoscleral lesion measuring 11 × 8 mm in nasal quadrant wherein, the superior edge of the lesion was extending up to the filtering bleb. After ruling out intraocular invasion or regional spread, he underwent complete tumor excision with “no touch” technique along with cryotherapy and surface reconstruction and a perilesional injection of Interferon α2B. At 6-month visit, he shows no locoregional recurrence and has controlled IOP.

The treatment of recurrent conjunctival and corneal intraepithelial neoplasia with interferon alfa-2b and retinoic acid: ~9 years' follow-up on tumor control

PURPOSE

To evaluate the long-term follow-up of recurrent conjunctival and corneal intraepithelial neoplasia (CCIN) treated with combination topical interferon alfa-2b and retinoic acid (I/RA).

METHODS

Our study represents a retrospective observational interventional series of 82 eyes from 82 patients from a single institution, reviewed for CCIN. All were administered topical interferon alfa-2b 1 million IU/mL QID and retinoic acid 0.01% every other day. Patients had been diagnosed by biopsy. A Kaplan-Meier survival analysis, Wilcoxon signed-rank test and a multivariate logistic regression were statistical tests used to correlate recurrence with patient and tumor variables.

RESULTS

79 eyes assessed for CCIN diagnoses and treated with I/RA achieved tumor resolution. The median tumor-free follow-up was ~109.1 months with a median time to resolution being ~2.8 months. Our median treatment duration was ~11.3 months. The greatest difference in the mean total residual tumor size was identified between Months 0-1 [-7.63 mm²]. The difference in mean total residual tumor size remained significant till 36-months. A statistically significant correlation with recurrence was identified for biopsy type [OR 0.138]. 6 patients experienced papillary conjunctivitis which resolved with dosage reduction.

CONCLUSIONS

Combination I/RA was effective in treating CCIN lesions with few transient side effects. The combination of retinoids and interferons may represent a viable topical therapeutic agent with an extended tumor-free follow-up and a large proportion of our study's patients achieving >10 year's tumor-free follow-up. Our treatment duration is long, but by cost-comparing surgical against medical interventions, topical I/RA may serve as a safe and effective alternative.

Clinical demographics of pterygium excision and prevalence of conjunctival intraepithelial neoplasia: a 15-year review

PURPOSE

To find clinical demographics of pterygium surgery and prevalence of conjunctival intraepithelial neoplasia (CIN) in pterygium specimen.

METHODS

This is a retrospective, institutional study. The records of patients who had received pterygium excision from 2000 to 2014 were reviewed. Patients after complete ophthalmic "examinations", surgical procedures, and pathological reports were enrolled. Surgical procedures, pathology, external eye photography, prevalence of CIN in specimen, and demographic data were described.

RESULTS

Of 1787 pterygium cases, 928 were male and 859 were female. The mean age was 65.19 ± 14.21 years. Of these 1787 cases, 1435 (80.3%) cases had primary pterygium excision, while the others (n = 352; 19.7%) had pterygium excision for recurrence. Four cases presented CIN within pterygium tissue (0.22%). The mean age of pterygium patients with CIN was 57.75 ± 7.80 years. In stratified data, our patients who received primary and secondary pterygium excision were found prevalent in the eighth (28.2%) and seventh (26.1%) decade, respectively. Twelve percent of patients who underwent secondary pterygium excision had a recurrence and required another surgery. Patients requiring amniotic membrane transplantation (AMT) during primary pterygium excision were significantly younger (median, 58 years) than those (median, 67 years) without the assistance of AMT (p < 0.001). Similarly, AMT was utilized in younger patients (median, 56 years) during secondary pterygium excision, compared to those without AMT (median, 64 years) (p = 0.001).

CONCLUSION

CIN combined with pterygium is very rare. However, the possibility of the development of ocular surface squamous neoplasia in pterygium tissue should not be ignored. Meticulous pathological investigation of the surgical samples is important.

Management Issues in Conjunctival Tumours: Ocular Surface Squamous Neoplasia

Ocular surface squamous neoplasia is the most common tumour of the ocular surface. It is a spectrum of disease from intraepithelial dysplasia to invasive squamous cell carcinoma. Recent years have seen an increase in the use of topical chemotherapeutic agents to treat this condition, often as primary treatment without full-thickness biopsy. This practical approach provides a critical appraisal of the evidence base with the goal being to aid the clinician in the management of these patients.

Use of High-Resolution Optical Coherence Tomography in the Surgical Management of Ocular Surface Squamous Neoplasia: A Pilot Study

PURPOSE

To evaluate whether high-resolution optical coherence tomography (HR-OCT) can detect histologic tumor margins of ocular surface squamous neoplasia (OSSN).

