Topical chemotherapy for ocular surface squamous neoplasia

Therapeutic Response to Treatment of a Papillomatous Ocular Surface Squamous Neoplasia With Intramuscular Human Papillomavirus Vaccine

PURPOSE

The purpose of this study was to describe the response of a papillomatous ocular surface squamous neoplasia (OSSN) to the intramuscular (IM) 9-valent human papillomavirus (HPV) vaccine after failed medical and surgical interventions.

METHODS

A 79-year-old White man with a conjunctival lesion underwent a biopsy which revealed OSSN and positivity for high-risk HPV. Initially treated with medical therapy and surgical excisions, the patient developed a recurrence and refused further surgery. He was given 4 doses of IM HPV vaccine at the 6-week interval.

RESULTS

A dramatic reduction in lesion size and reduced epithelial thickening and hyperreflectivity was noted on slitlamp examination and high-resolution anterior segment optical coherence tomography after receiving the IM HPV vaccine. Although lesion size was markedly reduced, the therapy did not achieve total resolution, resulting in further treatment with topical 1% 5-fluorouracil (5-FU) eye drops and later 0.04% mitomycin C eye drops. The patient then elected to discontinue further treatment and solely observe.

CONCLUSIONS

This case report adds to the growing literature demonstrating the potential therapeutic use of vaccines in cancer treatment. Although HPV vaccination is currently approved for prophylaxis, the use of HPV vaccines as a therapeutic option for various HPV-mediated diseases, including OSSN, should be further explored. The HPV vaccine yielded significant initial improvement in this patient who refused further surgical interventions. The use of IM HPV vaccine as an adjunctive treatment of papillomatous OSSN may represent a potential therapeutic option in cases refractory to standard treatment modalities.

Topical Application of 5-Fluorouracil for the Treatment of Sinonasal Adenocarcinoma and Inverted Papilloma

BACKGROUND

Sinonasal tumors represent a rare and heterogeneous group of rhinologic neoplasms. Even with advancements in surgical approaches, mortality rates of patients with sinonasal adenocarcinoma (SNAC) have not significantly improved and persistently high rates of recurrence in certain patients with inverted papilloma (IP) are seen. The use of 5-fluorouracil (5-FU) has been successfully described as an adjuvant treatment of SNAC and in the prevention of IP recurrence.

OBJECTIVE

This review aims to present the current evidence on the management of SNAC and IP with topical 5-FU.

METHODS

A three-author independent literature review was conducted to identify research involving the use of topical 5-FU for the treatment of SNAC and IP. A total of nine papers on the treatment of SNAC and IP were collected.

RESULTS

The earliest study looking at the combination of adjuvant low-dose radiation and topical 5-FU for adenocarcinoma of the ethmoid sinus showed a 5-year survival rate of 100%. A follow-up study evaluating a similar protocol reported adjusted disease-free survival at 2, 5, and 10 years of 96%, 87%, and 74%, respectively. Similar results have been demonstrated for adjuvant 5-FU use following endoscopic resection and have even been described in the novel setting of transcutaneous 5-FU delivery following frontal trephination. Topical 5-FU has also been described in the treatment of aggressive IP. The largest case series described the use of 5-FU for eighteen cases and demonstrated only a single recurrence.

CONCLUSION

The use of topical 5-FU currently represents an underutilized therapeutic modality within the treatment of rhinologic neoplasms. Available literature suggests that neoadjuvant use of topical 5-FU can improve survival and decrease recurrence for SNAC and IP. However, the small sample sizes prevent advocation for routine use in the general population and further research on 5-FU is necessary.

Unusual presentation of ocular surface squamous neoplasia in a young healthy patient: A case report

PURPOSE

To report an unusual case of ocular surface squamous neoplasia (OSSN) associated with human papilloma virus (HPV)-16 infection with an atypical morphology in a young otherwise healthy patient.

CASE DESCRIPTION

A 17 year-old healthy male was referred to our department for evaluation of a corneal infiltrate with anterior stromal neovascularization in the right eye. One year before, the patient underwent an excision of a corneo-conjunctival lesion that was located inferiorly in the same eye. Histopathological analysis had shown moderate and severe dysplasia of the conjunctival epithelium and resulted positive for HPV-16. We performed a diagnostic incisional biopsy of the limbal conjunctiva and of the corneal epithelium for histological examination and molecular testing for HPV and Chlamydia by using polymerase chain reaction (PCR). Histopathologic evaluation demonstrated low-grade dysplasia of conjunctiva. PCR testing of the corneal epithelium was positive for HPV-16, similarly to the first biopsy performed by another centre. The patient was successfully treated with topical interferon alfa-2b (1,000,000 IU/ml) for a total of six months. After the treatment, the corneal infiltrate improved dramatically with regression of neovascularization and improvement of corneal transparency and vision.

DISCUSSION

The present report described an atypical presentation of HPV-related OSSN due to its unusual morphology, young age of onset and absence of associated comorbidity.

CONCLUSION

Conservative treatment with topical interferon-alpha 2b could be used to treat successfully HPV-16 positive OSSN, with no corneal irregularity or potential loss of vision compared to surgical excision.

Use of Cemiplimab, an Immune Checkpoint Inhibitor for Conjunctival Intraepithelial Neoplasia

PURPOSE

Immune checkpoint inhibitors (ICIs) have been recently introduced for the treatment of locally unresectable conjunctival squamous cell carcinoma. We present 2 cases with conjunctival intraepithelial neoplasia (CIN) who were treated with ICIs.

