[Downloaded free from http://www.ijo.in on Wednesday, February 19, 2020, IP: 223.185.151.

47]

Original Article

Clinicodemographic profile and treatment outcome in patients of ocular

surface squamous neoplasia

Rachna Meel, Rebika Dhiman, Murugesan Vanathi, Neelam Pushker, Radhika Tandon, Saranya Devi

Purpose: The aim is to study the clinicodemographic profile and treatment outcome of ocular surface Access this article online
squamous neoplasia (OSSN). Methods: This was a retrospective observational study of 57 eyes (56 cases) Website:
with clinically diagnosed OSSN, presenting in our center over the past year. Results: The median age www.ijo.in
of presentation was 55 years with male:female ratio being 4.5:1. Systemic predisposing conditions were DOI:
xeroderma pigmentosa (1) postkidney transplant immunosuppression (1), and human immunodeficiency 10.4103/ijo.IJO_251_17
virus infection (1). Patients with predisposing conditions had a younger median age of onset (33 years). PMID:
*****
The majority of tumors were nodular (61.4%), gelatinous (61.4%), and had limbal involvement (96%). On
ultrasound biomicroscopy (UBM), mean tumor height was 2.93 ± 1.02 mm, and intraocular extension was Quick Response Code:
evident in seven eyes. OSSN with intraocular extension had a mean tumor height of 4.3 ± 1.32 mm. Nodal
metastasis was seen in one case at presentation. As per American Joint Committee for Cancer Classification
seventh edition staging‑two cases were T1, one was T2, 46 were T3 and eight were T4. Treatment advised
included conservative therapy for 39; wide local excision (4 mm margin clearance) with cryotherapy for
seven; enucleation in four; and exenteration in four eyes. Overall, complete regression was achieved in
88% of cases during a mean follow‑up of 13.5 ± 4.6 months. Recurrence was seen in three cases, which
were treated with exenteration, radical neck dissection, and palliative chemo‑radiotherapy, respectively.
Conclusion: Although associated with old age, earlier onset of OSSN is seen in patients with systemic
predisposing conditions. Thicker tumors in the setting of a previous surgery or immunocompromised status
should be considered high‑risk features for intraocular extension and should be evaluated on UBM.

Key words: Demography, ocular surface squamous neoplasia

The term ocular surface squamous neoplasia (OSSN) refers to In the wake of changing trends in the incidence and
a spectrum of epithelial squamous malignancies, ranging from management options for OSSN, there is little knowledge of
dysplasia to invasive squamous cell carcinoma.[1] OSSN has a the clinic‑demographic profile and treatment outcome of these
reported worldwide incidence of 0.02–3.5 cases per 100,000 patients in the Indian scenario. Herein, we report the current
people.[2] The incidence increases with decreasing latitude, clinicodemographic profile and treatment outcome of patients
being higher in countries located close to the equator.[3] The presenting with OSSN at a tertiary eye care center.
average age of presentation is usually the sixth and seventh
decades of life. However, in immunocompromised individuals, Methods
OSSN may occur at a younger age.[4,5] This was a retrospective study. The medical records of all
Risk factors for developing OSSN include exposure to patients presenting to our center and clinically diagnosed with
ultraviolet radiation, human immunodeficiency virus (HIV) OSSN between March 2015 and March 2016 were reviewed.
infection, human papillomavirus infection,[6] heavy cigarette Institutional ethical committee approval was obtained for the
smoking,[7,8] male gender and age.[9] Several studies have study.
reported a dramatic increase in the incidence of OSSN following Demographic and clinical history details of the patients
the outbreak of HIV.[10,11] were noted, which included– age at presentation, gender,
The standard modality for treatment of OSSN has been wide laterality, occupation, socioeconomic status (using modified
surgical excision with “no‑touch” technique[12] and adjunctive Kuppuswamy scale [15] ), duration of symptoms, risk
cryotherapy. However, due to high recurrence rates ranging from factors (history of ocular trauma or surgery, sunlight
5% to 66% after surgical excision,[13] nonsurgical management exposure, any predisposing conditions, genetically
with topical chemotherapeutic agents (5‑fluorouracil) and predisposed state), and previous treatment history. A history
mitomycin C (MMC) or interferon‑a 2b (IFNα2b) has become
the preferred choice for management of OSSN.[14]
This is an open access article distributed under the terms of the Creative
Commons Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows
others to remix, tweak, and build upon the work non‑commercially, as long as the
Dr. R P Centre for Ophthalmic Sciences, All India Institute of Medical
author is credited and the new creations are licensed under the identical terms.
Sciences, New Delhi, India
Correspondence to: Dr. Rachna Meel, Oculoplasty and Ocular For reprints contact: reprints@medknow.com
Oncology Services, Dr. R. P. Centre for Ophthalmic Sciences All India
Institute of Medical Sciences, Ansari Nagar, New Delhi ‑ 110 029, India. Cite this article as: Meel R, Dhiman R, Vanathi M, Pushker N, Tandon R,
E‑mail: dr.rachnameel@gmail.com Devi S. Clinicodemographic profile and treatment outcome in patients of ocular
surface squamous neoplasia. Indian J Ophthalmol 2017;65:936-41.
Manuscript received: 05.04.17; Revision accepted: 17.08.17