METHODS

Eight eyes of 8 patients with OSSN undergoing excision were studied prospectively. Immediately before surgery, the tumor was imaged using commercially available HR-OCT to identify the conjunctival margins of the neoplastic lesion. The tumor borders of the lesion determined by HR-OCT were mapped in relation to an anatomic reference point and transferred intraoperatively. The tumor was excised with 4-mm margins from the visible edge of the lesion with a "no-touch" technique. The specimens were sent for pathologic analysis and the histologic tumor margin was compared to the HR-OCT predicted tumor border.

RESULTS

Mean age of the 8 patients was 67 ± 9.9 years. Seven were male, 7 were white, and, ethnically, 3 were Hispanic. All 8 tumors were bulbar and in the exposure zone. Seven tumors were limbal. Corneal extension was present in 5. Mean tumor area was 17.5 ± 11.1 mm². Clinically, 2 of the tumors were leukoplakic, 1 papillomatous, and 3 gelatinous. A conjunctival tumor margin identified with the HR-OCT coincided with the pathologically confirmed margin mark in all eyes.

CONCLUSIONS

HR-OCT has the potential to predict histologic tumor margins in OSSN. Optical identification of tumor margins could potentially decrease the incidence of residual positive margins and minimize healthy tissue removal. Advances in HR-OCT technology and integration into a microscope for "real-time" imaging are needed to further improve this technique. NOTE: Publication of this article is sponsored by the American Ophthalmological Society.

Factors affecting recurrence after surgical treatment in cases with ocular surface squamous neoplasia

AIM

To evaluate the risk factors leading to recurrence in patients with ocular surface squamous neoplasia (OSSN).

METHODS

The records of 112 patients with OSSN who underwent treatment and follow-up between February 1999 and August 2018 were reviewed retrospectively.

RESULTS

Totally 67 patients (59.8%) were male and 45 patients (40.2%) were female. The mean age at presentation was 63.7y (range 22-87y). Partial lamellar scleroconjunctivectomy (PLSC) was performed in 105 (93.7%) cases and enucleation was performed in 7 (6.3%) cases due to bulbus invasion as the first step treatment. Treatments used in addition to PLSC included cryotherapy in 78 eyes (74.3%), alcohol epitheliectomy in 57 eyes (54.3%) for presence of corneal involvement, and amniotic membrane transplantation in 17 eyes (16.2%) for ocular surface reconstruction. Topical mitomycin C was used in 10 patients (9.5%) and strontium-90 (Str-90) treatment in 4 (3.8%) patients because surgical margins were tumor positive at the histopathological examination. Postoperative histopathologic diagnoses were squamous cell carcinoma (52 cases), carcinoma in situ (44 cases), moderate conjunctival intraepithelial neoplasia (11 cases), and mild conjunctiva intraepithelial neoplasia (5 cases). At a mean follow-up of 20.1mo, tumor recurrence was observed in 21 (18.8%) cases. The rate of recurrence was found to be lower in cases that underwent supplemental cryotherapy compared to those that did not (P<0.001). There was no metastasis in any case.

CONCLUSION

In our series, the recurrence rate is 18.8% and overall globe salvage rate is 90.2% for OSSN at relatively short-term follow-up.

Utility of high-resolution anterior segment optical coherence tomography in the diagnosis and management of sub-clinical ocular surface squamous neoplasia

Background

To evaluate the frequency and characteristics of sub-clinical ocular surface squamous neoplasia (OSSN) detected by high-resolution anterior segment tomography (HR- OCT) in patients with clinically unapparent disease following topical treatment.

Methods

A retrospective chart review of patients with OSSN identified through a pharmacy database at the Bascom Palmer Eye Institute from January 2013 to December 2018 was conducted. Patients undergoing primary therapy with topical 5-fluorouracil 1% (5-FU) (4 times a day for 7 days with a 21-day break) or interferon-alpha-2b (IFN) (4 times a day) were reviewed. Patients were separated into two groups. Group 1 included individuals whose clinical resolution of OSSN aligned with complete resolution on HR-OCT. Group 2 (sub-clinical OSSN group) included individuals with clinical OSSN resolution but with features of persistent disease on HR- OCT. Patients excluded included those treated at an outside institution and those who used topical therapy as a surgical adjunct.

Results

A total of 95 patients (95 eyes) were reviewed. Sub-clinical OSSN was detected at a frequency of 17% in our study patients (n = 16 patients, 9 treated with 5-FU and 7 treated with IFN). In the 16 individuals, the mean time to clinical resolution was 3.6 ± 1.0 cycles for 5-FU and 4.0 ± 0.0 months for IFN. An additional 2.1 ± 0.8 cycles for 5-FU and 1.2 ± 0.4 months for IFN were needed to achieve HR-OCT resolution of OSSN. Recurrence in Group 1 was noted in 10 patients (12%) while no recurrences occurred in Group 2, the cohort with subclinical disease that received the extended medical therapy. The mean follow-up was 24.0 ± 17.9 months.

