MULTIMODAL APPROACH (EXCISION/CRYOTHERAPY + BEVACIZUMAB + MMC) FOR OCULAR SURFACE SQUAMOUS NEOPLASIA IN A YOUNG IMMUNOCOMPETENT PATIENT

To present the clinical case of an Ocular Surface Squamous Neoplasia (OSSN) with corneal stromal invasion in an immunocompetent patient, highlighting the therapeutic management and the clinical and functional response to a multimodal therapy.

A 33-year-old male patient, healthy, presented with a rapidly growing limbal lesion. The initial diagnosis was a corneoconjunctival tumor lesion unresponsive to antibiotic and corticosteroid medication. Infectious or immunosuppressive pathologies were ruled out. The clinical extension and lack of response to therapy suggested progression or an underestimated diagnosis, leading to planning for a surgical approach with excision of the conjunctival lesion. The capacity to infiltrate the stroma is a factor directly related to its degree of malignancy.

A salmon-pink corneoconjunctival mass was observed at the superotemporal limbus of the left eye, measuring 4.6×5 mm, with corneal opacity, neovascularization, and invasion into the corneal stroma and visual axis. Anterior segment Ultrasound Biomicroscopy (UBM) and Optical Coherence Tomography (OCT) confirmed an epithelial lesion occupying the corneal stroma without invasion of Descemet's membrane, iris, or ciliary body. Infectious tests (HIV, TB, HPV) were negative. Limbal conjunctival excision with cryotherapy was performed and sent for pathological examination. The subsequent management consisted of Bevacizumab (3 doses) and topical Mitomycin C (MMC) 0.02%(2 cycles of 2 weeks). It is not typical for precancerous lesions like dysplasia to infiltrate the corneal stroma, but it is characteristic of the invasive form and a sign of poorer prognosis. Stromal invasion defines invasive squamous cell carcinoma, as the malignant cells disrupt the epithelial basement membrane at this point.

Histopathological study confirmed OSSN consistent with mild dysplasia. Following the combined treatment (anti-angiogenic and topical chemotherapy), lesion and neovascularization regression was achieved, with partial resolution of the opacity. Uncorrected visual acuity prior to treatment was 0.6 LogMAR and improved post-treatment to LogMAR 0.2. No recurrences were recorded during the initial follow-up.

They range of OSSN are from premalignant lesions (mild, moderate dysplasia, or carcinoma in situ) to Invasive Ocular Surface Squamous Cell Carcinoma, which is malignant. The etiology is multifactorial. Timely detection and therapy are crucial to prevent invasion and preserve vision. The combination of surgical excision/cryotherapy with a targeted rescue protocol including Bevacizumab as an anti-angiogenic agent and Mitomycin C as topical chemotherapy is a safe and highly effective approach to achieve regression of corneal invasion, resulting in an excellent anatomical and functional outcome.