Long-Term Results of Topical Mitomycin C 0.02% for Primary and Recurrent Conjunctival-Corneal Intraepithelial Neoplasia

Iatrogenic Ocular Surface Complications After Surgery for Ocular and Adnexal Tumors

Background/Objectives: The management of ocular tumors often necessitates surgery, either alone or in combination with radiotherapy, chemotherapy, or other modalities. While crucial for tumor control, these treatments can significantly impact the ocular surface, leading to both acute and chronic complications. This review examines iatrogenic ocular surface diseases resulting from oncologic interventions, emphasizing their pathophysiology, diagnostic challenges, and management strategies. Methods: A literature review was conducted to identify studies on iatrogenic ocular surface complications associated with ocular tumor treatments. Results: Ocular surface complications include direct damage from surgical manipulation, leading to corneal opacities and persistent epithelial defects, as well as dry eye disease secondary to postoperative chemosis. These disruptions may progress to more severe conditions such as keratopathy, corneal ulcers, limbal stem cell deficiency, and stromal scarring, further impairing visual function. Structural alterations contribute to eyelid malpositions-including ectropion, entropion, round eye, and lagophthalmos-which exacerbate exposure-related damage and ocular surface instability. In cases of uveal melanomas, the exposure of episcleral brachytherapy plaques can induce chronic conjunctival irritation, promoting adhesion formation and symblepharon. Surgical interventions disrupt ocular surface homeostasis, while radiotherapy and chemotherapy exacerbate these effects through cytotoxic and inflammatory mechanisms. Conclusions: Preventing and managing iatrogenic ocular surface complications require a multidisciplinary approach involving early diagnosis, personalized treatment strategies, and targeted postoperative care. Comprehensive pre- and postoperative planning is essential to optimize both visual function and long-term ocular surface integrity, ultimately ensuring a balance between oncologic control with functional and aesthetic preservation.

Interferon alpha-2b versus 5-fluorouracil as primary treatment modalities for ocular surface squamous neoplasia: a study of 116 eyes

PURPOSE

To compare the efficacy and side-effect profile of interferon alpha-2b (IFNα2B) and topical 5-fluorouracil (5-FU) as primary treatment modalities for ocular surface squamous neoplasia (OSSN).

METHODS

Retrospective comparative study of 116 OSSN eyes treated with topical 1 MIU IFNα2B with/without 5 MIU/cc subconjunctival injection (group 1) or topical 1% 5-FU (group 2) in mutually exclusive time periods of treatment.

RESULTS

Of the 116 eyes with OSSN, 64 eyes belonged to group 1 and 52 eyes to group 2. The mean tumor basal conjunctival diameter for groups 1 and 2 was 10 mm (median, 10 mm; range 0-28 mm) and 5 mm (median, 4 mm; range, 0-24 mm) respectively (p < 0.0001). Complete tumor regression with medical management alone was achieved in 51 (80%) eyes in group 1 and 43 (83%) eyes in group 2 (p = 0.6814). The mean number of sessions/cycles of treatment for complete tumor regression was 3 (median, 3; range, 1-6) for group 1 versus 2 (median, 2; range, 1-6) for group 2 (p < 0.0001). Tumor recurrence was noted in 3 (5%) eyes in group 1 over a mean follow-up period (months) of 11 (median, 7; range, 3-41) versus 1 (2%) in group 2 (p = 0.25) over a mean follow-up period (months) of 6 (median, 5; range, 1-25). Side-effects included transient conjunctival hyperemia (9%), and flu-like symptoms (3%) in group 1 versus transient conjunctival hyperemia (2%), punctal stenosis (2%), and partial limbal stem cell deficiency (2%) in group 2.

CONCLUSION

Primary treatment of OSSN with IFNα2b or 5-FU offers comparable and good tumor control with minimal side-effects.

Update in the Diagnosis and Management of Ocular Surface Squamous Neoplasia (OSSN)

Ocular surface squamous neoplasia (OSSN) includes a variety of ocular surface tumors ranging from mild epithelial dysplasia to invasive squamous cell carcinoma. OSSN is one of the most frequent non-pigmented malignancies of the ocular surface. Debate persists between surgical excision and medical management concerning the optimal regimen for OSSN treatment, with surgical excision continuing to be the recognized standard of care in contemporary medicine. Medical and conservative therapy techniques have advanced significantly in recent years, leading to widespread use in everyday ophthalmology practice. This study aims to look into the efficacy of current treatment options for conjunctival squamous cell carcinoma and to evaluate the available evidence for the most up-to-date approach for the management of the disease.

Successful management of large conjunctival squamous cell carcinoma with excisional biopsy, topical interferon, and amniotic membrane grafting: A case report

INTRODUCTION AND IMPORTANCE

Conjunctival squamous cell carcinoma (SCC) is the most advanced form of ocular surface squamous neoplasia (OSSN), with varying incidence rates influenced by factors such as age, UV exposure, and occupation. Early detection is crucial, but misdiagnosis is common, especially when SCC mimics benign conditions like pterygium.

CASE PRESENTATION

An 83-year-old Caucasian male farmer presented with a rapidly enlarging nasal limbal lesion, initially misdiagnosed as pterygium. Clinical evaluation suggested malignancy, and an excisional biopsy using the "No Touch" technique was performed to avoid tumor seeding. Histopathology confirmed conjunctival SCC, with 10 % of the lesion remaining post-excision due to its large size. Adjuvant treatment with topical Interferon alpha-2a (1 MIU/cc) targeted the residual tumor. Amniotic membrane grafting was employed to manage the wound, and topical Mitomycin C was used to reduce the risk of recurrence. Follow-ups at 1 month, 3 months, 6 months, and 1 year showed no signs of recurrence.

DISCUSSION

This case underscores the importance of distinguishing conjunctival SCC from benign lesions. The combined approach of surgical excision, topical immunotherapy, and chemoprophylaxis was effective in treating this advanced SCC case, preventing tumor recurrence.

CONCLUSION

A multidisciplinary treatment strategy can effectively manage advanced conjunctival SCC, as seen in this case, where no recurrence occurred after one year of follow-up. Early detection and comprehensive care are essential for positive outcomes.

