Recurrent Dysplastic Conjunctival Lesion In An Immunosuppressed Patient: The Importance Of Surgical Management And Follow-Up.

To present the clinical evolution, surgical and medical management of an immunosuppressed patient with a dysplastic conjunctival lesion and to show its clinical features and evolution revealed by anterior segment optical coherence tomography (AS-OCT) and anterior segment images.

Hospital Universitario Infanta Cristina. Department of Ophthalmology. Madrid, Spain

A 62-year-old female reported growth of a conjunctival lesion in her left eye (OS) in the last month. She had a previous history of immunosuppression secondary to kidney transplant, high blood pressure and diabetes. She presented a vascular limbal raised conjunctival lesion with 1 millimeter (mm) of corneal invasion suspected of malignancy. The lesion was recorded by AS-OCT and retinographies. Surgical removal was decided with excisional biopsy following “no touch” technique, cryotherapy applied to all margins in a “double freeze slow thaw” technique, de-epithelialization with ethanol 20% and adjuvant amniotic membrane graft. Anatomic pathology results showed mild focal dysplasia.

Seven months after surgery, during follow-up, a smaller granuloma with corneal invasion was found in the same location as the primary lesion. A new surgical excision was decided with adjuvant Mitomycin C 0.02%. Anatomic pathology results came inconclusive this time due to insufficient tissue. The patient is still in follow-up with good results one month after the second surgery.

The ocular surface squamous neoplasia group, which includes dysplasia, conjunctival intraepithelial neoplasia (CIN) and invasive squamous cell carcinoma, is the most common ocular malignancy. It is more common in elderly and immunosuppressed patients with important sunlight exposure. Surgical excision of this neoplasms has been associated with high rates of recurrence so avoiding potential seeding during surgery and using adjuvant techniques such as cryotherapy, ethanol or topical chemotherapy is key to minimize this risk. However, it is important to take this risk into account, explain it to the patient and follow up to treat recurrences as soon as possible.