Ocular Surface Squamous Neoplasia – Appropriate Approach Of Suspicious Lesions

Ocular surface squamous neoplasia (OSSN) describes a spectrum of slowly progressive epithelial lesions of the conjunctiva and cornea, mostly located at the limbus. The lesion may appear gelatinous, leukoplakic or papillomatous. Corneal involvement may present as a translucent epithelial sheet. Risk factors include ultraviolet light exposure, aging, smoking, immunosuppression, among others. Metastatic disease is rare. This case report aims to describe the clinical findings of two patients with suspicious conjunctival lesions, emphasizing the alarm signals and risk factors of OSSN, the appropriate clinical approach and different therapeutic options available.

The diagnosis and clinical approach of the reported cases took place at the Ophthalmology Department of Hospital Pedro Hispano, Unidade Local de Saúde de Matosinhos, Portugal.

Report of two cases of OSSN suspected lesions that were differently managed.

An 87-year-old female presented an irregular fibrovascular lesion at the temporal limbus of her right eye showing corneal extension. The lesion was surgically excised with 4-mm margins and adjunctive cryotherapy. The corneal portion of the tumor was managed with absolute alcohol-assisted epithelial curettage. The histologic exam confirmed high grade conjunctival intraepithelial neoplasia. Six months later the tumor reappeared, and it was managed with topical chemotherapy.

The second case describes a 68-year-old female that presented a vascularized, salmon-colored perilimbal lesion in her right eye, with peripheral corneal invasion. This patient was primary treated with topical chemotherapy, demonstrating tumor regression.

Atypical pterygium-like lesions that are elevated and extensive, fixed to underlying tissues, with large feeder-vessels, suggest possible malignancy. During the initial evaluation of OSSN suspected lesions, the clinician should obtain a detailed history, perform a complete eye examination and document the lesion appearance and extension. The classification of OSSN lesions as conjunctival or corneal intraepithelial neoplasia or squamous cell carcinoma is defined by histologic criteria. The standard treatment strategies include wide-margin surgical excision with cryotherapy and/or topical chemotherapy with interferon-α2b, mitomycin C or 5-fluorouracil. Long-term follow-up is essential because recurrences are not infrequent.