METHODS

A report of 2 cases with CIN who were treated with systemic cemiplimab (350 mg IV every 3 weeks).

RESULTS

A 70-year-old man was treated with cemiplimab for metastatic cutaneous squamous cell carcinoma. The pre-existing CIN continued to progress over the nasal bulbar conjunctiva and cornea, while the other metastatic sites, including parotid glands, and neck lymph nodes showed a complete response after 16 cycles of treatment. An 84-year-old woman had bilateral diffuse CIN involving bulbar and lower eyelid palpebral conjunctiva. Cemiplimab was started because of the extent of involvement. While the bulk of CIN was reduced, it progressed over the cornea and forniceal conjunctiva on OU after 10 cycles of treatment. Excisional biopsies of conjunctival lesions after cemiplimab confirmed CIN in both patients.

CONCLUSIONS

Although conjunctival squamous cell carcinoma tumors are reported to be highly responsive to ICIs, a similar effect has not been observed in 2 patients with CIN. Further studies are needed to evaluate ICIs in the management of CIN.

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.

Long term study of topical interferon α-2b eye drops as primary treatment of ocular surface squamous neoplasia

PURPOSE

To assess the efficacy of topical interferon α-2β(IFN) eye drops as a primary treatment for ocular surface squamous neoplasia(OSSN) and evaluate factors that impact response to treatment and recurrence of OSSN.

METHOD

A retrospective study of 143 OSSN patients treated with topical IFN(1MIU/ml) from January 1998 to June 2021. The diagnosis was based on clinical examination and anterior segment optical coherence tomography, with histologic confirmation was present in 46.2% of patients. Data on demographic, tumor characteristics, treatment outcome, and side effects were collected. The primary outcomes were tumor resolution frequency and recurrence rate. Secondary outcomes were predictive factors for resolution and recurrence and side effects of treatment.

RESULT

Participants were mostly older (mean age, 69 years, SD 12.9, range 29-97), white(89%) males (74%). Complete tumor resolution was achieved in 80.4% of individuals with a mean time to resolution of 4.2 months (SD 2, range 0.5-12.3 months). On multivariable analysis, history of skin cancer (HR: 0.66, p = 0.05, 95%CI: 0.44-0.99) and immune system abnormalities (HR: 0.37, p = 0.009, 95%CI: 0.18-0.79) reduced the risk of tumor resolution, while a prior history of OSSN (HR: 3.49, p < 0.001, 95%CI: 1.76-6.93) increased the risk of resolution. With a mean follow-up time of 44.3 months (SD 50.9, 0-290 months), the recurrence rate was 0%, 2.3% and 3.1% at 1, 2, and 5 years respectively. Mild hyperemia(18.9%) and pain(10.6%) were the two most common side effects.

CONCLUSION

Topical IFN eye drops are a safe and effective primary treatment modality for OSSN with a reasonable side effect profile.

Medical treatment for ocular surface squamous neoplasia

Ocular surface squamous neoplasia (OSSN) is the most common non-melanocytic tumour of the ocular surface. Surgical excision with wide margins using the "no-touch" method was originally the most popular treatment for OSSN. However, in the past two decades, the use of topical medications for OSSN treatment has gained a reputation amongst ophthalmologists for being an effective alternative to surgical excision. Furthermore, technological advancements, such as those seen in high-resolution optical coherence tomography (HR-OCT) for the anterior segment, have facilitated the diagnosis and monitoring of OSSN. When selecting a topical agent, interferon alpha-2b (IFNα-2b) and 5-fluorouracil (5-FU) are two of the gentlest medications used for OSSN and are often considered first line therapies due to their high-resolution rates and mild side effect profiles. Mitomycin C (MMC), on the other hand, has a highly toxic profile; therefore, while effective, in our hands it is considered as a second-line treatment for OSSN if the other modalities fail. In addition, newer and less studied agents, such as immune checkpoint inhibitors, retinoic acid, aloe vera, and anti-vascular endothelial growth factor have anti-neoplastic properties and have shown potential for the treatment of OSSN. We enclose an updated literature review of medical treatments for 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.

Epidemiology and survival outcomes of patients with orbital region non-cutaneous squamous cell carcinoma: a population-based analysis

Background

Non-cutaneous squamous cell carcinoma (ncSCC) of the orbital region is very rare. Thus, its epidemiological characteristics and prognosis are poorly understood. The aim of the study was to assess the epidemiological characteristics and survival outcomes of ncSCC of the orbital region.

Methods

Incidence and demographic data on ncSCC of the orbital region were extracted from the Surveillance, Epidemiology, and End Results (SEER) database and analyzed. The chi-square test was used to calculate the differences between groups. Univariate and multivariate Cox regression analyses were performed to determine the independent prognostic factors for disease-specific survival (DSS) and overall survival (OS).

Results

The overall incidence of ncSCC in the orbital region from 1975 to 2019 was 0.68/1,000,000, and the incidence showed an increasing trend during this period. A total of 1,265 patients with ncSCC of the orbital region (mean age, 65.3 years) were identified in the SEER database. Of these, 65.1% were aged ≥60 years, 87.4% were White, and 73.5% were male. The conjunctiva (74.5%) was the most common primary site, followed by the orbit (12.1%), lacrimal apparatus (10.8%), and overlapping lesion of the eye and adnexa (2.7%). Multivariate Cox regression analysis revealed that age, primary site, SEER summary stage, and surgery were independent prognostic factors for DSS, whereas age, sex, marital status, primary site, SEER summary stage, and surgery were independent prognostic factors for OS.

