Ocular Surface Squamous Neoplasia: A Masquerade

Ocular surface squamous neoplasia (OSSN) represents a rare spectrum of disease ranging from mild dysplasia to carcinoma in situ to invasive squamous cell carcinoma of the ocular surface, seen more common in elderly males with an incidence of 0.13–1.9 per 100,000. Here we present two cases of OSSN, the presentations of which were unique, with both cases being managed successfully using different modalities.

Our first patient 32 years/male (vision BE 6/6) presented with complaints of a progressively growing painless mass in his left eye, with associated irritation, itching, watering since 4 months. Examination revealed a gelatinous 8x5mm solitary non-tender elevated conjunctival lesion with overlying pigmentation adjoining nasal limbus, with a feeder vessel and stippled red strawberry-like papilliform growth extending 1mm onto the limbus at 9 o’clock exhibiting punctate uptake of Rose Bengal stain.

Our second patient 50 years/female, presented with complaints of gradual painless diminution of vision since 2-3 years (RE 6/36; LE HMCF with mature cataract). Examination of right eye revealed a papilliform velvety 8x6mm solitary non-tender elevated conjunctival lesion adjoining nasal limbus which was stippled red and strawberry-like extending 2mm onto the nasal limbus from 2 to 5 o’clock, with multiple feeder vessels, exhibiting punctate uptake of Rose Bengal stain. Examination of left eye revealed actinic keratosis. Gonioscopy ruled out angle involvement of mass. Anterior segment OCT (classical hyper-reflectivity) and ultrasound biomicroscopy supported the diagnosis of OSSN.

The first patient was managed with a 7-day trial of topical steroids, followed by a topical regimen of interferon alpha 2b.

The second patient was successfully operated for RE OSSN excision with amniotic membrane grafting using fibrin glue, utilising the ‘no touch technique’.

OSSN in a young patient is unusual and is usually secondary to systemic associations such as Xeroderma pigmentosa (XP), human immunodeficiency syndrome (HIV), or immunosuppression secondary to organ transplantation.

Despite our patient not fitting the usual profile of OSSN, it was necessary to have a high index of clinical suspicion, followed by a comprehensive ophthalmic evaluation so as to facilitate early diagnosis and treatment to reduce ocular morbidity.