© 2017 Indian Journal of Ophthalmology | Published by Wolters Kluwer - Medknow

[Downloaded free from http://www.ijo.in on Wednesday, February 19, 2020, IP: 223.185.151.47]

Meel, et al.: Clinical profile and treatment outcome in OSSN patients

October 2017 937

of prolonged sun exposure was determined by self‑reported lower class on assessment of socioeconomic status using
history and/or inferred from the occupation of the patient. Modified Kuppuswamy scale.
Previous treatment history included details of the type
Seventy percent of patients (39/56) were involved in the
of interventions (surgery/topical therapy) and number of
indoor occupation, and 30% (17/56) had an outdoor occupation.
recurrences. Details of histopathology reports were analyzed.
Of 56 patients, 34% (19/56) had prolonged history of sun
Previous pterygium surgery was included in the treatment
exposure, 34% (19/56) had a history of smoking, 13% (7/56)
history for OSSN, in the absence of a histopathological
had the previous history of ocular trauma or surgery unrelated
validation of pterygium.
to OSSN.
Clinical characteristics of the tumor were noted, which
For 26 patients, the right eye was involved in the injury,
included location, extent, tissues involved (conjunctiva, cornea,
and the left eye in 29 patients. Bilateral involvement was
eyelid, caruncle, sclera, intraocular, orbit), tumor multiplicity
seen in one case. Previous treatment history was present in
which was defined as the presence of two tumors separated
46% (26/56). Among them, five cases had a history of use
by a distance of at least 5 mm, presence of feeder vessels, of topical MMC, eight cases had a history of pterygium
growth pattern (nodular/sessile), clinical type (pappilliform, excision (no histopathology reports available), and 13 cases
gelatinous, fungating, ulcerative), presence of leukoplakia/ had a history of previous excision biopsy for OSSN. Of
pigmentation, tumor height as measured on ultrasound 13 cases with a history of excision biopsy, histopathology
biomicroscopic (UBM) examination, clock hours of limbal reports were available only for eight (62%) patients and
involvement, maximal basal diameter, and nodal or systemic revealed well‑differentiated squamous cell carcinoma in three
metastasis. Based on the number of clock hours of limbal cases, moderately differentiated squamous cell carcinoma in
involvement or maximum basal diameter, the tumor was two cases and poorly differentiated invasive squamous cell
classified as small (≤5 mm basal diameter or ≤3 clock hours carcinoma in three cases. Associated ocular pathologies seen
of limbal involvement), large (6–15 mm in basal diameter or in the affected eye were cataract (n = 10), senile ptosis (n = 3),
>3–6 clock hours of limbal involvement), or diffuse (more than lagophthalmos (n = 1), and symblepharon due to a previous
15 mm in basal diameter/forniceal/eyelid involvement or surgery (n = 1). Pterygium was noted in the fellow eye in eight
>6 clock hours of limbal involvement) [Fig. 1]. cases. Systemic risk factors were found in three patients and
Intraocular involvement was noted based on the presence included xeroderma pigmentosa (n = 1), HIV (n = 1), and renal
of cells in the anterior chamber, gonioscopy, dilated fundus transplantation (n = 1). OSSN was the presenting feature in the
examination, UBM [Fig. 2], and ocular ultrasonography HIV patient. The median age of presentation in these three
in cases with media opacity. Imaging scans of the orbit patients was 33 years (range: 10–51 years). Systemic associations
were reviewed in cases with forniceal involvement to rule were pulmonary tuberculosis (n = 1), hepatitis B (n = 1),
out any orbital extension. All the tumors were graded and Berger’s disease (n = 1). The patient with pulmonary
according to American Joint Committee for Cancer tuberculosis had a bilateral involvement, with intraocular
Classification (AJCC)‑tumor, node, metastasis of conjunctival and orbital extension in the left eye. The patient with Berger’s
