Ocular surface squamous neoplasia: report of an unusual case and review of the literature

UV Protection in the Cornea: Failure and Rescue

Simple Summary

The sun is a deadly laser, and its damaging rays harm exposed tissues such as our skin and eyes. The skin’s protection and repair mechanisms are well understood and utilized in therapeutic approaches while the eye lacks such complete understanding of its defenses and therefore often lacks therapeutic support in most cases. The aim here was to document the similarities and differences between the two tissues as well as understand where current research stands on ocular, particularly corneal, ultraviolet protection. The objective is to identify what mechanisms may be best suited for future investigation and valuable therapeutic approaches.

Abstract

Ultraviolet (UV) irradiation induces DNA lesions in all directly exposed tissues. In the human body, two tissues are chronically exposed to UV: the skin and the cornea. The most frequent UV-induced DNA lesions are cyclobutane pyrimidine dimers (CPDs) that can lead to apoptosis or induce tumorigenesis. Lacking the protective pigmentation of the skin, the transparent cornea is particularly dependent on nucleotide excision repair (NER) to remove UV-induced DNA lesions. The DNA damage response also triggers intracellular autophagy mechanisms to remove damaged material in the cornea; these mechanisms are poorly understood despite their noted involvement in UV-related diseases. Therapeutic solutions involving xenogenic DNA-repair enzymes such as T4 endonuclease V or photolyases exist and are widely distributed for dermatological use. The corneal field lacks a similar set of tools to address DNA-lesions in photovulnerable patients, such as those with genetic disorders or recently transplanted tissue.

Persistent socket pain postenucleation and post evisceration: a systematic review

PURPOSE

To investigate causes, diagnostics and treatment modalities for persistent socket pain (PSP) after enucleation and evisceration.

METHODS

A systematic search was undertaken in accordance with the PRISMA Statement, in PubMed, Embase.com and Thomson Reuters/Web of Science. We searched for relevant papers until the 28th of July 2016. Inclusion criteria were (1) patients with a history of enucleation or evisceration, (2) PSP, (3) report of the cause and/or used diagnostics and/or treatment modality, (4) full text in English, Dutch or Spanish language. Excluded were (1) review articles, (2) comments, and publications concerning, (3) nonhumans, (4) exenterated patients, (5) acute postoperative pain, or (6) periorbital pain without pain in the socket. Given the lack of high quality evidence from randomized controlled trials, we examined all available evidence from primary observational studies and assessed quality within this lower level of evidence.

RESULTS

A total of 32 studies were included. Causes of PSP found were prosthesis-related (n = 5), dry socket (n = 2), trochleitis (n = 3), compression of the trigeminal nerve (n = 2), implant-related (n = unknown), inflammation (n = 5), surgery-related (n = 4), neuromas (n = 8), malignant tumours (n = 3), psychiatric/psychosocial (n = 2), phantom pain (n = 149), rarer entities (n = 3) or unknown (n = 14). Nonsurgical treatments suffice for conditions as trochleitis, prosthesis-related pain, dry socket and for phantom pain. Other causes of pain may require more invasive treatments such as implant removal.

CONCLUSION

Careful history and examination can give some direction in the diagnostic procedure; however, PSP is probably multifactorial and the specific origin(s) may remain uncertain. Implant replacement can be an effective treatment. Studies to identifiy less invasive procedures are required.

Squamous cell carcinoma in the anophthalmic socket: a series of four cases with HPV-16 profiling

PURPOSE

To present the clinical and histological features of squamous cell carcinoma (SCC) in the anophthalmic socket in four adult patients, and to determine the presence of human papillomavirus infection (HPV).

METHODS

Retrospective case series of four adult patients with SCC of the anophthalmic socket. P16 immunohistochemistry and HPV testing was carried out in all cases. The authors report clinical findings, histopathology, management and outcomes for all four patients with conjunctival SCC. Previously reported cases of conjunctival SCC in anophthalmic sockets were reviewed.