Oncological principles in the management of ocular surface squamous neoplasia - A Review

Ocular surface squamous neoplasia (OSSN) is the most common neoplasia of the anterior segment. Accurate and timely diagnosis, including detailed clinical assessment and imaging, is essential to ascertain the extent of the disease. The gold standard treatment for OSSN has evolved over the years, transitioning from wide-margin surgical excision using the "no-touch" technique to topical immunotherapy, plaque brachytherapy, and targeted immunotherapy. The choice of treatment modality depends on a tailored approach based on the initial presentation and progression of the disease. This review consolidates a comprehensive understanding of the variable clinical presentations of OSSN, diagnostic and imaging techniques, and available treatment options. It also provides a foundation for the oncologic principles of managing OSSN while offering insights into future therapeutic approaches.

Efficacy and safety of topical 0.5% 5-Fluorouracil as primary treatment of ocular surface squamous neoplasia

OBJECTIVE

To assess the efficacy and safety of topical 0.5% 5-Fluorouracil (5-FU) as a primary therapy of ocular surface squamous neoplasia (OSSN).

DESIGN

Retrospective study.

PARTICIPANTS

Patients with clinically suspected OSSN referred to a Brazilian tertiary health center between October 2015 and December 2022.

METHODS

After diagnostic confirmation of OSSN with exfoliative cytology, 0.5% 5-FU was administered topically 4 times daily for 2 weeks followed by a pause of 2 weeks.

RESULTS

A total of 54 patients were included in this study, 32 males (59.3%), mean age of 62.9 years old. Complete resolution of OSSN was achieved in 70.4%. The median number of cycles was 2 (range 1-5). Side effects were reported in 35.2%, which included eyelid erythema, conjunctival hyperemia, and punctal stenosis. None of the patients stopped treatment due to adverse effects. Patients who had partial response to 0.5% 5-FU had complementary treatment with surgery, Mitomycin-C and/or Interferon ⍺2b. Overall recurrence was 14.8%. Median follow-up was 14 months (range 2-92 months). In a multivariate Cox regression analysis, the risk of relapse was 84% lower in patients who had complete response to 0.5% 5-FU (p = 0.018).

CONCLUSION

Topical 0.5% 5-FU may be considered a safe and effective primary therapy for OSSN, with a low rate of side effects.

Ocular Surface Squamous Neoplasia: Changes in the Standard of Care 2003 to 2022

PURPOSE

The aim of this review was to elucidate treatment preferences for ocular surface squamous neoplasia and to examine the changes in treatment modalities over the past 2 decades.

METHODS

An electronic survey was distributed to members of The Cornea Society, Ocular Microbiology and Immunology Group, and 4 international corneal specialist listservs. Questions examined medical and surgical treatment preferences, and results were compared with surveys administered in 2003 and 2012.

RESULTS

A total of 285 individuals responded to the survey; 90% of respondents were self-classified as corneal specialists. Seventy-three percent reported using primary topical monotherapy to treat ocular surface squamous neoplasia as compared with 58% in 2012 ( P = 0.008). Compared with 2003, the percentage use of topical interferon significantly increased ( P < 0.0001) from 14% to 55%, 5-fluorouracil increased ( P < 0.0001) from 5% to 23%, and mitomycin C decreased ( P < 0.0001) from 76% to 19% as a primary monotherapy. The frequency of performing excision without the use of postoperative adjunctive medical therapy decreased significantly ( P < 0.0001), from 66% to 26% for lesions <2 mm, 64% to 12% for lesions between 2 and 8 mm, and 47% to 5% for lesions >8 mm from 2003 to 2022. More clinicians initiated topical immuno/chemotherapy without performing a biopsy as compared to 2003 (31% vs. 11%, P < 0.0001).

CONCLUSIONS

These results demonstrate a paradigm shift in the management of ocular surface squamous neoplasia. The use of primary medical therapy as a first approach has significantly increased, with a reduction in the frequency of performing surgical excision alone.

Personalized treatment concepts in extraocular cancer

Background

The periocular skin is neoplasms-prone to various benign and malignant. Periocular malignancies are more aggressive and challenging to cure and repair than those in other skin areas. In recent decades, immunotherapy has significantly advanced oncology, allowing the autoimmune system to target and destroy malignant cells. Skin malignancies, especially periocular tumors, are particularly sensitive to immunotherapy. This technique has dramatically impacted the successful treatment of challenging tumors.

Main text

Extraocular cancers, including eyelid (basal cell carcinoma, squamous cell carcinoma, melanoma, merkel cell carcinoma), conjunctival tumors (conjunctival melanoma, ocular surface squamous neoplasia) and other rare tumors, are unique and challenging clinical situations. Several genetic alterations associated with the pathogenesis of these diseases have been identified, and molecular mechanism are essential for the development of the immunotherapy agents, such as Hedgehog pathway inhibitors (vismodegib and sonidegib) for basal cell carcinoma, BRAF/MEK inhibitors (vemurafenib, dabrafenib, and encorafenib) for melanoma, and immune checkpoint inhibitors (Avelumab, pembrolizumab) for Merkel cell carcinoma.

Conclusions

The optimal treatment for periocular skin cancer depends on the type and size of the tumor and whether it involves orbital and adnexal structures. Adjuvant and neoadjuvant therapy with chemotherapy-targeted therapies and immune checkpoint inhibitors should be considered based on tumor type, tumor molecular profile, expected response rate, and candidacy for systemic treatment.

Topical 5-fluorouracil 1% for moderate to extensive ocular surface squamous neoplasia in 73 consecutive patients: Primary versus secondary treatment

IMPORTANCE

Ocular surface squamous neoplasia (OSSN) is a spectrum of malignancies that generally includes conjunctival intraepithelial neoplasia (CIN) and squamous cell carcinoma (SCC). OSSN can be treated with topical therapies including interferon α-2b (IFN), mitomycin C (MMC), or 5-fluorouracil 1% (5FU). Recently, due to unavailability of IFN and toxicity associated with MMC, therapy has shifted towards 5FU.

OBJECTIVE

Herein, we compare the use of 5FU 1% as a primary versus (vs) secondary treatment regimen in eyes with moderate to extensive OSSN.

DESIGN SETTING AND PARTICIPANTS

Retrospective cohort study of 73 consecutive patients with unilateral moderate to extensive OSSN treated at a single tertiary ocular oncology center from 2016 to 2023. Mean follow up time was 478.2 days overall, with 283.0 days for primary 5FU group and 860.3 days for secondary 5FU group.

INTERVENTION

Topical 5FU 1% 4 times daily for 2 weeks with option for 2-weekly extension until tumor control, either as primary treatment or as secondary treatment to surgical resection, topical IFN or topical MMC, or cryotherapy.

