Case Report of Ocular Surface Squamous Neoplasia

INTRODUCTION

Ocular surface squamous neoplasia (OSSN) encompasses a spectrum of epithelial lesions ranging from conjunctival intraepithelial neoplasia (CIN) to invasive squamous cell carcinoma. These lesions commonly arise from the limbal stem cell region and are associated with several risk factors, including ultraviolet (UV) radiation exposure, human papillomavirus (HPV) infection, immunosuppression, and increasing age. OSSN is often presented as a painless, slowly growing conjunctival mass and may mimic benign conditions, leading to delayed diagnosis.^1-3

The standard management of OSSN involves surgical excision with wide margins using a no-touch technique, often combined with cryotherapy and adjuvant topical chemotherapy to reduce recurrence rates.^2,4 This case report describes the clinical features, surgical management, histopathological findings, and postoperative outcome of a patient with OSSN.

CASE REPORT

Clinical examination

On ocular examination, the best corrected visual acuity in the right eye was 6/60, improving to 6/36 with pinhole. The left eye visual acuity was 6/60, improving to 6/18 with pinhole. Extraocular movements were full and painless in both eyes.

Slit-lamp examination of the right eye revealed a whitish, greyish white polypoidal lesion measuring approximately 1 × 0.8 cm, located over the nasal conjunctiva and limbus, with encroachment onto the cornea. The lesion was slightly raised, opaque, and irregularly marginated. The surface appeared rough, and the lesion was non-tender. The surrounding conjunctiva showed no significant inflammation. The remainder of the anterior segment examination was within normal limits [Figure 1].

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Figure 1:

Right eye pre operative photo of patient

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The left eye anterior segment examination was unremarkable. Fundoscopic examination of both eyes revealed normal optic discs, maculae, and retinal peripheries.

Based on the clinical appearance and progression of the lesion, a provisional diagnosis of ocular surface squamous neoplasia was made.

Management

Surgical technique

The patient was planned for surgical excision of the lesion. Excisional biopsy was performed using the “no-touch technique” to minimize the risk of tumor seeding. Clinically, tumor-free margins of 2–4 mm were marked around the lesion. The conjunctiva was incised outside the marked margins, and the lesion was carefully dissected and lifted off the corneal surface without directly manipulating the tumor tissue [Figure 2].

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Figure 2:

Right eye post operative photo of patient

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Following excision, double freeze–thaw cryotherapy was applied to the conjunctival margins and limbus to destroy any residual dysplastic cells. Hemostasis was achieved, and the ocular surface was reconstructed appropriately. The excised tissue was sent for histopathological examination.

Histopathological findings

Histopathological examination of the biopsied specimen revealed hyperplastic squamous epithelium with features of low-grade dysplasia. The epithelial cells showed mild nuclear atypia, increased nuclear-to-cytoplasmic ratio, and disordered maturation confined to the lower epithelial layers. The basement membrane was intact, and there was no evidence of stromal invasion. These findings were consistent with ocular surface squamous neoplasia, specifically conjunctival intraepithelial neoplasia (low-grade) [Figure 3a and b].

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Figure 3:

(a) Histo-pathology picture 1 Stain: Hematoxylin and eosin, (b) Histo-pathology picture 2

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Postoperative management

The immediate postoperative period was uneventful. Topical antibiotics and lubricants were prescribed to promote epithelial healing. After complete epithelialization, one week postoperatively, the patient was started on adjuvant topical mitomycin-C 0.02%.

Mitomycin-C was administered four times daily for one week, followed by a 1-week drug-free interval. A total of two cycles was given. The patient was closely monitored for potential side effects, including conjunctival irritation, epithelial toxicity, and punctal stenosis, none of which were observed during treatment [Figure 4].

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Figure 4:

Right eye post op 1 week follow-up

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Follow-up and outcome

At 4 weeks postoperatively, the surgical site showed good healing with no evidence of residual or recurrent lesion. The ocular surface appeared stable, and the patient reported significant relief from foreign body sensation and watering. Visual acuity improved slightly, and there were no signs of surgical or topical chemotherapy complications.

The patient was advised to have regular follow-up visits due to the known risk of recurrence associated with OSSN.

DISCUSSION

OSSN is a relatively uncommon but potentially vision-threatening condition if left undiagnosed and untreated. It typically presents in elderly individuals and frequently involves the interpalpebral conjunctiva and limbus, areas most exposed to UV radiation.^1-3 Clinically, OSSN may appear as leukoplakic, gelatinous, or papilliform lesions with feeder vessels.²

The no-touch surgical excision technique with wide margins remains the gold standard treatment for localized OSSN. Adjunctive cryotherapy further reduces recurrence by destroying residual tumor cells at the margins. Histopathological confirmation is essential to determine the grade of dysplasia and rule out invasive disease.^2,4

Topical chemotherapeutic agents such as mitomycin-C, 5-fluorouracil, and interferon alpha-2b are increasingly used as adjuvant or primary therapy. Mitomycin-C is particularly effective in reducing recurrence rates, especially in cases with positive or close margins, multifocal disease, or high-risk features.^5-7

CONCLUSION

This case highlights the importance of early recognition and comprehensive management of ocular surface squamous neoplasia. Surgical excision using the no-touch technique combined with cryotherapy and adjuvant topical mitomycin-C resulted in successful treatment with good anatomical and functional outcomes. Long-term follow-up is essential due to the risk of recurrence. Prompt diagnosis and appropriate intervention can preserve vision and prevent progression to invasive disease.