carcinoma (7 th edition of AJCC [16]). Impression cytology disease was contemporaneously diagnosed with OSSN and
non‑Hodgkin lymphoma.
reports were reviewed for all cases, and HIV status was
noted. Treatment advised, treatment outcome, and follow Clinical characteristics and tumor staging
up was noted for patients. At our center, we routinely Mean duration of symptoms was 1.03 ± 2.3 years. The
perform impression cytology in all cases of ocular surface presenting symptom was an ocular surface mass in 78% of cases
masses. The conservative management of OSSN is based on and redness in 22% of cases. The tumor characteristics of 57 eyes
clinical impression alone. However, more aggressive surgical is described in Table 1. Majority of tumors had a gelatinous
treatment like enucleation and exenteration is done only appearance (61.4%) and a nodular growth pattern (61.4%).
after obtaining a biopsy, which may not be needed if the Leukoplakia was seen in 38.6% of cases and pigmentation in
impression cytology is positive. 24.6% of cases. The most common site of involvement was
Statistical analysis limbus (96.1%). Among 57 eyes, 3.5% of eyes (2/57) had AJCC
grade T1, 1.8% of eyes (1/57) had T2, 80.7% (46/57) had T3, and
Analysis was performed following compilation of data
14% (8/57) of eyes had T4 grade OSSN.
using SPSS (version 11, New York, Purchased by Department
of Biostatistics, AIIMS). Descriptive statistics were used for Intraocular involvement was found in seven patients (AJCC
demographic characteristics and the data being presented as T3 Grade‑4 cases and T4 Grade‑3 cases). Among these cases, the
percentages, mean, and standard deviation. intraocular invasion was clinically evident as corneal melting
and anterior segment invasion in one case. In the remaining six
Results cases, it was evident on UBM. A history of previous surgery
was present in 43% of cases with intraocular invasion (3/7)
Clinical and demographic details
and 1 case was HIV‑positive. One case with T4 tumor had
A total of 57 eyes of 56 patients were included in the study. a regional (preauricular) lymph node involvement at the
The median age of presentation was 55 years (range: presentation that was confirmed by fine‑needle aspiration
10–80 years). The median age of onset of symptoms was cytology. None of the cases had distant metastasis at presentation.
53 years. Twenty‑seven percent patients (15/56) were younger
than 50 years at presentation. There was a marked male Investigations and imaging
preponderance with male:female ratio of 4.5:1. Eighty‑nine Impression cytology and UBM examination were available for
percent (n = 50) of patients belonged to the upper lower and all except one paediatric patient. Impression cytology showed
[Downloaded free from http://www.ijo.in on Wednesday, February 19, 2020, IP: 223.185.151.47]

938 Indian Journal of Ophthalmology Volume 65 Issue 10

dysplasia in 70% (n = 39/56) cases. Mean tumor height on cases included medical management (with topical MMC
UBM was 2.93 ± 1.02 mm [Fig. 2a]. Intraocular involvement 0.04% QID or topical IFNα2b 1 MIU/ml QID or perilesional
was evident as ciliary body/choroid thickening in three IFNα2b) in 39 eyes; wide surgical excision (4 mm margin
cases [Fig. 2b], anterior segment invasion with ciliary body clearance) with cryotherapy in seven cases (AJCC T1 ‑ 1 eye,
thickening in two cases, and anterior segment invasion in T3 ‑ 2 eyes, AJCC T4 ‑ 3 eyes); enucleation with limited excision
one case. In the three cases where anterior segment invasion with amniotic membrane transplantation with cryotherapy
was detected on UBM, there were no clinical signs of anterior of conjunctival edges and adjunctive treatment (topical) in
segment cells on slit lamp examination. However, gonioscopy
could not be done due to large tumor overhanging the cornea
Table 1: Clinical characteristics of 57 eyes of ocular
in two cases and presence of corneal opacity in the third case.
surface squamous neoplasia (n=57)
Orbital extension, confined to anterior orbit, was noted in eight
cases on imaging [Fig. 3]. Clinical characteristics Number of cases (%)