Conclusions

The incidence of ncSCC in the orbital region has increased over the past 40 years. It usually affects White people, men, and people aged ≥60 years, and its most common site is the conjunctiva. Orbital SCC has worse survival outcomes than SCC of other sites in the orbital region. Surgery is the independent protective treatment for ncSCC of the orbital region.

The Management of Ocular Surface Squamous Neoplasia (OSSN)

The rise of primary topical monotherapy with chemotherapeutic drugs and immunomodulatory agents represents an increasing recognition of the medical management of ocular surface squamous neoplasia (OSSN), which may replace surgery as the standard of care in the future. Currently, there is no consensus regarding the best way to manage OSSN with no existing guidelines to date. This paper seeks to evaluate evidence surrounding available treatment modalities and proposes an approach to management. The approach will guide ophthalmologists in selecting the most appropriate treatment regime based on patient and disease factors to minimize treatment related morbidity and improve OSSN control. Further work can be done to validate this algorithm and to develop formal guidelines to direct the management of OSSN.

Conjunctival squamous cell carcinoma with massive apoptosis and immune cell infiltration: A case report

This case reports a rare case of conjunctival squamous cell carcinoma in China. The elderly (86-year-old) female patient was diagnosed and treated effectively after three times of diagnosis. During this period, she was misdiagnosed and ineffective treatment for many times. Therefore, we propose to make an integrated diagnosis based on histopathological diagnosis, combined with a variety of diagnostic methods including MRI and CDFI, supplemented by updated multiple immunohistochemically techniques, so as to achieve the purpose of accurate diagnosis.

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.

Efficacy and safety of topical 5-fluorouracil in conjunctival intraepithelial neoplasia refractory to interferon alpha-2b

PURPOSE

To report the efficacy and safety of 5-fluorouracil as the second line of treatment for two cases of conjunctival intraepithelial neoplasia refractive to topical interferon alpha-2b.

CASE REPORT

In the first case, a 77-year-old woman was evaluated because of a fleshy vascularized lesion in the temporal conjunctiva on her right eye with leukoplakia of the corneal epithelium from 10- to 5-o'clock limbus. In the second case, an 81-year-old man, a nodular lesion in the temporal conjunctiva on his RE, with corneal adjacent opalescence, one millimeter in extent, was observed. Both patients were initially treated with excisional surgery, the samples being reported as conjunctival intraepithelial neoplasia with high-grade dysplasia. Co-adjuvant treatment with topical interferon alpha-2b 1 mIU/mL was indicated 4 times/day uninterruptedly. In the first case, there was no response despite 8 months of treatment, while in the second, the corneal lesion progressed in an arboriform pattern after 4 months of topical chemotherapy.

MANAGEMENT & OUTCOME

In the absence of efficacy, the treatment was then changed to topical 5-fluorouracil (1%), 4 times/day for 7 days with a time-lapse of 21 days off, which constitutes a course. Two and four courses of treatment with 5-fluorouracil 1% were completed in both cases in the absence of important side effects. After the first course, both patients showed complete remission of the lesions. No clinical signs of relapse were noted after 1 year of follow-up.

DISCUSSION

The treatment with 5-fluorouracil is a good option as the second line of treatment for conjunctival intraepithelial neoplasia who are low-responders to interferon alpha-2b, with fewer side effects than other currently available alternatives.

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.

Topical Chemotherapy for Treating Ocular Surface Squamous Neoplasia with a Combination of Interferon α-2b and 5-Fluorouracil

Introduction

This study evaluated the efficacy of combined interferon α-2b (IFNα2b) and 5-fluorouracil (5-FU) as primary treatment for ocular surface squamous neoplasia (OSSN).

Methods

In this retrospective study, 27 eyes with OSSN followed by topical application of combined IFNα2b and 5-FU were examined. Reported outcome measures were tumor response, visual acuity, time to complete resolution, recurrence and treatment complications.

Results

Twenty-six patients (17 male, 9 female) had a mean age of 63.9 (median, 67; range 22–83) years. Complete tumor response was observed in 24 eyes (88.9%). Three eyes (11.1%) showed partial response to the chemotherapy agents and later underwent surgical tumor removal. The median time to complete resolution was 6 (mean, 6.1; range, 3–11) weeks. Of these, the patients received between one to three cycles of 5-FU therapy (median, 2; mean, 1.8). Complications noted were transient irritation at 5-FU cycle (11 eyes, 40.7%). There was no tumor recurrence at mean follow-up of 16.1 (median, 12; range 6–38) months.

Conclusions

Combination therapy of IFNα2b and 5-FU was a safe and effective treatment, inducing a short duration of administration and low recurrence rate for OSSN.

Trial Registration

Retrospectively registered, UHCT22048.

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.

Recombinant Interferon Alpha-2b as Primary Treatment for Ocular Surface Squamous Neoplasia

Purpose

To investigate the effects of topical and perilesional interferon alpha-2b as primary treatment for ocular surface squamous neoplasia (OSSN).

Methods

In this prospective interventional case series, topical interferon alpha-2b (3 MIU/mL) was used as the initial treatment of OSSN, with perilesional interferon alpha-2b (3 MIU/mL) added based on clinical response. The primary outcome was complete tumor resolution. Spearman's rank correlation test was used to investigate the association of complete tumor resolution and time to resolution with baseline tumor characteristics and the American Joint Committee on Cancer (AJCC) classification for OSSN.

