Squamous cell carcinoma of the conjunctiva as initial presenting sign in a patient with acquired immunodeficiency syndrome (AIDS) due to human immunodeficiency virus type-2

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.

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.

Ocular surface squamous neoplasia as the initial presenting sign of human immunodeficiency virus infection in 60 Asian Indian patients

PURPOSE

To study the importance of routine human immunodeficiency virus (HIV) screening in patients with ocular surface squamous neoplasia (OSSN) and describe their clinical features and management.

METHODS

Retrospective study.

RESULTS

Of 228 cases of OSSN screened for HIV by enzyme-linked immunosorbent assay, 86 (38%) patients were HIV positive. Of these 86 patients, 60 (70%) were unaware of their HIV-positive status prior to HIV screening. These 60 (26%) patients with newly detected HIV-positive status were included in this study. Ocular surface squamous neoplasia was the sole presenting feature of HIV infection in these patients. Mean age at presentation was 41 years. Bilateral involvement occurred in 9 (15%) cases. The mean tumor basal diameter was 11 mm. Orbital involvement was noted in 6 (9%) cases, and intraocular tumor extension occurred in 1 (1%) case. Based on American Joint Committee Classification, T2 (n = 35, 51%) was most common. The primary treatment for OSSN included excision biopsy (n = 52, 75%), topical chemotherapy with Mitomycin-C (n = 5, 7%), extended enucleation (n = 4, 6%), and orbital exenteration (n = 8, 12%). Tumor recurrence occurred in 23% cases during a mean follow-up period of 9 months. On histopathology, invasive squamous cell carcinoma was more common (n = 38, 55%).

CONCLUSION

OSSN was the presenting sign of underlying HIV infection in 26% cases, and 70% were unaware of their HIV-positive status prior to HIV screening. In this study, T2 tumor was most common, and 26% cases required extended enucleation/orbital exenteration to achieve complete tumor resection.

Ocular Manifestations in Patients with HIV Infection/AIDS who were Referred from the ART Centre, Hassan, Karnataka, India

BACKGROUND

Ocular involvement in HIV infection/AIDS is very common and it includes various clinical presentations which may be asymptomatic or atypical or they may be the initial manifestations of the underlying disease. The severity of these lesions increases as the immune competency decreases, leading to visual impairment or blindness.

OBJECTIVE

The purpose of this study was to determine the prevalence and the types of HIV associated ocular conditions and their effect on the vision in patients with HIV/AIDS.

METHODS

This cross sectional study was based on the patients with HIV infection/AIDS, who were referred to the Ophthalmic OPD, District hospital, Hassan. These patients were referred from the District ART Centre for a complete ophthalmic evaluation, irrespective of their immune status and the presence or absence of symptoms. All the patients underwent a complete ophthalmic examination, which included both anterior and posterior segment evaluation and colour vision assessment.

RESULTS

Out of the 553 patients, 66% belonged to the age group of 21-40 years. 87% of the patients had a BCVA of >6/18, whereas 4.7% had very poor vision. 37.6% of the patients had ocular manifestations. Anterior segment, posterior segment and neuro-ophthalmic manifestations were seen in 7%, 9.94% and 5.79% of the patients respectively. The most common anterior segment manifestation was recurrent lid infections, while HIV microangiopathy was the most common posterior segment manifestation. The other unusual findings included an abnormal colour vision in 6.3% of the patients and bilateral lid retraction in 8.5% of the patients.

CONCLUSION

Since ocular manifestations are very common and as they can occur at any time during the course of HIV infection, an awareness on various patterns of the ocular disease and the screening of all the patients with HIV infection/AIDS is a must.

Anterior segment manifestations of human immunodeficiency virus/acquired immune deficiency syndrome

Ocular complications are known to occur as a result of human immunodeficiency virus (HIV) disease. They can be severe leading to ocular morbidity and visual handicap. Cytomegalovirus (CMV) retinitis is the commonest ocular opportunistic infection seen in acquired immune deficiency syndrome (AIDS). Though posterior segment lesions can be more vision-threatening, there are varied anterior segment manifestations which can also lead to ocular morbidity and more so can affect the quality of life of a HIV-positive person. Effective antiretroviral therapy and improved prophylaxis and treatment of opportunistic infections have led to an increase in the survival of an individual afflicted with AIDS. This in turn has led to an increase in the prevalence of anterior segment and adnexal disorders. Common lesions include relatively benign conditions such as blepharitis and dry eye, to infections such as herpes zoster ophthalmicus and molluscum contagiosum and malignancies such as squamous cell carcinoma and Kaposi′s sarcoma. With the advent of highly active antiretroviral therapy, a new phenomenon known as immune recovery uveitis which presents with increased inflammation, has been noted to be on the rise. Several drugs used in the management of AIDS such as nevirapine or indinavir can themselves lead to severe inflammation in the anterior segment and adnexa of the eye. This article is a comprehensive update of the important anterior segment and adnexal manifestations in HIV-positive patients with special reference to their prevalence in the Indian population.

Squamous cell carcinoma of the conjunctiva in patients with atopic eczema

PURPOSE

To report squamous cell carcinoma (SCC) of the conjunctiva in patients with atopic eczema.

METHODS

A retrospective study of six patients with conjunctival SCC associated with atopic eczema. Clinical and pathologic records were reviewed.

RESULTS

Ten patients with conjunctival SCC were seen from October 1999 to May 2002 at the Department of Ophthalmology at the University of Essen. Six of 10 patients had also atopic eczema. These six patients were treated either with local excision and ocular surface reconstruction or proton beam radiotherapy. None of the patients had local recurrences or metastases.

CONCLUSION

Atopic eczema is a common dermatological disease. An association with conjunctival SCC has not been reported so far. Squamous cell carcinoma has also been found in patients with AIDS and other immunosuppressed individuals. The dysfunction of T lymphocytes found in these disorders might play a crucial role in the malignant transformation of conjunctival tissue. Because of the reported frequency of SCC, patients with atopic eczema should be monitored for abnormalities.