Treatment and follow‑up Clinical appearance

Out of 56 patients, six (six eyes) were lost to follow up after Gelatinous 35 (61.4)
the initial evaluation. Treatment advised in the remaining Pappiliform 15 (26.3)
Ulcerative 5 (8.8)
Fungating 2 (3.5)
Growth pattern
Nodular 35 (61.4)
Sessile 22 (38.6)
Multiplicity
a b Single 52 (91.2)
Multiple 5 (8.8)
Structures involved
Limbus 50 (96.1)
Bulbar conjunctiva 48 (92.3)
Tarsal conjunctiva 8 (15.4)
c
Fornices 12 (23.1)
Figure 1: Clinical photographs showing the clinical classification
scheme of ocular surface squamous neoplasia based on the number Cornea 49 (94.2)
of clock hours of limbal involvement or maximum basal diameter as Lid 5 (9.6)
(a) small, (b) large, and (c) diffuse Intraocular 7 (13.5)
Feeder vessels
Present 57 (100)
Absent 0
Leukoplakia
Present 22 (38.6)
Absent 35 (61.4)
a b Pigmentation
Figure 2: (a) Measurement of the height of the lesion using ultrasound Present 14 (24.6)
biomicroscopy. (b) Intraocular extension in a case of ocular surface Absent 43 (75.4)
squamous neoplasia evident in the form of ciliary body thickening Impression cytology*
Positive 39 (69.6)
Negative 17 (30.4)
Based on the quadrant involvement
Small 19 (33.3)
Large 27 (47.4)
Diffuse 11 (19.3)
AJCC staging
T1 2 (3.5)
T2 1 (1.8)
T3 46 (80.7)
T4 8 (14)
Primary/recurrent cases
Primary 44 (77.2)
Figure 3: Contrast‑enhanced computed tomography (axial view) showing Recurrent 13 (22.8)
the anterior orbital involvement in ocular surface squamous neoplasia *Not done in 1 paediatric patient. AJCC: American Joint Committee on Cancer
[Downloaded free from http://www.ijo.in on Wednesday, February 19, 2020, IP: 223.185.151.47]

Meel, et al.: Clinical profile and treatment outcome in OSSN patients

October 2017 939

four cases (AJCC T3 ‑ 3 eyes, AJCC T4 ‑ 1 eye); exenteration Table 3. Thirty‑nine eyes were treated with IFNα2b therapy.
in three cases (all AJCC T4); and exenteration with radicle Of these, 66.67% (26/39) achieved complete resolution, and
lymph node dissection in one case (AJCC T4) [Fig. 4]. 25.64% (10/39) achieved partial resolution. Eight out of ten eyes,
Adjuvant external beam radiotherapy (EBRT) was advised in which the tumor showed a partial response to IFNα2b, were
in five cases with T4 disease and with positive surgical subsequently treated with MMC 0.04% (one week on and one
margin on histopathology (wide local excision: Three cases, week off) for a maximum of four cycles. Of these, 87.5% (7/8)
enucleation with excision: One case, exenteration: One case). achieved complete resolution. In three eyes, where the tumor
The remaining cases had negative surgical margins for achieved partial resolution with medical management, wide
tumor cells on histopathology. Mean duration of follow‑up local excision was performed.
was 13.3 ± 4.6 months. Treatment outcome and details of
patients are summarized in Table 2. Overall, 88% (44/50) were Overall, 6% (3/50) of patients developed recurrence, two
free of disease at last follow‑up. Medical therapy achieved in orbit with intracranial extension in one eye and one in
complete regression in 84.61% (33/39) cases, all of which were draining lymph node. They were treated with exenteration,
disease‑free at a mean follow up of 16.15 months (Range radicle neck dissection, and palliative chemo‑radiotherapy,
7.5‑28 months). Details of medical management are shown in respectively.

