Case
Report Histopaghological Studies Confirm
Rare Carcinoma
Referral for routine red eye reveals limbal tumor.
By
APRIL D. RODGERS, O.D.;STEPHEN J. PHIPPS, M.D.;DANIEL PETLEY, O.D. An
81-year-old white male was promptly referred to the eye clinic with the complaint
of a red eye for the past 1-2 weeks. The referring doctor described redness in
the medial aspect of the left eye that extended onto the cornea with conjunctival
injection. The patient reported no vision loss, pain or foreign body sensation
in the eye. There was no history of surgery or trauma to the eye.
The patient
stated that he had used unspecified drops, given by the pharmacist to “get
the red out,” for four days. His medical history was significant for chronic
obstructive pulmonary disease, colon polyps, bladder cancer, hypertension and
iron deficiency anemia. He was on the following medications: albuterol and ipratropium
bromide for bronchospasm, iron supplements and multivitamins. The patient reported
an allergy to mercury. Diagnostic Data
Best-correct visual
acuity was 20/40 O.U. Pupils were equal, round and reactive to light, with no
afferent defect. Motilities were unrestricted. Confrontation fields were full
by facial Amsler and central finger counting O.U.
Biomicroscopy revealed
a vascularized gelatinous lesion of the inferonasal limbus O.S., with maximal
elevation of 1.5mm and irregular borders. It measured 5mm horizontally by 8mm
vertically. A prominent sentinel vessel originated at the nasal canthus, crossed
the bulbar conjunctiva and extended to the mass. The lesion encroached about 2mm
onto the cornea.
Gonioscopy showed no evidence of invasion of the anterior
chamber. Nuclear sclerosis was present in both eyes. All other anterior segment
structures were unremarkable.
Intraocular pressures were 15mm Hg O.U.
A dilated fundus exam revealed pigmentary changes of the macula O.U. This nuclear
sclerosis appeared to account for the vision loss. The posterior segment was otherwise
unremarkable. Diagnosis
Differential diagnosis included squamous
cell carcinoma, mucoepidermoid carcinoma, carcinoma in situ, squamous papilloma,
dermoid, corneal fibrovascular pannus, inflamed pinguecula or pterygium and lymphoid
cyst. Management
We referred the patient to an ophthalmologist
for immediate evaluation and possible excisional biopsy. The excision occurred
six weeks later. Biopsy showed invasive, well-differentiated squamous cell carcinoma
of the conjunctiva and cornea.
The mass was removed and sent for histopathological
examination. The lesion was highly vascularized and caused significant bleeding
during surgery. After excision, double freeze-thaw cryotherapy was applied to
the tissue surrounding the excision.
At the end of surgery, half-strength
betadine was applied to the eye, followed by Maxitrol ointment (neomycin, polymyxin
B, dexamethasone) and cyclogyl 1%. The eye was patched and covered with a shield.
At 1-day post-op, the patient admitted to taking aspirin qd. He reported
that the eye “oozed blood until last evening, then it stopped.” He had
also complained of aching pain in the left eye, which also ceased the night of
the surgery.
External exam revealed blood-soaked gauze and a large clot
protruding through the eyelids. The clot was removed, and the conjunctiva again
began to bleed. The eye was re-patched repeatedly until the bleeding stopped.
Vessel coagulation was scheduled for the next day, but was canceled because there
was no observable bleeding. The patient was placed on polysporin qid and scopolamine
bid in the left eye. Additional follow-up was scheduled in 3-4 days.
At
1-week post-op, the patient reported that the eye was comfortable with no pain
or foreign body sensation. He continued the medications. Visual acuity in the
left eye was now 20/70, 20/50 pinhole. External exam revealed trace left lower
lid edema. The conjunctiva had mild inferonasal chemosis with resolving subconjunctival
hemorrhage. A 8mm-by-10mm defect was evident in the conjunctiva. The inferonasal
cornea had completely reepithelialized. The anterior chamber was quiet. The left
pupil was round and dilated with drops. IOP was 11mm Hg. We told the patient to
discontinue the scopolamine and taper the polysporin to bid.