MAIN OUTCOMES

Outcome measures included tumor response, need for additional surgery, complications, and visual outcomes.

RESULTS

A comparison (primary vs secondary treatment) revealed no difference in mean tumor basal dimension (19.6 vs 17.2 mm, P = 0.46), thickness (3.7 vs 3.4 mm, P = 0.64), or tumor extent (4.4 vs 4.5 clock hours, P = 0.92). The primary treatment group showed greater complete tumor control (77% vs 38%, P = 0.04). Multivariable analysis comparison (primary vs secondary treatment) showed primary treatment more likely to achieve complete tumor control (P = 0.01). There was no difference in the complication rate from 5FU treatment between the groups. There was no difference in visual outcome, and no tumor-related metastasis (0%) or death (0%).

CONCLUSION AND RELEVANCE

Topical 5FU 1% is efficacious and safe as a primary or secondary treatment for moderate to extensive OSSN. Tumors treated with primary 5FU 1% demonstrated more complete resolution. In patients with moderate to extensive OSSN, primary treatment with topical 5FU 1% may be warranted.

Periocular and ocular surface nonmelanoma skin cancer

Periocular and ocular surface nonmelanoma malignancies, including basal cell carcinoma (BCC), squamous cell carcinomas (SCC), and ocular surface squamous neoplasia (OSSN), are rare, but their management requires special considerations. The most common periocular malignancy is BCC, which constitutes 80% to 96% of tumors, followed by SCC, which represents 5% to 10% of tumors. OSSN represents a spectrum of diseases that encompass dysplastic alteration to the squamous epithelium of the eye. OSSN ranges from squamous dysplasia to conjunctival intraepithelial neoplasia/carcinoma in situ to invasive SCC, which is the most common ocular malignancy. These tumors can be staged using the eighth edition of the American Joint Committee on Cancer categorization system. The standard of care for periocular malignancies is Mohs micrographic surgery, while medical management with 5-fluorouracil (5-FU), interferon alfa-2b (INF), and mitomycin C (MMC) or "no touch" surgical excision are options for OSSN. Systemic therapies, including sonic hedgehog inhibitors for BCC and epidermal growth factor inhibitors and immune-checkpoint inhibitors for SCC, can be utilized for advanced disease. Recurrence rates are higher for periorbital and ocular malignancies than their respective cutaneous counterparts. These carcinomas and their respective treatments have unique side effects and considerations in an effort to preserve visual function.

A Case of Conjunctival Melanoma Presenting as a Squamous Cell Carcinoma

Introduction

Conjunctival melanoma (CM) is a rare but potentially lethal ocular malignancy that arises from melanocytes in the conjunctiva. Its clinical presentation can mimic other more common conjunctival lesions, such as squamous cell carcinoma (SCC), leading to diagnostic challenges.

Case Presentation

We present a case of CM initially misdiagnosed as conjunctival SCC due to overlapping clinical features.

Conclusion

CM presenting as nonpigmented, conjunctival tumor is a diagnostic challenge. Clinicians should maintain a high index of suspicion for conjunctival melanocytic or amelanotic lesions, particularly those with atypical features.

Safety and efficacy of topical interferon alpha 2B and mitomycin C for localized conjunctival intraepithelial neoplasia: long-term report of their pharmacological safety and efficacy

PURPOSE

Ocular surface squamous neoplasia (OSSN) comprises a wide spectrum of squamous tumors, from which corneal/conjunctival intraepithelial neoplasia (CIN) is the most common one. The classic treatment is complete excision, but recurrence rates are high. Antineoplastic drugs such as mitomycin C (MMC) and interferon alpha 2b (IFNα2b) have been used as adjuvants or as primary treatment. To evaluate the efficacy and safety of topical IFNα2b and MMC in patients with CIN, a phase IIb double-blind clinical trial was performed.

METHODS

Patients diagnosed with localized CIN were evaluated by slit lamp and impression cytology and were randomly given MMC 0.04% or INF2b (1 million IU/mL) 4 times daily until neoplasia resolution. Time of resolution and frequency of adverse effects were analyzed to determine the pharmacological efficacy and safety of both medications.

RESULTS

Seventeen patients were included. Nine patients were treated with MMC and 8 with IFNα2b. All patients responded to treatment. The resolution time in days was 59.11 ± 24.02 in patients treated with MMC and 143.50 ± 47.181 in those treated with IFNα2b (p < 0.001). In the MMC group, one recurrence was reported (11%). There were no recurrences at 2 years of follow-up in the IFNα2b group. Regarding adverse effects, one or more mild adverse reaction occurred in 77% of patients managed with MMC and in 50% of patients managed with IFNα2b (p > 0.05). No serious adverse effects were reported.

CONCLUSIONS

Topical chemotherapy with MMC and IFNα2b demonstrate pharmacological safety and efficacy. Therefore, these drugs could be considered as primary therapies for localized CIN .

Medical treatment for ocular surface squamous neoplasia

Ocular surface squamous neoplasia (OSSN) is the most common non-melanocytic tumour of the ocular surface. Surgical excision with wide margins using the "no-touch" method was originally the most popular treatment for OSSN. However, in the past two decades, the use of topical medications for OSSN treatment has gained a reputation amongst ophthalmologists for being an effective alternative to surgical excision. Furthermore, technological advancements, such as those seen in high-resolution optical coherence tomography (HR-OCT) for the anterior segment, have facilitated the diagnosis and monitoring of OSSN. When selecting a topical agent, interferon alpha-2b (IFNα-2b) and 5-fluorouracil (5-FU) are two of the gentlest medications used for OSSN and are often considered first line therapies due to their high-resolution rates and mild side effect profiles. Mitomycin C (MMC), on the other hand, has a highly toxic profile; therefore, while effective, in our hands it is considered as a second-line treatment for OSSN if the other modalities fail. In addition, newer and less studied agents, such as immune checkpoint inhibitors, retinoic acid, aloe vera, and anti-vascular endothelial growth factor have anti-neoplastic properties and have shown potential for the treatment of OSSN. We enclose an updated literature review of medical treatments for OSSN.

Clinicopathological profile, management and clinical outcomes in recurrent cases of ocular surface squamous neoplasia at a tertiary care centre

PURPOSE

This study was taken up to look into the various causes of recurrence, clinicopathological profile and final outcomes in recurrent cases of ocular surface squamous neoplasia (OSSN).