Table 2: Treatment outcome of ocular surface squamous neoplasia

Treatment n (57) Tumor grade Treatment outcome Follow up
(months)
T1 T2 T3 T4 CR PR LFU Rec
Conservative therapy (topical/perilesional injection) 39 1 ‑ 37 1 @
33 3 3 ‑ 6.15
Wide local excision + cryotherapy 7 1 ‑ 3 3^ 5 ‑ 1 1# 16.7
Enucleation + limited excision 4 ‑ ‑ 3 1 3 ‑ ‑ 1@ 17.3
Exenteration 4 ‑ ‑ ‑ 4* 3 ‑ ‑ 1# 13
LFU without treatment 6 ‑ ‑ ‑ ‑ ‑ ‑ ‑ ‑
@
Regressed partially with interferon injections and underwent wide local excision; ^EBRT was advised, defaulted and did not receive EBRT; #Recurrence in orbit;
*1 case underwent radicle lymph node dissection with exenteration; @Recurrence in preauricular lymph node. CR: Complete regression, PR: Partial regression,
LFU: Lost to follow up, Rec: Recurrence, EBRT: External beam radiotherapy

Table 3: Details of medical management

Medical therapy (n) n (%) CR (%) PR (%) LFU Time taken to achieve CR (mean)
Rx with interferon (39)
Eye drops 26 (66.7) 17 (65.38) 7 (26.92) 2 8 weeks
Perilesional inj. 13 (33.3) 09 (69.23) 3 (23.01) 1 6 weeks
Total 39 26 (66.67) 10 (25.64) 3
Rx with MMC* (n=8) 8 (20.5) 7 (87.5) 1 (12.5) 0 4.5 weeks
Overall total 39 33 (84.61) 3 (7.7) 3 (7.7%)
CR: Complete resolution, PR: Partial resolution, LFU: Lost to follow up. *8 of 10 cases that achieved PR with interferon were treated with MMC, while rest 2
cases underwent wide local excision

a b c d e

f g h i j
Figure 4: (a) Clinical picture showing diffuse gelatinous ocular surface squamous neoplasia left eye; (b) complete resolution posttreatment with
topical interferon; (c) large nodular ocular surface squamous neoplasia left eye, (d) posttreatment photo after immunoreduction and wide local
excision, (e) large papillary ocular surface squamous neoplasia right eye with (f) intraocular invasion into the ciliary body area (arrows) on ultrasound
biomicroscopy; (g) healthy anophthalmic socket postenucletion and wide local excision; (h) same eye with artificial eye in place; (i) diffuse ocular
surface squamous neoplasia with corneal melt right eye with orbital involvement; (j) postexenteration healthy socket lined by skin
[Downloaded free from http://www.ijo.in on Wednesday, February 19, 2020, IP: 223.185.151.47]