Conclusion

We found that at least 17% of individuals with apparent clinical resolution of OSSN have sub-clinical disease detected on HR-OCT. This information can be used to optimize treatment and extend therapy past the point of clinical resolution.

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.

Update on Diagnosis and Management of Conjunctival Papilloma

Conjunctival papilloma is an acquired benign squamous cell tumor that can present at any age, but most frequently in the third and fourth decades of life. Papillomas have been associated with human papilloma virus (HPV) infection, usually types 6 and 11. Although histopathological diagnosis remains the gold standard, the advent of newer non-invasive imaging modalities such as optical coherence tomography (OCT) is transforming the way we diagnose and treat ocular surface tumors, including conjunctival papilloma. Management of these lesions can prove a challenge to the treating physician since not all lesions respond to medical and/or surgical therapy and in fact may worsen after surgical manipulation. In this review, the epidemiology, pathophysiology, clinical characteristics, and diagnosis of conjunctival papilloma including the use of OCT are discussed. Indications, efficacy, and side effects of currently available management options are also reviewed to guide the selection of the best treatment approach.

Comparison of Topical 5-Fluorouracil and Interferon Alfa-2b as Primary Treatment Modalities for Ocular Surface Squamous Neoplasia

PURPOSE

To compare the efficacy of topical 5-fluorouracil 1% (5FU) and interferon alfa-2b 1 MIU/mL (IFN) eye drops as primary treatment modalities for ocular surface squamous neoplasia (OSSN).

DESIGN

Retrospective, comparative, interventional case series.

METHODS

Fifty-four patients who received 5FU and 48 patients who received IFN as primary therapy for OSSN were included. Primary outcome measures were the frequency of clinical resolution and time to OSSN recurrence by treatment modality. Secondary outcome was the frequency of side effects with each therapy.

RESULTS

The mean age of patients was 68 years. More Hispanics were treated with 5FU. In a univariable analysis, frequency of OSSN resolution was higher with 5FU (96.3%, n = 52) than with IFN (81.3%, n = 39), P = .01. In a multivariable analysis, treatment modality did not remain a significant predictor of resolution. In patients whose OSSN resolved, time to resolution was similar with both agents, (5FU mean 6.6 months, standard deviation (SD) 4.5 vs IFN mean 5.5 months, SD 2.9, P = .17). Of the 52 eyes whose OSSN resolved with 5FU, 11.5% of lesions (n = 6) recurred, whereas of the 39 eyes whose OSSN resolved with IFN, 5.1% of lesions (n = 2) recurred, P = .46. Kaplan-Meier survival curves of OSSN recurrence were similar between groups (log-rank = 0.16). One-year recurrence rates were 11.4% with 5FU and 4.5% with IFN. Eyelid edema (P = .04) and tearing (P = .02) were more significant with 5FU.

CONCLUSIONS

This is the first direct comparison study between 5FU and IFN eye drops as primary treatment modalities for OSSN. Both modalities resulted in a high frequency of tumor resolution and low recurrence rates and are effective treatment options for OSSN.

Ocular and Periocular Tumors in Xeroderma Pigmentosum: A Study of 120 Asian Indian Patients

PURPOSE

We studied the incidence, treatment, and outcome of ocular and periocular tumors in patients with xeroderma pigmentosum (XP).

DESIGN

Retrospective case series.

METHODS

This single-institution study included 120 patients with XP who underwent intervention with excisional biopsy, enucleation, or orbital exenteration. The primary outcome measures were the occurrence of eyelid or ocular surface tumor, globe salvage, locoregional and systemic metastasis, and death.

RESULTS

The mean age at presentation was 19 years. A family history of XP was present in 32 (27%) patients. Over a mean follow-up of 61 months, 34 (28%) patients developed no ocular/adnexal tumor, 86 (72%) developed ocular surface malignancy, 15 (13%) developed eyelid malignancy, and 22 (18%) developed other head and neck malignancies. Of the 86 patients with ocular surface malignancy, 48 (56%) had unilateral tumor and 38 (44%) had bilateral tumors. Invasive squamous cell carcinoma (n = 51, 41%) was the most common ocular surface tumor. Of the 15 patients with eyelid tumors, 14 (93%) had unilateral tumor and 1 (7%) had bilateral involvement. Basal cell carcinoma (n = 8, 50%) was the most common eyelid tumor. There were events of ocular surface tumor recurrence (n = 55 eyes, 44%), eyelid tumor recurrence (n = 5 eyes, 31%), locoregional lymph node metastasis (n = 3, 2%), systemic metastasis (n = 1, 1%), and death (n = 1, 1%). Overall, globe salvage was achieved in 119 (99%) patients (both eyes were salvaged in 92 [76%] patients and at least 1 eye was salvaged in 27 [23%] patients).

CONCLUSION

XP is frequently associated with ocular surface, eyelid, and other head and neck malignancies. Lifelong follow-up is mandatory in these patients.