METHODOLOGY

A prospective cohort study was conducted and total 18 patients were recruited. All patients were subjected to detailed history, comprehensive eye examination and imaging studies. A treatment plan was formulated based on the size and extent of the lesion. The primary outcome measure was complete response to treatment with no evidence of recurrence after12 months and secondary outcome measure was complication associated with each treatment modality.

RESULTS

The common cause of recurrence in our study was misdiagnosis of the lesion as in 15 cases it was diagnosed as pterygium and in 03 cases it was actinic keratosis. Excision Biopsy with adjunctive cryotherapy was the preferred treatment modality followed by topical interferon-alpha 2b drop-in our study. We could achieve good outcomes in terms of complete response to the treatment in 16 cases. The complication associated with this treatment was minimal in our study as few patients complained redness and irritation which subsided after application of topical lubricants. There was no sign of recurrence even at 12 months of follow-up in all 18 cases.

CONCLUSION

The current study provided clinicopathological characteristics and treatment outcomes in recurrent cases of OSSN. In our study, adopting appropriate treatment strategy, regular follow-up to assess the response to treatment and change over to new treatment plan in cases with inadequate response helped in achieving good outcomes in recurrent cases of OSSN.

Topical 1% 5-fluorouracil eye drops as primary treatment for ocular surface squamous neoplasia: Long-term follow-up study

PURPOSE

To determine the efficacy and safety of topical 1% 5-fluorouracil (5FU) eye drops as primary treatment of ocular surface squamous neoplasia (OSSN).

METHODS

Patients were diagnosed with OSSN based on slit-lamp examination and anterior segment optical coherence tomography (AS-OCT). In ambiguous cases an incisional biopsy was performed. All were treated with 5FU eye drops as primary therapy and retrospectively reviewed. Data on demographics, tumor characteristics, treatment outcome, and side effects were collected. The primary outcome measures were resolution frequency and recurrence rate of OSSN. Secondary outcomes were risk factors for resolution and recurrence, and side effects of treatment.

RESULTS

The mean age of 251 subjects (258 eyes) was 67.5 ± 11.7 years, 182 were male. Patients were followed up on average for 752 ± 580 days. Overall, 87% of patients experienced complete tumor resolution. Multivariable analysis revealed that superior tumor location (HR: 0.62, 95% CI: 0.41-0.93, p = 0.02) and leukoplakia (HR: 0.65, 95% CI: 0.41-0.93, p = 0.02), decreased the likelihood of tumor resolution. The recurrence rate was 4% at six months, 8% at one year, and 19% at two years. Larger tumor area increased chances of tumor recurrence (HR: 1.01, 95% CI: 1.00-1.02 p = 0.03). The most common side effects of 5-FU were mild hyperemia and pain, which occurred in 26% and 23% of patients, respectively. Among the sight-threatening side effects, limbal stem cell deficiency occurred in only 3% of patients.

CONCLUSIONS

Topical 1% 5FU eye drops are a safe and effective medication for OSSN. Superior tumor location and leukoplakia decreased the chance of tumor resolution.

The Management of Ocular Surface Squamous Neoplasia (OSSN)

The rise of primary topical monotherapy with chemotherapeutic drugs and immunomodulatory agents represents an increasing recognition of the medical management of ocular surface squamous neoplasia (OSSN), which may replace surgery as the standard of care in the future. Currently, there is no consensus regarding the best way to manage OSSN with no existing guidelines to date. This paper seeks to evaluate evidence surrounding available treatment modalities and proposes an approach to management. The approach will guide ophthalmologists in selecting the most appropriate treatment regime based on patient and disease factors to minimize treatment related morbidity and improve OSSN control. Further work can be done to validate this algorithm and to develop formal guidelines to direct the management of OSSN.

A Case of Combination Therapy of IFN-β1b and Mitomycin-C on Recurred Ocular Surface Squamous Neoplasia

Purpose: To report a case of combination therapy with interferon β1b (IFN-β1b) and mitomycin-C (MMC) for recurrent ocular surface squamous neoplasia (OSSN).Case summary: A 72-year-old female presented with a white mass at the medial conjunctiva of the right eye. A gelatinous, nodular white lesion was observed near the medial limbus of the right eye. On histological examination, it was diagnosed as squamous cell carcinoma in situ. A white nodule was found at the resection site 1 year after the resection. IFN-β1b (1 mIU/mL) and 0.02% MMC were administered daily with a diagnosis of recurrent OSSN. IFN-β1b was instilled four times a day for 1 month, while MMC was instilled four times a day for 4 weeks. After 1 month of the combination treatment, the lesion disappeared. MMC was stopped, while IFN-β1b was reduced to twice daily instillation, maintained for 1 month, and then stopped. On examination 12 months after discontinuation of the combination treatment, there were no recurrences or drug-related complications.Conclusions: Combination therapy with IFN-β1b and MMC for recurrent OSSN after surgical resection was relatively safe with no major complications.

Recombinant Interferon Alpha-2b as Primary Treatment for Ocular Surface Squamous Neoplasia

Purpose

To investigate the effects of topical and perilesional interferon alpha-2b as primary treatment for ocular surface squamous neoplasia (OSSN).

Methods

In this prospective interventional case series, topical interferon alpha-2b (3 MIU/mL) was used as the initial treatment of OSSN, with perilesional interferon alpha-2b (3 MIU/mL) added based on clinical response. The primary outcome was complete tumor resolution. Spearman's rank correlation test was used to investigate the association of complete tumor resolution and time to resolution with baseline tumor characteristics and the American Joint Committee on Cancer (AJCC) classification for OSSN.

Results

Ninety-two patients (92 OSSN tumors) were included in the study. The total follow-up duration was 13.57 ± 2.14 months (median: 12, range: 3-23). The median basal tumor diameter was 4 mm (mean: 4.13 ± 1.37). Complete tumor resolution was achieved in 89 cases (96.73%), with a median time to complete tumor resolution of 5 months (mean: 4.64 ± 1.92). Complete tumor resolution was 57 of 57 in T1 (100%), 8 of 9 in T2 (88.88%), and 21 of 23 in T3 (91.30%). There were statistically significant correlations between AJCC classification and complete tumor resolution (Spearman's r = -0.22, P = 0.03) and maximal basal tumor diameter and the time to complete resolution (Spearman's r = 0.35, P = 0.001). There were no recurrences during the study follow-up period.