Results

Ninety-two patients (92 OSSN tumors) were included in the study. The total follow-up duration was 13.57 ± 2.14 months (median: 12, range: 3-23). The median basal tumor diameter was 4 mm (mean: 4.13 ± 1.37). Complete tumor resolution was achieved in 89 cases (96.73%), with a median time to complete tumor resolution of 5 months (mean: 4.64 ± 1.92). Complete tumor resolution was 57 of 57 in T1 (100%), 8 of 9 in T2 (88.88%), and 21 of 23 in T3 (91.30%). There were statistically significant correlations between AJCC classification and complete tumor resolution (Spearman's r = -0.22, P = 0.03) and maximal basal tumor diameter and the time to complete resolution (Spearman's r = 0.35, P = 0.001). There were no recurrences during the study follow-up period.

Conclusion

Topical interferon alpha-2b is effective and well tolerated as a primary treatment for OSSN, with a high rate of tumors responding completely to therapy.

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: 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.

Ocular Oncology-Primary and Metastatic Malignancies

Several neoplastic processes can involve the eye, either primarily or secondary to a systemic malignancy. The most common primary tumors of the eye include conjunctival and uveal melanoma, retinoblastoma, conjunctival and intraocular lymphoma, and ocular surface squamous neoplasia. Metastatic spread from systemic malignancies, especially of the breast and lung, also can involve the eye. A combination of ophthalmologic examination, ancillary testing, and cytologic/histopathologic evaluation leads to accurate diagnosis. Management consists of surgery, radiotherapy, chemotherapy, and immunotherapy delivered in various forms.

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.

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.

Comparison of the Effectiveness of Onion Extract, Topical Steroid, and Petrolatum Emollient in Cosmetic Appearance of Upper Blepharoplasty Scar

Purpose

To compare the effectiveness of onion extract, topical steroid, and petrolatum emollient in the prevention of scars in cases who underwent bilateral upper eyelid blepharoplasty.

Methods

A prospective, interventional, comparative, double-blinded case series was designed on cases who underwent upper lid blepharoplasty. After suture removal (1 week following the surgery), the eyelids of participants were randomly allocated into the three groups: The first group used onion extract on the right eyelids (n = 18), and the second group used topical steroid on the right eyelids (n = 19). In the third group, the control group, petrolatum emollient was used on the left eyelids (n = 37) of the first and second group's cases. They used drugs for 2 months and were evaluated by the Manchester Scar Scale (MSS) objectively by two graders who were blinded to the type of medication. MSS evaluates five different characteristics of the scar in addition to the Visual Analog Scale (VAS). These characteristics include color, distortion, contour, texture, and transparency. VAS scores the overall scar appearance which ranged among 0-10. The sum of the scores for the five different parameters, and VAS was calculated, analyzed, and compared among the groups.

Results

A total of 37 cases (74 eyelids) who underwent bilateral upper blepharoplasty were included. The mean ± standard deviation (SD) of age was 51.94 ± 9.26 years, 49.40 ± 9.37 years, and 47.00 ± 9.06 years in the onion extract, topical steroid, and petrolatum emollient groups, respectively (P = 0.275). There were no statistically significant differences in the mean ± SD of the sum of the MSS scores among the three groups (P = 0.924) or between the onion extract and topical steroid groups (P = 0.951). Furthermore, the color, distortion, contour, texture, transparency, and VAS scores were not statistically significantly different among the three groups or between the onion extract and topical steroid groups (P > 0.05).

Conclusion

There were no significant differences among these three groups of drugs regarding the appearance of the upper blepharoplasty scar.

Ocular surface complications of local anticancer drugs for treatment of ocular tumors

Local chemotherapy is increasingly used, either in combination with surgery or as monotherapy, for management of ocular tumors. Yet many of the local chemotherapeutic agents used for ocular tumors are cytotoxic drugs that are frequently associated with toxicities in normal ocular tissues. Understanding and managing these side effects are important because they affect treatment tolerability, outcome and quality of vision. Herein, we review local anticancer drugs administered for the treatment of ocular tumors, with an emphasis on their toxicities to the ocular surface, adnexa and lacrimal drainage system. We provide the underlying mechanisms and management strategies for the ocular side effects. Recent innovations in anticancer immunotherapy and ocular drug delivery systems also are discussed as new potential therapeutic modalities for alleviation of side effects.

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.

AS-OCT Guided Treatment Of Diffuse Conjunctival Squamous Cell Carcinoma With Resection, Amniotic Membrane Graft And Topical Mitomycin C

Purpose

To evaluate the efficacy of combined limited surgical resection, amniotic membrane graft and topical mitomycin C in treatment of diffuse conjunctival squamous cell carcinoma (CSCC) diagnosed and followed up by anterior segment optical coherence tomography (AS-OCT).

Subjects and methods

A prospective study was performed on 24 eyes with diffuse CSCC. Fifteen eyes underwent lesion limited resection followed by postoperative topical mitomycin C 0.04% eye drop (MMC group) while nine eyes underwent complete excision and cryotherapy (no MMC group). Amniotic membrane graft was applied in all cases. The diagnosis was based on clinical and AS-OCT specific criteria of CSCC and was confirmed by histopathological results.

