This article is more than 5 years old. Information may no longer be current.
Case study: Progression of ocular surface squamous neoplasia after clear corneal phaco
An elderly woman recently had cataract surgery on the same eye that had an untreated lesion.
Click Here to Manage Email Alerts
Ocular surface squamous neoplasia includes precancerous and cancerous epithelial lesions of the conjunctiva and cornea, such as dysplasia, carcinoma in situ and squamous cell carcinoma. We would like to share our experience with a case of ocular surface squamous neoplasia that progressed after clear corneal phacoemulsification.
Case study
A 78-year-old female patient came to us with a history of cataract surgery in the left eye 2 days prior. The surgery was performed at another center. She also gave a history of an elevated lesion in the left eye for the past 2 years. There was no history of pain or rapid growth with the lesion.
 Amar Agarwal |
On examination, there was a pink, papillomatous lesion (Figure 1) with an irregular surface measuring about 7 mm by 4 mm circumferentially along the limbus from 8 o’clock to 11 o’clock. It was not tender and did not bleed on touch. The patient was pseudophakic in the eye. The anterior chamber was within normal limits. Fundus examination showed evidence of age-related macular degeneration.
There were no palpable lymph nodes detected. Her systemic examination was within normal limits. Best corrected visual acuity in the eye was 20/40, and IOP with non-contact tonometer was 14 mm Hg.
The main port of the clear corneal phacoemulsification was at 12 o’clock, about 3 mm from the edge of the lesion, and the side port was at 4 clock hours. Despite explanation to the patient about the suspicious nature of the lesion, she refused any treatment.
On her follow-up visit at 1 month, she gave a history of sudden increase in lesion size with irritation and redness. Slit lamp examination showed an increase in size (Figure 2) of the lesion with the upper edge reaching the 12 o’clock position and extending over the incision site. There was also a definite increase in the amount of extension onto the cornea. IOP was 12 mm Hg, and BCVA was 20/40. No epithelial defect was noted on staining.
The patient underwent en toto excision using no-touch, alcohol-assisted epitheliectomy, conjunctivo-tenonectomy and superficial lamellar sclerectomy with double freeze-thaw cryotherapy to the conjunctival margins. A 2-mm margin was removed on the corneal side, and a keratectomy was done because of deeper corneal involvement seen during surgery. A 4-mm margin was taken on the conjunctival side. Histopathology showed the specimen to be a moderately differentiated squamous cell carcinoma of conjunctiva with clear margins. The patient is at her 3-month postoperative visit with 20/40 BCVA and no evidence of recurrence.
Discussion
There have been various reports on etiologies, management options and intraocular invasion of ocular surface squamous neoplasia. In this case, the reasons for the sudden activity and rapid growth in a tumor of relatively long duration could be due to the proximity of the phacoemulsification ports to the tumor site or due to accidental injury or micro-trauma by intraoperative handling of the tumor. Even though the Bowman’s layer interruption secondary to corneal incision occurred away from the upper limit of the lesion, the tumor extended.
We propose that loss in integrity of Bowman’s layer along with the seeding of tumor cells occurring intraoperatively during handling of the ocular tissues resulted in rapid spread of the tumor intracorneally as well as along the ocular surface. A breach or trauma to the surface epithelium and Bowman’s anywhere on the ocular surface might be a trigger factor for progression of such a tumor. Therefore, we would like to emphasize the importance of diagnosis of any ocular surface lesion preoperatively before phacoemulsification and that treating a suspicious ocular surface condition should be the first priority in any patient with such clinical presentation to prevent postoperative progression.
 Immediate postoperative phacoemulsification picture showing the papillomatous lesion (ocular surface squamous neoplasia) along with phaco ports (main and side ports as shown by arrow). Images: Agarwal A |  One month postoperative phacoemulsification picture showing an increase in the size of the papillomatous lesion. | |
For more information:
- Amar Agarwal, MS, FRCS, FRCOphth is director of Dr. Agarwal’s Group of Eye Hospitals. Prof. Agarwal is the author of several books published by SLACK, Incorporated, publisher of Ocular Surgery News, including Phaco Nightmares: Conquering Cataract Catastrophes, Bimanual Phaco: Mastering the Phakonit/MICS Technique, Dry Eye: A Practical Guide to Ocular Surface Disorders and Stem Cell Surgery, and Presbyopia: A Surgical Textbook. He can be reached at 19 Cathedral Road, Chennai 600 086, India; fax: 91-44-28115871; e-mail: dragarwal@vsnl.com; Web site: www.dragarwal.com.
References:
- Agarwal A. Handbook of Ophthalmology. Thorofare, NJ: SLACK Incorporated; 2005.
- Agarwal A. Phaco Nightmares: Conquering Cataract Catastrophes. Thorofare, NJ: SLACK Incorporated; 2006.
- Agarwal S, Agarwal A, Agarwal A. Phacoemulsification –Two volume set. 3rd ed. Informa Healthcare; 2004.