Conclusion

Topical interferon alpha-2b is effective and well tolerated as a primary treatment for OSSN, with a high rate of tumors responding completely to therapy.

Management of ocular surface squamous neoplasia: Bowman Club Lecture 2021

The gold-standard treatment for ocular surface squamous neoplasia (OSSN) has traditionally been surgical excision with wide margins and a no-touch technique. However, surgery may be associated with several unfavourable sequelae, as well as significant recurrence rates if margins are positive. In recent years, topical chemotherapy with 5-fluorouracil, interferon α-2b and mitomycin C have emerged as valuable agents capable of effectively treating OSSN with varying adverse effects. These medical treatment options usually present additional costs to the patient but can allow patients to avoid surgery with fewer long-term effects. Anterior segment high-resolution optical coherence tomography is an excellent tool for diagnosing and monitoring OSSN and can be a useful aid for both surgical and medical treatments of OSSN.

Ocular surface squamous neoplasia: management and outcomes

Ocular surface squamous neoplasia (OSSN) is the most common ocular tumour with an incidence ranging from 0.03 to 1.9 per 100,000 persons/year. The diagnosis is made on clinical suspicion and confirmed with anterior-segment optical coherence tomography (AS-OCT), cytology, or histology. The purpose of this review is to provide an overview of the management options available for OSSN and review their success and recurrence rates. Surgery is the gold standard for the management of small OSSN lesions. With the increased use of less invasive diagnostic modalities such as AS-OCT and cytology, there has been a move to use topical therapies for the management of OSSN. The most commonly used agents are interferon-α2b (IFN), mitomycin-C (MMC) and 5-fluorouracil (5FU). They have been shown to have similar resolution and recurrence rates but differ in cost and side effect profile. IFN has the lowest side effect profile, but is also the most expensive, whereas MMC has the greatest surface toxicity and is priced midway between the three. 5FU is the cheapest of the three topical agents with less surface toxicity than MMC. Radiotherapy is mostly employed as adjuvant therapy. Newer novel therapies are available but have not been widely adopted as mainstream therapy due to cost and lack of clinical evidence. OSSN has the benefit of many management options. No single modality has been shown to superior and some patients will need the use of combination therapy to achieve an optimal clinical outcome.

Iatrogenic Ocular Surface Diseases Occurring during and/or after Different Treatments for Ocular Tumours

Simple Summary

The ocular surface represents a finely regulated system that allows the protection of the eye. It can be affected by therapies used for the treatment of various intraocular tumours, particularly conjunctival cancers and uveal melanoma. In these conditions, treatments are chosen according to the characteristics of the lesion, and include a combination of selective surgery, anticancer eye drops, and/or radiotherapy delivered through different mechanisms. Possible side effects affecting the ocular surface range from transient dry eye or keratitis up to more severe complications such as corneal melting and perforation. These complications deserve careful evaluation for the risk of permanent sight-threatening sequelae. Physicians involved in the management of patients affected by ocular tumours should be aware of this risk in order to reach an early diagnosis and promptly set up an adequate treatment. The present review summarizes acute and chronic complications affecting the ocular surface following different therapies for the treatment of conjunctival cancers and uveal melanoma, and also reports clinical cases of representative patients who experienced these complications.

Abstract

The ocular surface represents a finely regulated system that allows the protection of the eye. It is particularly susceptible to different treatments for intraocular tumours, such as uveal melanoma and conjunctival cancers. Traditionally, the management of ocular tumours depends on the characteristics of the lesion, and is based on a combination of selective surgery, topical chemotherapy, and/or radiotherapy delivered through different mechanisms (e.g., charged-particle radiotherapy or brachytherapy). Possible complications involving the ocular surface range from transient dry eye disease or keratitis up to corneal melting and perforation, which in any case deserve careful evaluation for the risk of permanent sigh-threatening complications. Clinicians involved in the management of these patients must be aware of this risk, in order to reach an early diagnosis and promptly set up an adequate treatment. The present review of the literature will summarize acute and chronic complications affecting the ocular surface following different therapies for the treatment of ocular tumours.

Comparison of the Effectiveness of Onion Extract, Topical Steroid, and Petrolatum Emollient in Cosmetic Appearance of Upper Blepharoplasty Scar

Purpose

To compare the effectiveness of onion extract, topical steroid, and petrolatum emollient in the prevention of scars in cases who underwent bilateral upper eyelid blepharoplasty.

Methods

A prospective, interventional, comparative, double-blinded case series was designed on cases who underwent upper lid blepharoplasty. After suture removal (1 week following the surgery), the eyelids of participants were randomly allocated into the three groups: The first group used onion extract on the right eyelids (n = 18), and the second group used topical steroid on the right eyelids (n = 19). In the third group, the control group, petrolatum emollient was used on the left eyelids (n = 37) of the first and second group's cases. They used drugs for 2 months and were evaluated by the Manchester Scar Scale (MSS) objectively by two graders who were blinded to the type of medication. MSS evaluates five different characteristics of the scar in addition to the Visual Analog Scale (VAS). These characteristics include color, distortion, contour, texture, and transparency. VAS scores the overall scar appearance which ranged among 0-10. The sum of the scores for the five different parameters, and VAS was calculated, analyzed, and compared among the groups.

Results

A total of 37 cases (74 eyelids) who underwent bilateral upper blepharoplasty were included. The mean ± standard deviation (SD) of age was 51.94 ± 9.26 years, 49.40 ± 9.37 years, and 47.00 ± 9.06 years in the onion extract, topical steroid, and petrolatum emollient groups, respectively (P = 0.275). There were no statistically significant differences in the mean ± SD of the sum of the MSS scores among the three groups (P = 0.924) or between the onion extract and topical steroid groups (P = 0.951). Furthermore, the color, distortion, contour, texture, transparency, and VAS scores were not statistically significantly different among the three groups or between the onion extract and topical steroid groups (P > 0.05).

Conclusion

There were no significant differences among these three groups of drugs regarding the appearance of the upper blepharoplasty scar.

Ocular surface complications of local anticancer drugs for treatment of ocular tumors

Local chemotherapy is increasingly used, either in combination with surgery or as monotherapy, for management of ocular tumors. Yet many of the local chemotherapeutic agents used for ocular tumors are cytotoxic drugs that are frequently associated with toxicities in normal ocular tissues. Understanding and managing these side effects are important because they affect treatment tolerability, outcome and quality of vision. Herein, we review local anticancer drugs administered for the treatment of ocular tumors, with an emphasis on their toxicities to the ocular surface, adnexa and lacrimal drainage system. We provide the underlying mechanisms and management strategies for the ocular side effects. Recent innovations in anticancer immunotherapy and ocular drug delivery systems also are discussed as new potential therapeutic modalities for alleviation of side effects.