Results

The study population was similar between the two groups. Mean postoperative follow-up was 27.1±4.1 months. The mean extent of the limbal involvement was 7.0±0.7 and 7.25±0.6 clock hours in MMC and no MMC groups, respectively. The mean size of conjunctival defect after tumor excision in MMC group (60.8±9.2 mm²) was significantly lower than in no MMC group (92.4±17.3 mm²). Histopathological diagnosis revealed invasive SCC in all specimens. The mean preoperative conjunctival epithelial thickness decreased significantly in both groups at 2-year follow-up. It decreased from 267±24.2 and 256±19.1 μm preoperatively to 56.7±11.6 and 60.4±9.6 μm at 2-year follow-up in MMC and no MMC groups, respectively. The mean number of MMC treatment cycles was 2.1±0.85 cycles. Recurrence was recorded in zero (0%) and 1 (11%) patients at 2-year follow-up in MMC and no MMC groups, respectively. Histopathological diagnosis revealed invasive SCC in all specimens. The mean preoperative conjunctival epithelial thickness decreased significantly in both groups at 2-year follow-up. It decreased from 267±24.2 and 256±19.1 μm preoperatively to 56.7±11.6 and 60.4±9.6 μm at 2-year follow-up in MMC and no MMC groups, respectively. The mean number of MMC treatment cycles was 2.1±0.85 cycles. Recurrence was recorded in zero (0%) and 1 (11%) patients at 2-year follow-up in MMC and no MMC groups, respectively.

Conclusion

The treatment of diffuse CSCC with AS-OCT guided combined therapy includes limited surgical resection, AMG, and postoperative topical MMC, achieves a complete tumor resolution and good functional and cosmetic outcomes minimizing the burden of surgery, and improves postoperative patient comfort in our study cohort.

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.

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.

Interferon Alfa 2b for Ocular Surface Squamous Neoplasia: Factors Influencing the Treatment Response

PURPOSE

To study the factors influencing the response to treatment with interferon alfa 2b (IFN) in ocular surface squamous neoplasia (OSSN)Methods: Retrospective study of 91 patientsResults: The mean age at presentation of patients with OSSN was 58 years (median, 60 years; range, 21 to 83 years). The mean number of clock hours of conjunctiva/cornea/limbus involvement by the tumor was 6 (median, 6; range, 1 to 12). The mean duration of topical IFN was 3 months (median, 3 months; range, 1 to 6 months) and the mean number of subconjunctival injections of IFN was 2 (median, 2; range, 0 to 6), till complete tumor regression or initiation of alternate treatment. Of 91 OSSN cases treated with IFN, 72 (79%) patients showed complete response to treatment, while 19 (21%) showed partial response displaying mean % tumor reduction of 34% (median, 20%; range, 5% to 90%). Patient demographics, immune status, disease chronicity, tumor location, or morphological pattern were not predictive of tumor response to IFN. The only factor predictive of incomplete response of OSSN to IFN was more than 6 clock hour involvement of ocular surface by OSSN (p = .04). Of 31 (34%) cases with OSSN >6 clock hours, 23 (74%) patients showed complete tumor regression with IFN alone, while 8 (26%) patients displayed incomplete response; and of 60 (66%) cases with OSSN ≤6 clock hours, 49 (82%) patients showed complete tumor regression with IFN alone, while 11 (18%) patients displayed incomplete response. Tumor recurrence was noted in 3% cases and one case had corneal perforation secondary to infective keratitis over a mean follow-up period of 14 months (median, 8 months; range, 3 to 58 months).

CONCLUSION

Clock hour involvement of ocular surface by OSSN determines the response to IFN. Interferon alfa 2b is an effective immunotherapy agent for tumors ≤6 clock hours of ocular surface in 82% cases and serves as an immunoreducing agent for larger tumors involving >6 clock hours of ocular surface in 26% cases.

Spontaneous regression of conjunctival keratoacanthoma

An 83-year-old white man presented with a rapidly growing conjunctival mass in his left eye over the course of 1 month. While awaiting surgical intervention, the tumour underwent partial, spontaneous regression to half its original size. The lesion was ultimately excised with wide margins using a no-touch technique and application of cryotherapy to the corneal and conjunctival margins and scleral bed. Histopathological analysis revealed a conjunctival keratoacanthoma. To our knowledge, this is the first case documenting the partial, spontaneous regression of a conjunctival keratoacanthoma over a 5 week time course from the time of diagnosis to surgical excision.

Detection of Malignancy in Ocular Surface Lesions by Inverse Spectroscopic Optical Coherence Tomography and Two-Photon Autofluorescence

Purpose

Advanced imaging is increasingly important in the diagnosis of ocular surface malignancy. Inverse spectroscopic optical coherence tomography (ISOCT) and two-photon autofluorescence microscopy (2P-AF) are emerging techniques capable of quantifying ultrastructural and metabolic changes, respectively. We aimed to detect malignancy in ocular surface lesions using ISOCT and 2P-AF.

Methods

Portions of excised specimens from patients undergoing conjunctival biopsy at Boston Medical Center were imaged by ISOCT and/or 2P-AF, and submitted for histologic diagnosis. Lesions were categorized as malignant, premalignant (with dysplasia) or benign. ISOCT and 2P-AF findings were compared between categories.

Results

Fourteen specimens from 13 patients were collected. The IS-OCT marker D was 2.2-fold higher in combined malignant and premalignant (4.27 ± 0.28, n = 3) versus benign (1.92 ± 0.26, n = 11) lesions (P = 9 × 10⁻⁴). ISOCT markers μ_s and μ_b were not significantly different. By 2P-AF, the redox ratio was 0.24-fold lower in premalignant (0.11 ± 0.004, n = 2) versus benign (0.45 ± 0.04, n = 9) lesions (P = 1.08 × 10⁻⁵).

