Ocular surface squamous cell neoplasia associated with unpredictable visual outcomes

Recurrences of ocular surface squamous cell neoplasia are more frequent in patients with severe conjunctival intraepithelial neoplasia, conjunctival squamous cell carcinoma in situ, and invasive squamous cell carcinoma. The visual outcomes are unpredictable. Systemic metastasis is possible, according to Raquel Benavides, MD, from the Department of Ophthalmology, Hospital Mexico, San Jose, Costa Rica.

"Squamous cell neoplasia can occur as a localized lesion confined to the surface conjunctival epithelium, conjunctival intraepithelial neoplasia or dysplasia, or as a more invasive squamous cell carcinoma that has broken through the basement membrane and invaded the underlying stroma. The lesions appear as fleshy sessile or minimally elevated lesion usually at the limbus in the intrapalpebral fissure and less commonly in the forniceal or palpebral conjunctiva," Dr. Benavides explained.

Conjunctival intraepithelial neoplasia has no theoretic potential to metastasize, but invasive carcinoma can gain access to the conjunctival lymphatics and regional lymph nodes. Most squamous cell neoplasias are related to human papillomavirus infection of the conjunctival epithelium.

The author conducted a retrospective, nonrandomized, single-center case series that included 19 patients (19 eyes) with different ocular surface squamous cell neoplasias. The mean patient age was 67 years. There was a male predominance of this condition in 16 patients (84%). Eleven eyes had undergone previous tumor resections.

The nasal and temporal quadrants were involved more frequently in 53% and 47%, respectively. The bulbar conjunctiva and limbus were involved in almost all cases (95% each). The initial treatment was surgery in nine eyes (47%), seven eyes (37%) were treated with mitomycin C for three or four cycles, and three eyes (16%) had chemoreduction with mitomycin C and underwent surgery. Nine eyes (47%) had corneal alcohol epitheliectomy during surgery.

The mean follow-up was 16 months. Four tumors (21%) recurred. One death that was unrelated to tumor treatment occurred during follow-up. No cases of mild or moderate conjunctival intraepithelial neoplasia recurred. The final visual acuity was 20/20 to 20/50 in 10 eyes, 20/60 to 20/100 in three eyes, and 20/200 to light perception in five eyes. One eye underwent enucleation because of recurrences. Eight eyes (42%) had decreased visual acuity levels compared with the visual acuity; the vision remained stable in six eyes (32%) and improved in five eyes (26%), Dr. Benavides reported.Systemic metastasis (cervical lymph node metastasis and the other lung metastasis) developed in two patients (11%) at a mean of 11 months after the initial evaluation.

"Ocular surface squamous cell neoplasias occur more often in men," Dr. Benavides concluded. "The bulbar conjunctiva of the nasal and temporal quadrants is frequently involved. Recurrences usually involve the cornea despite the initial treatment and are more frequent in patients with severe conjunctival intraepithelial neoplasia, conjunctival squamous cell carcinoma in situ, and invasive squamous cell carcinoma. The final visual outcome is unpredictable. Systemic metastasis is possible in patients with ocular surface squamous cell neoplasia."