Efficacy of BCG vaccine and Mitomycin C for the treatment of ocular squamous cell carcinoma in bovines

Bovine ocular squamous cell carcinoma (BOSCC) also called cancer eye, represents the most economically important neoplasm in large animals. Hereditary factors, environmental factors, lack of eyelid pigmentation, age and dietary habits have all been reported to play a role in the etiopathogenesis of bovine ocular squamous cell carcinoma. In group I, six animals with small, localized eye cancer where vision was not affected were included and subjected to intralesional injection of Bacillus Calmette- Guerin (BCG) vaccine at 0, 14, 35, and 56 days interval. In group II (six animals), surgical excision and Mitomycin C 0.04% topically on alternate weeks for two months as adjunctive therapy. All the animals recovered completely with no recurrence for a follow up period of one year.

The treatment of recurrent conjunctival and corneal intraepithelial neoplasia with interferon alfa-2b and retinoic acid: ~9 years' follow-up on tumor control

PURPOSE

To evaluate the long-term follow-up of recurrent conjunctival and corneal intraepithelial neoplasia (CCIN) treated with combination topical interferon alfa-2b and retinoic acid (I/RA).

METHODS

Our study represents a retrospective observational interventional series of 82 eyes from 82 patients from a single institution, reviewed for CCIN. All were administered topical interferon alfa-2b 1 million IU/mL QID and retinoic acid 0.01% every other day. Patients had been diagnosed by biopsy. A Kaplan-Meier survival analysis, Wilcoxon signed-rank test and a multivariate logistic regression were statistical tests used to correlate recurrence with patient and tumor variables.

RESULTS

79 eyes assessed for CCIN diagnoses and treated with I/RA achieved tumor resolution. The median tumor-free follow-up was ~109.1 months with a median time to resolution being ~2.8 months. Our median treatment duration was ~11.3 months. The greatest difference in the mean total residual tumor size was identified between Months 0-1 [-7.63 mm²]. The difference in mean total residual tumor size remained significant till 36-months. A statistically significant correlation with recurrence was identified for biopsy type [OR 0.138]. 6 patients experienced papillary conjunctivitis which resolved with dosage reduction.

CONCLUSIONS

Combination I/RA was effective in treating CCIN lesions with few transient side effects. The combination of retinoids and interferons may represent a viable topical therapeutic agent with an extended tumor-free follow-up and a large proportion of our study's patients achieving >10 year's tumor-free follow-up. Our treatment duration is long, but by cost-comparing surgical against medical interventions, topical I/RA may serve as a safe and effective alternative.

Clinical Management of Squamous Cell Carcinoma of the Conjunctiva

Patient: Female, 33-year-old

Final Diagnosis: Conjunctival squamous cell carcinoma

Symptoms: Tumorous lesion on the nasal bulbar conjunctiva • red eye

Medication: —

Clinical Procedure: The conjunctival tumor was excised. The histopathological diagnosis suggested a conjunctival squamous cell carcinoma. A treatment with topical MMC was admistered

Specialty: Ophthalmology

Management Issues in Conjunctival Tumours: Ocular Surface Squamous Neoplasia

Ocular surface squamous neoplasia is the most common tumour of the ocular surface. It is a spectrum of disease from intraepithelial dysplasia to invasive squamous cell carcinoma. Recent years have seen an increase in the use of topical chemotherapeutic agents to treat this condition, often as primary treatment without full-thickness biopsy. This practical approach provides a critical appraisal of the evidence base with the goal being to aid the clinician in the management of these patients.

Update on pharmacotherapy for ocular surface squamous neoplasia

The most frequently encountered non-pigmented tumor of the ocular surface is ocular surface squamous neoplasia (OSSN). Over the past two decades, the pharmacological management of OSSN has grown, with topical 5-fluorouracil, mitomycin, and interferon alpha 2b all being successfully used to treat this disease. Other agents, such as anti-vascular endothelial growth factor (VEGF), retinoic acid, cidofovir and Aloe vera, have less frequently been used in the treatment of OSSN. This review will discuss these pharmacologic agents, summarizing available data and presenting the approach to the treatment of these tumors.

[Management of squamous cell carcinoma of the conjunctiva in a young patient: Case report]

Squamous cell carcinoma is the most common malignant tumor of the bulbar conjunctiva. However, it often remains under-diagnosed and exposed to therapeutic delay. The aim of this work is to elucidate the diagnostic and therapeutic difficulties posed by this tumor and to appreciate its prognosis.

Topical chemotherapy for giant ocular surface squamous neoplasia of the conjunctiva and cornea: Is surgery necessary?

Purpose:

The purpose of this study is to report on the efficacy and safety of topical chemotherapy alone for giant ocular surface squamous neoplasia (OSSN).

Methods:

In this retrospective, interventional series, 10 eyes with giant OSSN underwent exfoliative biopsy to confirm the diagnosis followed by application of interferon alpha 2b (IFN α2b) and/or 5 fluorouracil, 1% (5FU). Reported outcome measures were tumor response, visual acuity, recurrence, systemic metastasis, and treatment complications.

Results:

Ten patients (3 female, 7 male) had a mean age of 73 (median, 69; range 40–89) years. Mean tumor diameter was 13.1 (median, 12.3; range 8.2–19.4) mm. Five (50%) eyes were treated with IFN-α2b alone; 1 (10%) with 5-FU alone and 4 (40%) required both IFN-α2b and 5-FU. The mean duration of treatment was 3, 0.5, and 6.4 months for IFN-α2b alone, 5-FU alone, and both IFN-α2b and 5-FU respectively. Complete tumor response was observed in all 10 cases at mean follow-up of 12.8 (median, 11.5; range, 3–25) months. Complications noted were transient irritation and burning (n = 4), dry eyes (n = 2), and transient flu-like symptoms (n = 2). There was no evidence of chemotherapy-related symblepharon, stem cell deficiency, scleral thinning, or corneal opacity. There were no tumor recurrences, and no patient required surgical excision or cryotherapy.