Conclusions

Conjunctival lesions with higher malignant potential had higher D and lower redox ratios. Higher D can correlate with ultrastructural changes associated with malignancy, similar to what has been seen in cancers of the gut mucosa. Lower redox ratios can suggest the presence of the Warburg effect, which is associated with tumorigenesis.

Translational Relevance

IS-OCT and 2P-AF can potentially be applied to the detection of malignancy or malignant potential in ocular surface lesions. ISOCT allows for the detection of nanoscale ultrastructural changes that are not resolvable by conventional OCT.

Resolution of giant ocular surface squamous neoplasia with topical 5-fuorouracil 1

An 82-year-old man presented with a left eye elevated single ocular surface squamous neoplasia. The tumor involved 360° of limbus, three quadrants of cornea and conjunctiva; this was compatible with the diagnosis of giant ocular surface squamous neoplasia. Topical 5-fluorouracil 1% was planned four times daily for 1 week followed by 3 weeks off-treatment. Patient inadvertently continued 5-fluorouracil, four times daily for 4 weeks, presenting with clinical resolution of the ocular surface squamous neoplasia and subtotal corneal epithelial defect associated with 5-fluorouracil toxicity. One month later, we observed a transparent cornea and no signs of toxicity. Total tumor resolution was observed for at least 6 months of follow-up.

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.

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.

Topical chemotherapy for giant ocular surface squamous neoplasia of the conjunctiva and cornea: Is surgery necessary?

Purpose:

The purpose of this study is to report on the efficacy and safety of topical chemotherapy alone for giant ocular surface squamous neoplasia (OSSN).

Methods:

In this retrospective, interventional series, 10 eyes with giant OSSN underwent exfoliative biopsy to confirm the diagnosis followed by application of interferon alpha 2b (IFN α2b) and/or 5 fluorouracil, 1% (5FU). Reported outcome measures were tumor response, visual acuity, recurrence, systemic metastasis, and treatment complications.

Results:

Ten patients (3 female, 7 male) had a mean age of 73 (median, 69; range 40–89) years. Mean tumor diameter was 13.1 (median, 12.3; range 8.2–19.4) mm. Five (50%) eyes were treated with IFN-α2b alone; 1 (10%) with 5-FU alone and 4 (40%) required both IFN-α2b and 5-FU. The mean duration of treatment was 3, 0.5, and 6.4 months for IFN-α2b alone, 5-FU alone, and both IFN-α2b and 5-FU respectively. Complete tumor response was observed in all 10 cases at mean follow-up of 12.8 (median, 11.5; range, 3–25) months. Complications noted were transient irritation and burning (n = 4), dry eyes (n = 2), and transient flu-like symptoms (n = 2). There was no evidence of chemotherapy-related symblepharon, stem cell deficiency, scleral thinning, or corneal opacity. There were no tumor recurrences, and no patient required surgical excision or cryotherapy.

Conclusion:

Topical chemotherapy was a safe and effective treatment, inducing complete regression in all cases of giant OSSN in this series. There were no sight-limiting complications.

[Ocular involvement in atopic dermatitis : Clinical aspects and therapy]

Patients with atopic dermatitis frequently complain of ocular symptoms. The general dermatitis can directly affect the periocular skin and patients often present with chronic atopic blepharokeratoconjunctivitis. Early diagnosis of the characteristic ophthalmological alterations, such as blepharitis, allergic conjunctivitis, keratoconjunctivitis sicca, conjunctival scarring with formation of symblepharon and lid malpositioning, filiform keratitis, corneal plaques, (persistent) epithelial defects, corneal ulcers and keratoconus as well as appropriate stage-adapted treatment, including lid hygiene with preservative-free lubricants, topical and sometimes systemic anti-inflammatory therapy and surgical treatment are important for patients to prevent long-term damage of the ocular surface leading to severe visual impairment.

Amniotic membrane transplantation with topical interferon alfa-2b after excision of ocular surface squamous neoplasia

To evaluate the outcome of amniotic membrane transplantation (AMT) after tumor excision followed by topical interferon alfa-2b (IFNα2b) drops for primary ocular surface squamous neoplasia (OSSN). Twelve eyes of 12 patients with a mean age of 66±10y were included. The average follow-up was 23±10mo. All 12 patients had limbal involvement. Smooth ocular surface and transparent cornea were achieved in all cases. No sign of inflammation, neovascularization, symblepharon or recurrence was noted at the last follow-up. We conclude that AMT with topical IFNα2b drops restores a healthy ocular surface in OSSN without recurrence.

Trabeculectomy bleb needling and antimetabolite administration practices in the UK: a glaucoma specialist national survey

AIMS

To evaluate, describe and quantify the diversity in postoperative antimetabolite administration and bleb needling practices among glaucoma specialists performing trabeculectomy surgery within the UK and Ireland.

METHODS

A cross-sectional online survey was distributed to all consultant glaucoma specialists who are on the United Kingdom and Eire Glaucoma Society (UKEGS) contact list. Participants were asked specific questions about their current practices for post-trabeculectomy antimetabolite administration followed by questions directly related to bleb needling procedures.