940 Indian Journal of Ophthalmology Volume 65 Issue 10

Statistical analysis involvement and were eventually picked up on UBM. However,

Treatment outcome could not be compared between different their mean tumor height was greater (4.3 mm); there was a
tumor grades due to a skewed distribution of cases on AJCC previous history of surgery in three cases, and one patient
classification. No statistically significant difference was noted was HIV‑positive. Therefore, thicker tumors in the setting of
in the clinical grades of tumor (small, large, and diffuse) using a previous surgery/biopsy or immunocompromised status
ANOVA with various parameters such as age (P = 0.21), duration should be considered as a high‑risk feature for an intraocular
of complaints (P = 0.16), clinical appearance (P = 0.17), growth extension. UBM should be done in all such cases to pick up the
pattern (P = 0.22), presence of leukoplakia (P = 0.56), presence silent intraocular extension.
of pigmentation (P = 0.43), location of tumor (P = 0.61), and At our center, we have devised our own clinical classification
duration of treatment (P = 0.36). In the conservative treatment scheme (small, large and diffuse) based on the clock hours of
group, the treatment outcome with medical management did limbal involvement and maximal basal diameter, which is
not correlate with any tumor characteristic, including tumor used to decide treatment for tumors without intraocular or
dimension. orbital extension (T1, T2, and T3). We adhere to the following
protocol for treatment: Surgical excision or topical/peri‑lesional
Discussion interferon therapy for small tumors, perilesional/topical
OSSN is a common lesion in tropical countries. In a recent interferon treatment for large tumors and topical interferon
study from the developing world, extensive OSSN was treatment for diffuse tumors. Interferons are used as the
reported to be the most common conjunctival lesion requiring first‑line conservative therapy. MMC is given if there is partial
exenteration.[17] The pathogenesis of OSSN is multifactorial. or no regression with interferon. This classification shows a
Risk factors for OSSN in our study were similar to those more even distribution of OSSN cases as compared to AJCC
reported in the literature, including ultraviolet radiation, classification where the distribution is skewed toward T3
cigarette smoking, old age, male gender, ocular trauma/ stage [Table 1]. However, the treatment outcome of OSSN with
surgery, and immunosuppression.[6‑9] In the current study, a medical management does not show any correlation with the
majority of cases presented during the fifth to sixth decade size as reported by various studies in the literature.[27] Hence,
with a marked male preponderance (82%). Similar findings a classification based on tumor size will not predict treatment
have been reported in other studies.[18‑21] However, studies from outcome but can provide a guide for an appropriate treatment
Africa report a younger age of onset and female predominance option for OSSN.
that has been linked with high HIV prevalence.[9,10,22] Younger
Sixty‑seven percent (67%) of tumors in our study were
age of presentation in HIV‑positive individuals has also been
large/diffuse. Seventy‑five percent (six out of eight) of tumors
reported from other developing countries.[23‑25] In the current
with orbital extension were large and 67% (4 out of 6) of
study, the mean age of presentation in immunocompromised
tumors with intraocular extension were diffuse. The mean
patients was significantly lower (34 years). Furthermore,
duration of symptoms was longer in tumors with orbital
recent studies from the subcontinent have quoted a high
and/or intraocular extension (1.89 ± 1.2 years). Mean tumor
incidence (38%) of HIV in young onset OSSN (<40). However,
height of OSSN on UBM with orbital and intraocular
the findings of our study do not support the same.[26]
involvement was 5.9 mm and 4.3 mm respectively, that was
The majority of tumors in our study were nodular (61.4%) or more than the overall mean height (2.93 mm). Hence, in our
gelatinous (61.4%) and had limbal involvement (96%). Chauhan study majority of advanced tumors were larger and thicker
et al.[20] and Dandala et al.[23] also reported nodular form as the than the mean cohort, as was also seen by Kao et al. in a
most common morphological growth pattern. retrospective study of 612 OSSN cases and have a longer
duration of pathology.[21]
In our cohort, according to AJCC classification, the majority
of tumors (80.7%) belonged to T3 stage. There was only one eye Metastasis is rare in OSSN with a reported incidence of
with T2 stage OSSN. As the limbus is the most common site of 0%–16% in cases of squamous cell carcinoma.[29] Metastasis was
origin for OSSN, larger lesions are likely to involve adjacent seen in 6% (3/60) cases in the current study, all of which were
cornea. Hence, only a small percentage of tumors classify as in T4 tumors. Among these, metastasis to draining lymph node
T2 (larger than 5 mm and not involving cornea/other adjacent was seen in one case (2%) at presentation and in another (2%)
structures). The percentage of OSSN presenting in stage T2 on follow‑up, and orbital recurrence with metastasis to the
reported in other studies varies from 0% to 7%.[27,28] Hence, central nervous system was seen in one case.
we agree with other authors that the current staging system
In the present study, over all (44/50) 88% patients were
needs to be modified.
disease free at a mean follow up of 13.3 months. Three
OSSN with intraocular involvement are clubbed in AJCC cases (6%) showed recurrence at a mean follow up of around
T3 grade along with those having extension into other adjacent 5.67 months in our study. All three cases had T4 disease and
structures such as cornea, sclera, plica, caruncle, lacrimal positive surgical margins for tumor cells on histopathology.
puncta, tarsal conjunctiva, and eyelid margin. We believe Two of these cases defaulted and did not receive EBRT, and
that there should be a separate categorization of tumors with the third patient who received EBRT had a recurrence in the
intraocular involvement, as they require more aggressive draining lymph node. The recurrence rate of 10% to 36%
surgical treatment (enucleation) compared to other T3 stage during a follow‑up of one to 2.5 years have been reported in
tumors. Twelve percent (7/57) of T3 tumors in this study had OSSN.[18,20,30,31] The strength of our study is that the treatment
intraocular extension. On examination, 86% (6/7) of cases outcome for all stages of the tumor has been analyzed. The
did not have any clinical features suggestive of intraocular limitation of our study is a short follow up.
[Downloaded free from http://www.ijo.in on Wednesday, February 19, 2020, IP: 223.185.151.47]