At three weeks
post-op, best-corrected visual acuity was 20/50, pinhole to 20/40 O.S. IOP was
17mm Hg. The cornea had completely healed, and the conjunctiva showed thinning
at 7-10 o’clock. All other anterior segment structures were unremarkable.
We discontinued the antibiotic and scheduled follow-up in a few weeks. We will
monitor him closely over the next two years for possible recurrence of the lesion.
Discussion
Tumors
of the conjunctiva and cornea look alike because their stem cells locate at the
limbus. But their anatomy and function are very different.1 There are three general
classes of epithelial tumors (see table above).
Epithelial dysplasia,
carcinoma in situ and squamous cell carcinoma may all represent different stages
of the same disease process.1,3 Invasive squamous cell carcinoma can arise from
these precursors.2 Limbal lesions can be misdiagnosed as chronic conjunctivitis
or conjunctival lesions such as papillomas, pterygia or pingueculae.1
Histopathological
examination is essential.1,2,5 Conjunctival intraepithelial neoplasia exists when
dysplastic cells are present and the basement membrane is intact. If dysplastic
cells breach the basement membrane, then this is invasive squamous cell carcinoma.1
The
incidence of squamous cell carcinoma varies with geography,3 and declines 49%
for every 10° increase in latitude from the equator.3,6 The main risk factor
is sun exposure.3,5 Others are smoking, exposure to petroleum products, human
papilloma virus and herpes simplex virus type 1.1,3
Patients are typically
white, fair skinned, in their 40s and 50s, and typically male (a 6:1 predilection).1-3
Possible autosomal recessive conditions associated with squamous cell carcinoma
are xeroderma pigmentosum and oculocutaneous albinism.3,7 Patients with the former
tend to have a recurrence despite treatment.3
Cryotherapy with surgical
excision decreases the recurrence rates vs. either procedure alone.1 Recurrence
may result from inadequate excision. In surgery alone, the tumor will recur 15-52%
of the time.3 Cryotherapy with excision reduces the rate to 7-22%, with the average
being 12%.3 The lesion tends to return within two years of excision, but it has
been reported to redevelop up to seven years after excision.3,8 Squamous cell
metastasizes in fewer than 10% of cases.1 Tumors of the conjunctiva and
cornea are not a typical finding during routine eye exams. This case shows histopathological
examination is essential for a definitive diagnosis and effective treatment.
Dr.
Rodgers recently graduated from Pennsylvania College of Optometry and now practices
in Butler, Pa. Dr. Phipps is associated with Hershey (Pa.) Medical Center and
Lebanon (Pa.) Veteran’s Affairs Medical Center. Dr. Petley is on staff at
the Lebanon VA Medical Center. 1. Schwartz GS, Holland
EJ. Management of Conjunctiva and Cornea Neoplasia. In: Krachmer JH, Mannis MJ,
Holland EJ, eds. Cornea Volume III Surgery of the Cornea and Conjunctiva. Philadelphia:
Mosby 1997;1911-1924.
2 Arffa RC. Grayson’s Disease of the Cornea Fourth
Edition. Philadelphia: Mosby 1997;707-733.
3. Yang J, Foster CS. Squamous cell
carcinoma of the conjunctiva. Int Ophthalmol Clin 1997;37(4):73-85.
4. Olasode
BJ, Bankole OO, Adeoye AO. Invasive squamous cell carcinoma of limbus: Case Report.
East Afr Med J 1996;73 (9):627-8.
5. Bhattacharyya N, Wenokur RK, Rubin PA.
Metastasis of squamous cell carcinoma of the conjunctiva: a case report and review
of the literature. Am J Otolaryngol 1997;18 (3):217-9.
6. Newton R, Ferlay
J, Reeves G, Beral V, Parkin DM. Effects of ambient solar UV radiation on incidence
of squamous cell carcinoma of the eye. Lancet 1996; 347(9013):1450-1.
7. Yanoff
M, Duker JS. Ophthalmology. Philadelphia: Mosby 1999;5.1:15-17; 5.2:7-8; 7.12:2-4;
10.23:2-3.
8. Lee GA, Hirst LW. Retrospective study of ocular surface squamous
neoplasia. Aust N Z J Ophthalmol 1997:25(4):269-76. |