RESULTS

60 (83%) of UKEGS glaucoma subspecialty consultants completed the survey. 70% of respondents administered 5-fluorouracil (5-FU) in their clinic room while 30% used a separate treatment room. Doses of 5-FU varied considerably but 70% used 5 mg as standard. Techniques used to reduce corneal toxicity included precipitation with amethocaine (44%) or benoxinate (14%), saline wash (14%) and modified injection technique (8%). Topical antibiotics and/or betadine were used to prevent infection following 5-FU injection in just over 50%. Bleb needling was exclusively performed in operating theatre by 56% of respondents and solely at the slit lamp in the clinic room by 12%. A further 30% used a combination of both theatre and outpatient clinic rooms. Anti-metabolites used were 5-FU (72%) and mitomycin C (22%) with 12% using either of the two substances.

CONCLUSIONS

There is a significantly wide variety of current practices for antimetabolite administration and bleb needling within the UK and Ireland. This may be influenced by a glaucoma surgeon's specific experience and audit results as well as particular clinical set-up, availability of antimetabolite and clinic room space.

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.

Topical Imiquimod in the Treatment of Conjunctival Actinic Keratosis

Conjunctival actinic keratosis is rare and difficult to treat, as recurrences are common. Imiquimod, an immune response modulator, is currently Food and Drug Administration-approved for cutaneous actinic keratosis and superficial basal cell carcinomas. Emerging reports have shown it to be effective in treating some periocular and conjunctival lesions. The authors present a case of a 68-year-old white man with recurrent actinic keratosis involving the pretarsal conjunctiva, which was successfully treated with 5% topical imiquimod following previous failure with cryotherapy and interferon α-2b. The patient had ocular irritation that resolved on cessation of treatment. To the authors' knowledge, this is the first report of conjunctival actinic keratosis being treated with and successfully eradicated by topical imiquimod.

Neoadjuvant chemotherapy for invasive squamous cell carcinoma of the conjunctiva: A case report

A 40-year-old male presented with an orbital extension of conjunctival squamous cell carcinoma (SCC). The orbital mass was seen protruding outward from the left palpebral fissure overhanging the lower eyelid, completely obscuring the globe and lower lid. The patient gave a history of excision biopsy, which was histopathologically diagnosed as ocular surface squamous neoplasia. He also gave a history of tumor recurrence, which gradually progressed to assume the form of the presently visible orbital mass. Computed tomography of the orbits showed the mass extending into the left orbit causing superior displacement of the globe. After a negative locoregional and systemic metastatic screening, neoadjuvant intravenous systemic chemotherapy with cisplatin and 5-fluorouracil were initiated in an attempt to reduce the size of the tumor. Three cycles of tri-weekly chemotherapy resulted in a significant reduction of the orbital tumor size with the globe and the lower lid being visible, thus making a lid-sparing orbital exenteration possible. The patient subsequently underwent an orbital exenteration and at 6-month follow-up, the patient was free from local and regional disease. To our knowledge, this is the first reported case where systemic neoadjuvant chemotherapy has been used to reduce the size of invasive SCC with orbital extension, thereby permitting a lid-sparing orbital exenteration.

Surgery Versus Interferon Alpha-2b Treatment Strategies for Ocular Surface Squamous Neoplasia: A Literature-Based Decision Analysis

PURPOSE

To compare treatment strategies for ocular surface squamous neoplasia (OSSN), ranging from surgical excision to empiric topical interferon alpha-2b (IFN-α2b).

METHODS

A decision model was constructed to determine which of 4 treatment strategies minimized expected persistence/recurrence of disease in patients with OSSN: excision followed by repeat excision for positive surgical margins, excision followed by IFN-α2b for positive margins, incisional biopsy followed by IFN-α2b for positive biopsies, and empiric treatment with IFN-α2b. Probabilities were estimated from literature published between 1983 and 2015. Expected values for the probability of recurrence could range from 0 (no persistence/recurrence) to 1 (persistence/recurrence). Sensitivity analyses were performed for each variable.

RESULTS

Excision followed by IFN-α2b for positive margins was estimated to minimize persistence/recurrence of OSSN (expected value 0.13 versus 0.17 for empiric IFN-α2b, 0.22 for excision-only, and 0.30 for incisional biopsy-directed IFN-α2b). The optimal strategy was sensitive to 3 variables: efficacy of IFN-α2b, recurrence after negative surgical margins, and accuracy of excisional biopsy.

CONCLUSIONS

In our decision analysis using studies published between 1983 and 2015, surgical excision followed by IFN-α2b for positive margins is the favored strategy for minimizing persistence/recurrence of OSSN. Future prospective studies would add to the certainty of these conclusions.

Electron beam radiotherapy for the management of recurrent extensive ocular surface squamous neoplasia with orbital extension

Recurrent extensive ocular surface squamous neoplasia (OSSN) with orbital invasion can be successfully managed with external radiotherapy using electrons resulting in eye and vision salvage. We report a case of right eye recurrent OSSN in an immunocompetent adult Indian male, with extensive orbital involvement. The patient had two previous surgical excisions with recurrent disease. At this stage, conventionally exenteration is considered the treatment modality. However, he was treated with 5040 cGy radiotherapy (15eV electrons) resulting in complete disease regression. At the end of 3 years follow-up, the patient was disease free, maintained a vision of 20/25, with mild dry eye, well-managed with topical lubricants. Extensive OSSN with orbital invasion does not always need exenteration. External beam electron radiotherapy provides a noninvasive cure with organ and vision salvage and should be considered in extensive OSSN not amenable to simple excision biopsies. Long-term studies to evaluate the effect of radiation on such eyes are suggested.

Topical 5-Fluorouracil 1% as Primary Treatment for Ocular Surface Squamous Neoplasia

PURPOSE

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

DESIGN

Retrospective study.

PARTICIPANTS

Topical 5-FU was used as primary therapy in 44 patients with OSSN.

