Case presentation done by resident doctor

Ppt

1. PG- Dr Devangi Joshi
SR- Dr Shipra
Consultant- Dr Shikha Jain

2. §69 years, Male
§A resident of Haryana
§A retired govt officer by profession

3. §The patient presented with complaints of diminution of vision and
foreign body sensation in his right eye since 1.5 months at the time
of presentation

4. §The patient was apparently well 1.5 months ago when he started
experiencing:
§Diminution of vision
§In his right eye
§Painless
§Gradual in onset
§Progressively increasing over time
§Foreign body sensation in his right eye

5. §No history of similar complaints in the past
§No h/o redness, itching, or increased watering from the eyes
§No h/o discharge from the eyes
§No h/o trauma/ foreign body injury to the eye

6. §H/o presbyopic spectacle use since 15 years
§No similar complaints in the past
§No h/o systemic/ immunocompromised illness in the past
§No h/o any blood transfusions in the past
§No h/o any surgical intervention in the past
§No h/o any topical/systemic drug use

7. §Non-vegetarian by diet
§Normal sleep and appetite
§Normal bowel and bladder habits
§H/o beedi smoking + since 40-50 years (6-8 beedis per day)
§No h/o alcohol consumption
§No h/o multiple sexual partners in the past

8. §No similar complaints in the family

9. §Average built
§Was conscious, well oriented to time, place, person
§PR: 74/min
§BP: 134/82 mmHg in right arm, sitting position
§No pallor, icterus, cyanosis, clubbing, lymphadenopathy

10. RE LE
VISUAL ACUITY AIDED6/36

6/9

COLOR VISIONNormalNormal
HEAD POSTUREStraight with no face turn,
chin lift, head tilt
FACIAL SYMMETRYMaintainedMaintained
EOM Full and free in all gazesFull and free in all gazes

11. RE LE
EYELIDS AND
ADNEXA
Normal lid position , movements , lid margin,
eyelashes and skin of eyelids
Normal lid position, movements, lid margin,
eyelashes and skin of eyelids
LACRIMAL
APPARATUS
Normal puncta, lacrimal sac area , patent
nasolacrimal duct on syringing
Normal puncta, lacrimal sac area , patent
nasolacrimal duct on syringing
CONJUNCTIVANormal palpebral conjunctiva and fornices
Mild palpebral congestion + (temporal> nasal)
Early pinguecula formation in temporal region
Normal bulbar conjunctiva
palpebral conjunctiva and fornices
SCLERANormal with no discoloration , dilated vessels
and any other abnormalities
Normal with no discoloration , dilated vessels
and any other abnormalities

12. CORNEANormal shape and size with corneal sensations
intact
Spheroidal degeneration + at nasal and temporal
areas near the limbus
Transparent, lustrous, avascular with normal
shape, size and corneal sensation intact
EXAMINATION
•Location: 8-9 o’clock position temporally near the limbus
•Multifocal and Patchy involving 2.5 mm x 0.5 mm area
•Yellowish brown in colour
•Form- Sessile, nodular and raised with well-defined margins
•Feeder vessels +
•Fixed to the underlying structure, no intralesional cysts, no ulceration
•Corneal involvement + (patchy and multifocal, whitish in colour, involving till epithelium layer on
slit lamp examination, with no feeder vessels)
•No signs of lymphadenopathy

13. SLIT LAMP PHOTO

14. RE LE
ANTERIOR
CHAMBER
VH gd4, no cells, flare pigmentationsVH gd4, no cells, flare pigmentations
IRIS AND PUPILNormal colour and radial pattern
3mm in size, round in shape, one in number
normal reaction with direct light and swinging
light
Normal colour and radial pattern
3mm size, round shape, one in number, normal
reaction with direct light and swinging light
LENSPhakic , biconvex shape, transparentPhakic , biconvex shape, transparent
Fundus examination Red glow +
Media clear
Disc margins well defined
C:D Ratio- 0.3:1
A:V – 2:3
FR +
Periphery WNL
Red glow +
Media clear
Disc margins well defined
C:D Ratio- 0.3:1
A:V – 2:3
FR +
Periphery WNL
IOP (GAT)12 mmHg12mmHg

15. §Impression Cytology- smear showed very scant cellularity revealing very
occasional mature squamous cells and anucleated squamous cells

16. §Ocular surface squamous neoplasia (OSSN)
§Corneal degeneration (spheroidal degeneration)

17. §Right eye OSSN with corneal involvement with preexisting spheroidal
degeneration of cornea

18. §Topical chemotherapy:
§5- Fluorouracil (5- FU)- 1 cycle is 4 times a day for 1 week followed by 3 weeks
off. 2-4 cycles are necessary
§Topical lubricants