RESULTS

Four adult patients presented with eyelid lumps, discharge or change in prosthesis fit. Common examination findings included papillomatous changes, eyelid masses and epithelial changes. Three out of the four cases (75%) were positive for p16 by immunohistochemistry and the same cases positive for HPV-16 DNA. All patients received cryotherapy, topical or intralesional chemotherapy. Two patients proceeded to exenteration for control of invasive disease.

CONCLUSIONS

To the authors' knowledge, this is the largest series of SCC in the anophthalmic socket with comprehensive annotation of HPV status. Although socket conjunctiva is protected from environmental radiation, there is still a risk of neoplastic transformation in this tissue, thus patient education and regular checking of sockets by ophthalmologists should be undertaken as a preventative measure. The potential role of HPV in these tumours warrants further investigation.

Role of high resolution optical coherence tomography in diagnosing ocular surface squamous neoplasia with coexisting ocular surface diseases

PURPOSE

Coexistence of an ocular surface disease can mask the typical features of ocular surface squamous neoplasia (OSSN). The purpose of this study was to evaluate high resolution optical coherence tomography (HR-OCT) as an adjunct in the detection and differentiation of OSSN within coexisting ocular surface pathologies.

METHODS

Retrospective study of 16 patients with ocular surface disease and lesions suspicious for OSSN that were evaluated with HR-OCT. HR-OCT images of the lesions were taken to look for evidence of OSSN. Biopsies were performed in all cases, and the HR-OCT findings were compared to the histological results.

RESULTS

Of the 16 patients with OSSN and a coexisting ocular surface disease, 12 were found to have OSSN by HR-OCT and all were subsequently confirmed by biopsy. Two patients had OSSN with rosacea, one with pingueculum, two within pterygia, one with Salzmann' nodular degeneration, six with limbal stem cell deficiency (LSCD)/scarring. In all 12 cases HR-OCT images revealed classical findings of hyper-reflective, thickened epithelium and an abrupt transition from normal to abnormal epithelium. OSSN was ruled out by HR-OCT in four cases (2 Salzmann's, 1 mucous membrane pemphigoid, and 1 LSCD). Negative findings were confirmed by biopsy. HR-OCT was used to follow resolution of the OSSN in positive cases, and it detected recurrence in 1 case.

CONCLUSIONS

While histopathology is the gold standard in the diagnosis of OSSN, HR-OCT can be used to noninvasively detect the presence of OSSN in patients with coexisting ocular conditions.

Conjunctival Squamous Cell Carcinoma due to Long-term Placement of Ocular Prosthesis

Conjunctival squamous cell carcinoma (SCC) arising from an anophthalmic socket is quite rare, with few reports in the English literature. A 59-year-old man who had used an ocular prosthesis for 40 years had not removed the ocular prosthesis at all during the last 5 years. He had developed a mass on his entire right upper eyelid, and biopsy revealed a moderately differentiated SCC. Orbital exenteration including the upper and lower eyelid skin was performed. The defect was reconstructed with a free forearm flap followed by the placement of a facial epithesis. The pathology revealed an intraepithelial carcinoma on the upper palpebral conjunctiva, which seemed to infiltrate exclusively from that site to the upper eyelid and into the orbit. Other risk factors were not detected; therefore, chronic irritation or microtrauma of the upper conjunctiva from the prosthesis due to persistent prosthesis placement could have been the main trigger for the development of SCC. In cases where the ocular prosthesis is not fitted properly or removed appropriately, clinicians should be aware of this possible long-term consequence.

A case of orbital sebaceous gland carcinoma developing in an anophthalmic socket 65 years after enucleation

Although conjunctival squamous cell carcinoma is known to develop as a result of chronic irritation from wearing an ocular prosthesis, orbital sebaceous gland carcinoma arising in an anophthalmic pocket is extremely rare. We report a 68-year-old female who developed a sebaceous gland carcinoma 65 years after her right eye was enucleated (at the age of three years) due to congenital glaucoma. The patient had noticed increasing discharge and swelling of her right eyelid. Incisional biopsies of an underlying orbital mass revealed poorly differentiated sebaceous gland carcinoma. The sebaceous gland carcinoma in this case could have been caused by chronic irritation as a result of long-standing use of a poorly fitted ocular prosthesis. The current case of a malignant tumor occurring 65 years after enucleation emphasizes the importance of long-term clinical surveillance to monitor for tumor formation. Careful examination of the anophthalmic socket should be part of the physical examination.