METHODS

5-Fluorouracil 1% administered topically 4 times daily for 1 week followed by a drug holiday of 3 weeks. Patients were identified through a pharmacy database. Patients were excluded if 5-FU was used as adjuvant therapy, if they did not complete therapy, or if they were still actively receiving treatment for OSSN at the time of last follow-up.

MAIN OUTCOME MEASURES

The primary outcome measures were the frequency of complete resolution with topical 5-FU treatment and the rate of OSSN recurrence.

RESULTS

Of the 44 patients identified, 32 were men and 12 were women. The mean age was 68 years. Complete resolution of OSSN was noted in 82% of patients (36/44); 18% (8/44) were considered treatment nonresponders. Patients were treated with a median of 4 cycles (range, 2-9 cycles). Nasal location was the only risk factor identified for nonresponse to therapy (P = 0.04). The median follow-up after resolution was 10 months (range, 2-77 months). In the 36 patients who showed complete resolution, 4 experienced tumor recurrence. Recurrence rates at 1 and 2 years were 6% and 15%, respectively, using Kaplan-Meier survival analysis. At least 1 side effect from the medication was reported by 61% of patients (21/44), but only 1 patient discontinued the medication because of intolerance. The most common side effect was pain (n = 17; 39%), followed by tearing (n = 10; 23%), photophobia (n = 6; 14%), itching (n = 4; 9%), swelling (n = 2; 5%), and infection (n = 1; 2%). No long-term complications were reported.

CONCLUSIONS

5-Fluorouracil is effective and well tolerated as a primary treatment for OSSN, with 82% of tumors responding completely to therapy.

Surgical versus Medical Treatment of Ocular Surface Squamous Neoplasia: A Cost Comparison

PURPOSE

The objective of this study was to compare the cost associated with surgical versus interferon-alpha 2b (IFNα2b) treatment for ocular surface squamous neoplasia (OSSN).

DESIGN

A matched, case-control study.

PARTICIPANTS

A total of 98 patients with OSSN, 49 of whom were treated surgically and 49 of whom were treated medically.

METHODS

Patients with OSSN treated with IFNα2b were matched to patients treated with surgery on the basis of age and date of treatment initiation. Financial cost to the patient was calculated using 2 different methods (hospital billing and Medicare allowable charges) and compared between the 2 groups. These fees included physician fees (clinic, pathology, anesthesia, and surgery), facility fees (clinic, pathology, and operating room), and medication costs. Time invested by patients was calculated in terms of number of visits to the hospital and compared between the 2 groups. Parking costs, transportation, caregiver wages, and lost wages were not considered in our analysis.

MAIN OUTCOME MEASURES

Number of clinic visits and cost of therapy as represented by both hospital charges and Medicare allowable charges.

RESULTS

When considering cost in terms of time, the medical group had an average of 2 more visits over 1 year compared with the surgical group. Cost as represented by hospital charges was higher in the surgical group (mean, $17 598; standard deviation [SD], $7624) when compared with the IFNα2b group (mean, $4986; SD, $2040). However, cost between the 2 groups was comparable when calculated on the basis of Medicare allowable charges (surgical group: mean, $3528; SD, $1610; medical group: mean, $2831; SD, $1082; P = 1.00). The highest cost in the surgical group was the excisional biopsy (hospital billing $17 598; Medicare allowable $3528), and the highest cost in the medical group was interferon ($1172 for drops, average 8.0 bottles; $370 for injections, average 5.4 injections).

CONCLUSIONS

Our data in this group of patients previously demonstrated equal efficacy of surgical versus medical treatment. In this article, we consider costs of therapy and found that medical treatment involved two more office visits, whereas surgical treatment could be more or equally costly depending on insurance coverage.

Challenges in the Management of Inverted Papilloma: A Review of 72 Revision Cases

OBJECTIVES/HYPOTHESIS

We report on the treatment outcome of endoscopically managed sinonasal inverted papilloma, focusing on revision cases. Our aim was to identify the properties of revision cases that affect treatment outcome by comparing them to primary cases in a single center. We propose using 5-fluorouracil (5-FU) in the postoperative management of inverted papilloma.

STUDY DESIGN

A retrospective single-center case series. This study met the criteria for approval by the local medical ethics committee.

METHODS

We performed a retrospective chart review identifying patients operated on between January 2003 and September 2013. Data were collected about patient demographics, symptoms, tumor attachment site, imaging, intraoperative and pathological findings, surgical approaches, postoperative treatment, follow-up, and recurrence.

RESULTS

One hundred and twenty-one (72 revision and 49 primary) cases were retrieved with a minimum follow-up of 1 year. Revision cases have significantly higher Krouse staging (P = 0.003), different distribution of tumor attachment sites, and higher recurrence rates. The recurrence rate was 4.1% for primary cases (mean follow-up 35.5 months) and 18.1% for revision cases (mean follow-up 45 months). Eight of the recurrent cases recurred within the first year. 5-fluorouracil was applied postoperatively in 18 (5 primary and 13 revision) cases, which included one (5.6%) recurrence and one minor complication (transient periorbital swelling).

CONCLUSION

The most important factors in preventing the recurrence of inverted papilloma are the determination of the location of the attachment and the completeness of resection in the primary endoscopic surgery. Revision cases have a higher recurrence rate, and the attachment sites are surgically more challenging. The use of 5-FU might have a place in the postoperative treatment of surgically challenging inverted papilloma.

LEVEL OF EVIDENCE

4.