Conclusion:

Topical chemotherapy was a safe and effective treatment, inducing complete regression in all cases of giant OSSN in this series. There were no sight-limiting complications.

Challenging Treatment of Ocular Surface Squamous Neoplasia in Patients with Atopic Disease

PURPOSE

Few studies have described ocular surface squamous neoplasia (OSSN) and its association with atopic diseases and there is no consensus on the course of OSSN in atopic patients. We thereby report three patients with atopy and OSSN.

METHODS

Retrospective case series.

RESULTS

Three male patients with mean age of 73 presented with OSSN and history of atopy treated with immunosuppressant therapy. Their histories included atopic dermatitis and keratoconjunctivitis. All patients had treatment complicated by multiple surgeries, recurrences, or advanced disease. The patients initially received medical treatment with topical interferon-alpha-2b (IFNα2b). However, all the patients had recurrences and required modification of treatment including topical 5-fluorouracil (5-FU).

CONCLUSION

We report on three patients with a history of atopy whose OSSN presentation and course was challenging. Overall, our cases responded better to topical 5-fluorouracil compared to topical interferon-alpha-2b, but recurrences were common. These patients may benefit from more aggressive and long-term treatment.

Retrospective Comparative Study of Topical Interferon α2b Versus Mitomycin C for Primary Ocular Surface Squamous Neoplasia

PURPOSE

To compare the efficacy and safety of topical interferon alpha 2b (IFNα2b) and mitomycin C (MMC) for ocular surface squamous neoplasia.

METHODS

In this retrospective study, medical records of 51 eyes of 50 patients with a diagnosis of primary ocular surface squamous neoplasia were included. All cases were treated with either topical IFNα2b (1 million IU/mL) or MMC (0.4 mg/mL) 4 times a day. The primary outcome measure was frequency of clinical resolution of tumors along with failure and recurrence rates after treatment. Other outcome measures included the duration of treatment and adverse effects associated with both topical therapies.

RESULTS

Twenty-six eyes were treated with topical IFNα2b and 25 eyes were treated with topical MMC. A complete response was achieved in 23 (89%) and 23 (92%) eyes with topical IFNα2b and MMC, respectively (P = 0.67). The median time to lesion resolution was significantly different between the groups (median 3.5 months in the IFNα2b group and 1.5 months in the MMC group) with an average difference of 1.7 months (P < 0.005). Five (10%) of 51 patients showed no or partial response to topical therapy. Subsequently, they underwent surgical excision. Adverse effects occurred in 3 (12%) patients using IFNα2b and 22 (88%) patients using MMC (P < 0.005).

CONCLUSIONS

Both IFNα2b and MMC seemed to be equally effective topical monotherapies. Despite a prolonged time to lesion resolution, IFNα2b-treated eyes had better safety and tolerance in comparison with MMC-treated eyes.

Pharmacotherapy and Immunotherapy of Conjunctival Tumors

Conjunctiva and cornea tumors represent a large spectrum of conditions ranging from benign lesions to aggressive and life-threatening malignancies. Topical pharmacotherapies and immunotherapies have recently acquired a relevant role in the management of conjunctival tumors and, in the past 2 decades, there has been a shift from surgery alone toward the use of these agents, both as a sole therapy or as adjunct to surgery (before or after surgery). The 3 main agents that have been used for topical medical treatment of conjunctival tumors are mitomycin-C, 5-fluorouracil, and interferon-α2b. Advantages of topical pharmacotherapies and immunotherapies include the ability to treat the entire ocular surface and prevention of surgical side effects and complications. The aim of this review is to summarize the current use of topical pharmacotherapy and immunotherapy in the management of conjunctival tumors.

Diagnosis and Medical Management of Ocular Surface Squamous Neoplasia

INTRODUCTION

Topical chemotherapy has gained popularity among clinicians for the treatment of ocular surface squamous neoplasia (OSSN). The principal topical chemotherapy agents used in the management of OSSN are interferon-α2b, 5-fluorouracil, and mitomycin C. High-resolution optical coherence tomography (HR-OCT) is a non-invasive technique that can differentiate OSSN from other ocular surface lesions.

AREAS COVERED

This review highlights the current regimens and diagnostic modalities used in managing OSSN. A review of the literature was performed using the keywords "conjunctival intraepithelial neoplasia", "ocular surface squamous neoplasia", "optical coherence tomography", "interferon-α2b", "5-fluorouracil" and "mitomycin C".

EXPERT COMMENTARY

Topical chemotherapy for OSSN can be used as primary therapy, for chemoreduction prior to surgical excision, and postoperatively to prevent tumor recurrence. It has the advantage of treating microscopic disease as well as large tumors. HR-OCT provides an "optical biopsy" that can assist in diagnosis and guide management of OSSN lesions.

Topical 5-Fluorouracil 1% as Primary Treatment for Ocular Surface Squamous Neoplasia

PURPOSE

To determine the efficacy of topical 5-fluorouracil 1% (5-FU) as a primary treatment of ocular surface squamous neoplasia (OSSN).

DESIGN

Retrospective study.

PARTICIPANTS

Topical 5-FU was used as primary therapy in 44 patients with OSSN.

METHODS

5-Fluorouracil 1% administered topically 4 times daily for 1 week followed by a drug holiday of 3 weeks. Patients were identified through a pharmacy database. Patients were excluded if 5-FU was used as adjuvant therapy, if they did not complete therapy, or if they were still actively receiving treatment for OSSN at the time of last follow-up.

MAIN OUTCOME MEASURES

The primary outcome measures were the frequency of complete resolution with topical 5-FU treatment and the rate of OSSN recurrence.

RESULTS

Of the 44 patients identified, 32 were men and 12 were women. The mean age was 68 years. Complete resolution of OSSN was noted in 82% of patients (36/44); 18% (8/44) were considered treatment nonresponders. Patients were treated with a median of 4 cycles (range, 2-9 cycles). Nasal location was the only risk factor identified for nonresponse to therapy (P = 0.04). The median follow-up after resolution was 10 months (range, 2-77 months). In the 36 patients who showed complete resolution, 4 experienced tumor recurrence. Recurrence rates at 1 and 2 years were 6% and 15%, respectively, using Kaplan-Meier survival analysis. At least 1 side effect from the medication was reported by 61% of patients (21/44), but only 1 patient discontinued the medication because of intolerance. The most common side effect was pain (n = 17; 39%), followed by tearing (n = 10; 23%), photophobia (n = 6; 14%), itching (n = 4; 9%), swelling (n = 2; 5%), and infection (n = 1; 2%). No long-term complications were reported.