Ocular surface squamous neoplasia (squamous cell carcinoma) of the socket: management of extensive tumors with interferon

PURPOSE

To describe the clinical features and management of extensive ocular surface squamous neoplasia (OSSN) (squamous cell carcinoma) of the socket.

METHODS

Retrospective interventional case series. Interferon α 2b (IFNa2b) eye drops (1 million units/cc) 4 times daily and IFNa2b sublesional injection (5 million units/0.5cc to 8 million units/0.8 cc) were delivered for tumor control. Participants were 3 patients with ocular prosthesis who developed extensive socket OSSN. Tumor control was graded as complete regression, partial regression, or no regression.

RESULTS

OSSN was detected in the socket at age 60, 43, and 20 years in patients who had worn ophthalmic prostheses for 54, 26, and 13 years, respectively. The patients had chronic discharge and irritation (n = 3) managed with intermittent topical corticosteroids (n = 2). There were no predisposing factors of cigarette exposure, radiation exposure, eczema, systemic immune suppression, or organ transplantation. The prosthesis fit well with nonirritative edges. At presentation, OSSN was subtle (n = 3), vascular (n = 3), and multifocal (n = 3), with largest lesions or confluence of lesions measuring 20, 25, and 20 mm, respectively. The tumors involved the tarsal (n = 3), bulbar (n = 2), and forniceal (n = 2) surfaces. All patients were treated with topical and injection IFNa2b, with complete regression achieved in 2 cases (at 1 months and 20 months) and partial regression in one case (at 9 months). All patients continue on chronic maintenance IFNa2b topically. There were no recurrences, and IFNa2b injection side effects of nausea and chills were minor, lasting 1 day. No patient required surgical removal of tumors from the socket and no patient required exenteration.

CONCLUSIONS

Patients wearing ophthalmic prosthesis over a socket should be monitored for the development of OSSN. Combined topical and injection IFNa2b could represent a potentially effective therapy for this condition.

Conjunctival Squamous Cell Carcinoma of the Orbit 40 Years After Enucleation

Conjunctival squamous cell carcinoma developed in a 51-year-old man 40 years after he had enucleation of his left eye because of an explosion injury. He had worn several ocular prostheses for more than 40 years. Recently he had noticed an increasing sanguineous conjunctival discharge, a foreign body sensation, and swelling of his left lower eyelid. Incisional biopsies of an underlying conjunctival mass revealed squamous cell carcinoma. His work history did not involve exposure to radiation, chemicals, or the sun. The authors concluded that squamous cell carcinoma in this case was caused by chronic irritation as the result of long-standing use of a poorly fitting ocular prosthesis.

The aetiology and associations of conjunctival intraepithelial neoplasia

AIM

To summarise the main causes and associations of conjunctival intraepithelial neoplasia (CIN) found in the literature to date.

METHOD

Literature search using Ovid databases on the NHS Scotland E-library, Medline, and the Cochrane Library. The internet search engine Google Scholar was also used to identify relevant articles.

RESULTS

The main causes and associations of CIN in the literature are sun exposure and distance from the equator; human papillomavirus infection, increased p53 expression, and HIV seropositivity. It has been found that in HIV positive individuals CIN is on the increase with people being affected with more aggressive tumours at younger ages.

CONCLUSION

Given that CIN is becoming more common in HIV infected populations and that it has the potential to cause severe disability, it is important to improve our understanding of the condition. Early identification of CIN by an understanding of its aetiology and associations may enable the implementation of preventative measures to reduce its incidence and potentially lead to the diagnosis and further management of conditions such as HIV. Young people presenting with CIN in particular may benefit from HIV testing.