Meel, et al.: Clinical profile and treatment outcome in OSSN patients

October 2017 941

Conclusion Trotti A. AJCC ophthalmic oncology task force: Carcinoma of

the conjunctiva. AJCC Cancer Staging Manual. 7th ed. New York:
To conclude, we present the clinicodemographic profile and Springer; 2010. p. 531‑7.
treatment outcome of patients of all stages of OSSN from a 17. Ali MJ, Pujari A, Dave TV, Kaliki S, Naik MN. Clinicopathological
developing country at a time when management of OSSN is profile of orbital exenteration: 14 years of experience from a tertiary
undergoing a shift toward conservative management. eye care center in South India. Int Ophthalmol 2016;36:253‑8.
18. Kim BH, Kim MK, Wee WR, Oh JY. Clinical and pathological
Financial support and sponsorship characteristics of ocular surface squamous neoplasia in an Asian
Nil. population. Graefes Arch Clin Exp Ophthalmol 2013;251:2569‑73.
Conflicts of interest 19. Shields CL, Demirci H, Karatza E, Shields JA. Clinical survey
of 1643 melanocytic and nonmelanocytic conjunctival tumors.
There are no conflicts of interest. Ophthalmology 2004;111:1747‑54.

References 20. Chauhan S, Sen S, Sharma A, Tandon R, Kashyap S, Pushker N, et al.

