LLL campaign assists in remote screening of ocular surface squamous neoplasia
Click Here to Manage Email Alerts
The ocular surface extends from the conjunctiva to the cornea, including the fornices and the inner surfaces of the lids.
The conjunctival mucosa is the predominant anatomical structure seen wrapping the entire ocular surface. The limbus and the cornea form the central zone of the ocular surface. The conjunctival stratified squamous mucous membrane is clinically divided as the bulbar surface, which is on the globe, the palpebral portion, which is closely applied on the tarsal surface, and the junction of the bulbar and palpebral known as the fornix. The caruncle is a small mound of medial canthus tissue containing fine hairs, sebaceous glands and sweat glands. The plica semilunaris is a vertical fold of skin lateral to the caruncle.
Ocular surface squamous neoplasia
Ocular surface squamous neoplasia (OSSN) is a rare spectrum of malignant pathologies on the ocular surface. It represents the spectrum of conjunctival and corneal squamous epithelial tumors including conjunctival intraepithelial neoplasia and squamous cell carcinoma. At presentation, the patient often complains about a mass or plaque on the conjunctiva or limbus. Any mass lesion in the exposed part of the conjunctiva, ie, on the bulbar part, is commonly noticed by patients, and therefore they seek early medical advice. However, the regions of the ocular surface that are often hidden by the lids, upper and lower fornices, caruncle and tarsal sides are rarely noticed by patients. This column highlights the need for the examination of the hidden ocular surface for early diagnosis of OSSN.
LLL concept
At our center, we recently started the “LLL” campaign for early detection of OSSN. LLL stands for lifting the lid, looking at the limbus and lowering the fornix.
Lifting the lids, especially the upper lid, will help in seeing the covered regions of the limbus, cornea and conjunctiva. The upper lid acts like a roof and hides the upper bulbar, palpebral and fornix. Thus, on external examination, one can miss the lesions located in the surfaces explained above. By lifting the upper lid, the visibility is improved, and the underlying lesions can be screened (Figures 1a and 1d).
Source: Dhivya Ashok Kumar, MD, FRCS, FICO, FAICO, and Amar Agarwal, MS, FRCS, FRCOphth
Looking at the limbus is essential, as most of the OSSN lesions originate from the limbus (Figures 1b and 1c). The limbus is a circumcorneal transitional zone surrounding the cornea at the corneoscleral junction. It is dominated by totipotent cells or stem cells at the palisades of Vogt, which has a more differentiating property. Thus, neoplasms are common in the limbus.
The fornix is a cul-de-sac that can harbor many lesions or foreign bodies due to gravity and its hidden nature. Lowering the fornix by pulling the lid down, one can observe the bulbar, palpebral and fornix of the lower lid. Burst granuloma and pyogenic granuloma can also be noticed by lowering the lower lid. OSSN can grow unidentified to a large size in the lower fornix, and thus, lowering the fornix (Figure 1e) helps to screen for OSSN.
Role of LLL
The LLL campaign has been initiated for screening in camps with torch light examination. When paramedics go to routine camps in rural regions without slit lamp examination or a trained ophthalmologist, one can follow these simple LLL rules to screen for OSSN. This can be done at any cataract or regular screening camp. It takes less time than a full examination, but it can be helpful to diagnose serious pathologies. High-level training is not required to master the LLL examination because it requires less training to detect any lumps or bumps in the examined region, namely the lid, limbus and fornix.
Preliminary training of paramedics and nonmedical camp associates can be performed in the outpatient department to show how to lift the lid and direct the torch for examination. The paramedics are also shown clinical pictures of previous patients diagnosed with OSSN. This makes them familiar with what they should look for. The paramedics screen patients, and suspicious cases are referred to a tertiary care hospital for specialist examination. If the suspicious lesions are confirmed clinically as OSSN, further treatment is planned. There are various modalities of treatment for OSSN, such as surgical excision, chemotherapy and immunotherapy. If the referred patient’s suspicious lesion is not clinically fitting into OSSN, then observation with clinical photography and follow-up are advised.
LLL at our center
The LLL campaign has been in practice at our center for the past few months. This patient (Figure 2) was referred from a rural camp by the paramedics. Thus, the patient was treated surgically, and histopathology confirmed OSSN. The LLL campaign not only aids to diagnose and treat OSSN in the early stages, but it also prevents vision loss and morbidity. Awareness has been created among health care personnel and staff so that they can help to treat malignancy through early detection.
Conclusion
LLL is a simple, cheap and effective method to screen for OSSN. Through this screening and detection, early management of these vision-threatening malignancies is possible.
- References:
- Kumar DA, et al. Eye Contact Lens. 2018;doi:10.1097/ICL.0000000000000391.
- Kumar DA, et al. Immediate preoperative FD-OCT used to measure ocular surface squamous neoplasia. Ocular Surgery News. www.healio.com/news/ophthalmology/20210429/immediate-preoperative-fdoct-used-to-measure-ocular-surface-squamous-neoplasia. Published May 10, 2021.
- Lee GA, et al. Surv Ophthalmol. 1995;doi:10.1016/s0039-6257(05)80054-2.
- Shields JA, et al. Eyelid, Conjunctival, and Orbital Tumors: An Atlas and Textbook. 2nd ed. Lippincott Williams and Wilkins; 2008:286-305.
- For more information:
- Amar Agarwal, MS, FRCS, FRCOphth, director of Dr. Agarwal’s Eye Hospital and Eye Research Centre, is the author of several books published by SLACK Books, sister company of Healio publisher 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; email: aehl19c@gmail.com; website: www.dragarwal.com.
Collapse
Click Here to Manage Email Alerts