CONCLUSIONS

5-Fluorouracil is effective and well tolerated as a primary treatment for OSSN, with 82% of tumors responding completely to therapy.

Conjunctival squamous cell neoplasia: the Liverpool Ocular Oncology Centre experience

PURPOSE

To report the outcome of patients with conjunctival squamous cell neoplasia (CSCN)--including conjunctival squamous cell carcinoma (SCC), conjunctival squamous intraepithelial neoplasia (C-SIN) and carcinoma in situ (CIS)-treated at the Liverpool Ocular Oncology Centre (LOOC).

METHODS

Patients treated between January 1993 and September 2011 were identified and categorised as having 'primary' or 'salvage' treatment, according to whether they had undergone a surgical procedure before referral to our centre. Invasive SCC was treated by excision with adjunctive ruthenium plaque radiotherapy. C-SIN or CIS was treated with topical 5-fluorouracil (5-FU), and in a few cases, cryotherapy.

RESULTS

Primary treatment was administered to 20 patients (16 males, four females). Mean age was 62 years (range, 33-85). Histological examination revealed C-SIN/CIS in ten patients and invasive SCC in nine. Median follow-up was 69 months (range, 34-168). Three patients required further topical chemotherapy for persistent/recurrent C-SIN. Salvage therapy was administered to 21 patients (15 males, six females). Mean age was 63 years (range, 26-82). Histology showed C-SIN/CIS in 11 patients and invasive SCC in ten. Median follow-up was 54.5 months (range, 36-120). At the close of this audit, there was no recurrence of invasive or metastatic disease in either the primary or salvage groups.

CONCLUSIONS

Our established protocol for treatment of CSCN has proven successful in local tumour control, and avoids ocular complications. We advocate adjunctive radiotherapy in patients with invasive SCC and chemotherapy in C-SIN/CIS. For improved patient outcome, prompt referral to a specialist centre is encouraged.

Use of topical bevacizumab for conjunctival intraepithelial neoplasia

PURPOSE

To report our experience in the treatment of intraepithelial neoplasia of the conjunctiva using topical bevacizumab.

METHODS

Ten eyes of 10 patients with conjunctival neoplasia received 25 mg/mL bevacizumab topically. Changes in the lesions were documented weekly using digital photography. After topical treatment, excisional biopsy was performed.

RESULTS

The mean age of the patients was 60.5 ± 12 (33-77) years. The mean duration of topical treatment was 7.8 ± 1.3 (5-14) weeks. The size and vascularity of the tumors reduced weekly. All patients underwent excisional biopsy, cryotherapy, and amnion membrane transplantation. The histopathologic diagnosis of the lesions was carcinoma in situ. No recurrence was observed during the follow-up of patients for 6 months.

CONCLUSIONS

Topical bevacizumab is an effective treatment to reduce the tumor size before surgery and may be a good alternative for adjuvant therapy of conjunctival neoplasms.

Surgical versus medical treatment of ocular surface squamous neoplasia: a comparison of recurrences and complications

PURPOSE

Treatment for ocular surface squamous neoplasia (OSSN) has historically been surgery, but nonsurgical interventions are increasingly used. Treatment with interferon is efficacious, but evidence is needed regarding recurrence and complication rates in comparison with surgery. The objective of this study is to compare the recurrence and complication rates of surgical treatment and interferon treatment for OSSN.

DESIGN

A matched, case-control study.

PARTICIPANTS

Ninety-eight patients with OSSN, 49 of whom were treated with interferon (IFN) α2b therapy and 49 of whom were treated with surgical intervention.

METHODS

Patients with OSSN were treated with surgery versus IFNα2b therapy, either in topical or injection form. Median follow-up after lesion resolution was 21 months (range, 0-173 months) for the IFNα2b group and 24 months (range, 0.9-108 months) for the surgery group.

MAIN OUTCOME MEASURES

The primary outcome measure for the study was the rate of recurrence of OSSN in each of the treatment groups. Recurrence rates were evaluated using Kaplan-Meier survival analysis.

RESULTS

Mean patient age and sex were similar between the groups. There was a trend toward higher clinical American Joint Committee on Cancer tumor grade in the IFNα2b group. Despite this, the number of recurrences was equal at 3 per group. The 1-year recurrence rate was 5% in the surgery group versus 3% in the IFNα2b group (P = 0.80). There was no statistically significant difference in the recurrence rate between the surgically and medically treated groups. Nonlimbal location was a risk factor for recurrence (hazard ratio, 8.96) in the entire study population. In patients who were treated successfully, the side effects of the 2 treatments were similar, with mild discomfort seen in the majority of patients in both groups. There was no limbal stem cell deficiency, symblepharon, or diplopia noted in either group. Two patients were excluded from the IFNα2b group because of intolerance to the medication.

CONCLUSIONS

No difference in the recurrence rate of OSSN was found between surgical versus IFNα2b therapy.

Local chemotherapeutic agents for the treatment of ocular malignancies

We critically analyze available peer-reviewed literature, including clinical trials and case reports, on local ocular cancer treatments. Recent innovations in many areas of ocular oncology have introduced promising new therapies, but, for the most part, the optimal treatment of ocular malignancies remains elusive.

Topical chemotherapy for ocular surface squamous neoplasia

PURPOSE OF REVIEW

Ocular surface squamous neoplasia (OSSN) is an umbrella term for a spectrum of epithelial dysplasias of the cornea, conjunctiva, and limbus. Treatment for OSSN has historically been surgery, but nonsurgical interventions have been increasingly adopted. Advantages of medical treatments include the ability to treat the entire ocular surface and prevention of surgical complications.

RECENT FINDINGS

The primary medical treatments for OSSN include mitomycin C, 5-fluorouracil, and interferon α2b. Mitomycin C has been shown in studies to be highly effective but has short-term and long-term side-effects that may be intolerable. 5-Fluorouracil and interferon α2b have been found to be similar in efficacy to mitomycin, with interferon being extremely well tolerated in the majority of patients. Most recently, other chemotherapeutic agents have been tried for OSSN including antivascular endothelial growth factor agents and vitamin A. The data regarding these latter treatment strategies are still limited.

SUMMARY

An understanding of the recent literature, with respect to the efficacy, advantages, and disadvantages of the various therapies for OSSN will allow us to tailor treatment to each patient.