American joint committee on cancer staging and clinicopathological
1. Lee GA, Hirst LW. Ocular surface squamous neoplasia. Surv high‑risk predictors of ocular surface squamous neoplasia: A
Ophthalmol 1995;39:429‑50. study from a tertiary eye center in India. Arch Pathol Lab Med
2. Yang J, Foster CS. Squamous cell carcinoma of the conjunctiva. Int 2014;138:1488‑94.
Ophthalmol Clin 1997;37:73‑85. 21. Kao AA, Galor A, Karp CL, Abdelaziz A, Feuer WJ, Dubovy SR,
3. Gichuhi S, Sagoo MS, Weiss HA, Burton MJ. Epidemiology of et al. Clinicopathologic correlation of ocular surface squamous
ocular surface squamous neoplasia in Africa. Trop Med Int Health neoplasms at Bascom Palmer Eye Institute: 2001 to 2010.
2013;18:1424‑43. Ophthalmology 2012;119:1773‑6.
4. Porges Y, Groisman GM. Prevalence of HIV with conjunctival 22. Spitzer MS, Batumba NH, Chirambo T, Bartz‑Schmidt KU,
squamous cell neoplasia in an African provincial hospital. Cornea Kayange P, Kalua K, et al. Ocular surface squamous neoplasia as
2003;22:1‑4. the first apparent manifestation of HIV infection in malawi. Clin
Exp Ophthalmol 2008;36:422‑5.
5. Balint GA. Situation analysis of HIV/AIDS epidemic in sub‑saharan
Africa. East Afr Med J 1998;75:684‑6. 23. Dandala PP, Malladi P, Kavitha. Ocular Surface Squamous
Neoplasia (OSSN): A retrospective study. J Clin Diagn Res
6. Gichuhi S, Ohnuma S, Sagoo MS, Burton MJ. Pathophysiology of
2015;9:NC10‑3.
ocular surface squamous neoplasia. Exp Eye Res 2014;129:172‑82.
24. Kamal S, Kaliki S, Mishra DK, Batra J, Naik MN. Ocular surface
7. Napora C, Cohen EJ, Genvert GI, Presson AC, Arentsen JJ,
squamous neoplasia in 200 patients: A case‑control study of
Eagle RC, et al. Factors associated with conjunctival intraepithelial
immunosuppression resulting from human immunodeficiency virus
neoplasia: A case control study. Ophthalmic Surg 1990;21:27‑30.
versus immunocompetency. Ophthalmology 2015;122:1688‑94.
8. Lee GA, Hirst LW. Retrospective study of ocular surface squamous
25. Pradeep TG, Gangasagara SB, Subbaramaiah GB, Suresh MB,
neoplasia. Aust N Z J Ophthalmol 1997;25:269‑76.
Gangashettappa N, Durgappa R, et al. Prevalence of undiagnosed
9. Gichuhi S, Macharia E, Kabiru J, Zindamoyen AM, Rono H, HIV infection in patients with ocular surface squamous neoplasia in
Ollando E, et al. Clinical presentation of ocular surface squamous a tertiary center in Karnataka, South India. Cornea 2012;31:1282‑4.
neoplasia in Kenya. JAMA Ophthalmol 2015;133:1305‑13.
26. Kaliki S, Kamal S, Fatima S. Ocular surface squamous neoplasia
10. Ateenyi‑Agaba C. Conjunctival squamous‑cell carcinoma as the initial presenting sign of human immunodeficiency virus
associated with HIV infection in Kampala, Uganda. Lancet infection in 60 Asian Indian patients. Int Ophthalmol 2016;
1995;345:695‑6.
27. Shields CL, Kaliki S, Kim HJ, Al‑Dahmash S, Shah SU, Lally SE,
11. Guech‑Ongey M, Engels EA, Goedert JJ, Biggar RJ, Mbulaiteye SM. et al. Interferon for ocular surface squamous neoplasia in 81 cases:
Elevated risk for squamous cell carcinoma of the conjunctiva Outcomes based on the American Joint Committee on Cancer
among adults with AIDS in the United States. Int J Cancer classification. Cornea 2013;32:248‑56.
2008;122:2590‑3.
28. Shah SU, Kaliki S, Kim HJ, Lally SE, Shields JA, Shields CL, et al.
12. Shields JA, Shields CL, De Potter P. Surgical management of Topical interferon alfa‑2b for management of ocular surface
conjunctival tumors. The 1994 Lynn B. McMahan Lecture. Arch squamous neoplasia in 23 cases: Outcomes based on American
Ophthalmol 1997;115:808‑15. Joint Committee on Cancer classification. Arch Ophthalmol
13. Tabin G, Levin S, Snibson G, Loughnan M, Taylor H. Late 2012;130:159‑64.
recurrences and the necessity for long‑term follow‑up in corneal 29. McKelvie PA, Daniell M, McNab A, Loughnan M, Santamaria JD.
and conjunctival intraepithelial neoplasia. Ophthalmology Squamous cell carcinoma of the conjunctiva: A series of 26 cases.
1997;104:485‑92. Br J Ophthalmol 2002;86:168‑73.
14. Nanji AA, Moon CS, Galor A, Sein J, Oellers P, Karp CL, et al. 30. Ramberg I, Heegaard S, Prause JU, Sjö NC, Toft PB. Squamous
Surgical versus medical treatment of ocular surface squamous cell dysplasia and carcinoma of the conjunctiva. A nationwide,
neoplasia: A comparison of recurrences and complications. retrospective, epidemiological study of Danish patients. Acta
Ophthalmology 2014;121:994‑1000. Ophthalmol 2015;93:663‑6.
15. Mishra D, Singh HP. Kuppuswamy’s socioeconomic status 31. Maudgil A, Patel T, Rundle P, Rennie IG, Mudhar HS. Ocular
scale – A revision. Indian J Pediatr 2003;70:273‑4. surface squamous neoplasia: Analysis of 78 cases from a UK ocular
16. Edge SB, Byrd DR, Compton CA, Fritz, AG, Greene, FL, oncology centre. Br J Ophthalmol 2013;97:1520‑4.