19. After 1 cycle of 5- FU
Vision improved to 6/24 in the R/E

21. §OSSN is the most common tumor of the ocular surface
§Itencompasses a wide and varied spectrum of diseases involving abnormal growth
of dysplastic squamous epithelial cells on the surface of the eye.
§The termOSSNwasgivenbyLeeandHirstin1995
§Worldwide incidence is 0.02 to 3.5 cases per 100,000 people
§Males> Females
§More common in the elderly age group (6thto 7thdecade)
§Theincidenceishigherincountries located close to the equator

22. §Excessive exposure to UV radiation
§Heavy cigarette smoking
§Immunosuppressive conditions: HIV infection (AIDS), chronic use of
immunosuppressants, post-organ transplantation
§Xeroderma pigmentosum
§Ocular surface injury
§Exposure to chemicals
§Vit A deficiency
§HPV infection

23. §SYMPTOMS: Redness and ocular irritation
§SIGNS:
§typically presents as a fleshy sessile lesion adjacent to the limbus in the interpalpebral
region involving the cornea and/ or bulbar conjunctiva
(Mutations inthelimbal stem cells might be the reason for the limbal location)
§The lesion maybe
§Flat/elevated
§Localised/ diffuse
§Varying degreesofsurfacekeratin
§Feeder vessels and or intrinsic vascularity
§Pearly greytopinkishredincolour with varying patterns of pigmentation

24. §Based on the number of clock hours of limbal involvement or maximum basal
diameter, the tumour can be classified as
§Small (<5mm basal diameter)
§Large (6- 15mm basal diameter or >3-6 clock hours)
§Diffuse (>15mm basal diameter or >6 clock hour)
§Multifocal OSSN- is reported in 4-26% of cases. It is described by the presence of 2
tumours separated by a minimum of 5mm distance in between them.
§Aggressive variants of SCC are
§Spindle cell variant
§Adenoid variant
§Mucoepidermoid variant

26. 1.Dysplasia
§Lesions exhibit varying degrees of cellular atypia that may involve varying thickness of the
epithelium and show epithelial cell disorganization and loss of normal cell polarity
§Classified into
§Mild dysplasia (atypical cells occupying the lower 1/3rd of the epithelium)
§Moderate dysplasia (extending to the middle 1/3rd of the epithelium)
§severe dysplasia (full thickness)
2.Carcinoma in situ (CIN)
§CIN lesions contain a mixture of spindle cells and epidermoid cells.
§There is disorganization of the cells, abnormal polarity, and an increase in the nuclear -to-
cytoplasmic ratio.Mitotic figures are sometimes seen.
§On pathology, there is a characteristic sharp demarcation line between normal and abnormal
epithelium
3.Invasive squamouscellcarcinoma (SCC)
§The basement membraneoftheepitheliumisbreachedandthesubepithelialtissueofthe
conjunctiva isinvaded
§Show surface keratinisation with cellular pleomorphism, hyperplastic and hyperchromatic cells,
dyskeratosis, keratin pearls, loss of cellular cohesiveness and atypical mitotic figures.

27. §Slit lamp examination

28. §Rose Bengal stain- stains the dead, degenerating and devitalized tissue
§Fluorescein stain- delineates the tumour margins especially on the corneal
surface
§Anterior segment optical coherence tomography (AS-OCT)
§Features of OSSN on ASOCT are
§Thickened epithelium
§Hypereflective epithelium
§Abrupt transition from normal to abnormal epithelium
§Back shadowing

29. §Exfoliative cytology
§helps in the diagnosis of neoplastic epithelial cells as they have poor cell adherence and
tend to desquamate. It uses a small cytobrush to obtain the sample.
§Impression cytology
§Simple, inexpensive and non-invasive method
§Uses cellulose acetate filter paper sheets
§Confocal microscopy
§helpful in guiding treatment since it is able to reveal cellular details
§Indicates hyperreflective pleomorphic dysplastic cells withincreased N: C ratio, well
border between neoplastic and normal epithelium and loss of sub basal corneal nerves
§Characteristic “starry sky” appearance
§Ultrasound biomicroscopy
§Helps indeterminingthethickness of the lesion and the extent of introcularinvasion
when present
§Orbital imaging
§By CT or MRI in cases with forniceal involvement to rule out any orbital extension

31. The different modalities available for OSSN treatment include:
§Wide surgical excision
§Cryotherapy
§Chemotherapy
§Immunotherapy
§Antiviral medications
§Topical or sub- conj anti- VEGF
§Radiotherapy
§Photodynamic therapy
§Extended enucleation
§Orbital exenteration

33. Indications:
§>2 quadrants of conjunctival involvement
§>180 degrees of limbal involvement (>3 or 4 clock hours)
§Clear corneal extension encroaching the pupillary axis
§Positive margin after excision
§Patient not fit for surgery

34. 4 times a day (4 days on
and 3 days off) for 4
weeks followed by 3
weeks drug holiday is
one cycle of treatment
4 times a day for 1 week
followed by 3 weeks off is
1 cycle
Topical dose is 4 times a
day