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Case presentation done by resident doctor
- 1. PG- Dr DevangiJoshi SR- Dr Shipra Consultant- Dr Shikha Jain
- 2. § 69 years,Male § A resident of Haryana § A retired govt officer by profession
- 3. § The patientpresented 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 patientwas 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 historyof 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 presbyopicspectacle 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 bydiet § 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 similarcomplaints 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 ACUITYAIDED 6/36 6/9 COLOR VISION Normal Normal HEAD POSTURE Straight with no face turn, chin lift, head tilt FACIAL SYMMETRY Maintained Maintained EOM Full and free in all gazes Full and free in all gazes
- 11. RE LE EYELIDS AND ADNEXA Normallid 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 CONJUNCTIVA Normal palpebral conjunctiva and fornices Mild palpebral congestion + (temporal> nasal) Early pinguecula formation in temporal region Normal bulbar conjunctiva palpebral conjunctiva and fornices SCLERA Normal with no discoloration , dilated vessels and any other abnormalities Normal with no discoloration , dilated vessels and any other abnormalities
- 12. CORNEA Normal shapeand 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.
- 14. RE LE ANTERIOR CHAMBER VH gd4, no cells, flare pigmentations VH gd 4, no cells, flare pigmentations IRIS AND PUPIL Normal 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 LENS Phakic , biconvex shape, transparent Phakic , 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 mmHg 12mmHg
- 15. § Impression Cytology-smear showed very scant cellularity revealing very occasional mature squamous cells and anucleated squamous cells
- 16. § Ocular surfacesquamous neoplasia (OSSN) § Corneal degeneration (spheroidal degeneration)
- 17. § Right eyeOSSN 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 cycleof 5- FU Vision improved to 6/24 in the R/E
- 21. § OSSN isthe most common tumor of the ocular surface § It encompasses a wide and varied spectrum of diseases involving abnormal growth of dysplastic squamous epithelial cells on the surface of the eye. § The term OSSN was given by Lee and Hirst in 1995 § Worldwide incidence is 0.02 to 3.5 cases per 100,000 people § Males> Females § More common in the elderly age group (6th to 7th decade) § The incidence is higher in countries located close to the equator
- 22. § Excessive exposureto 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: Rednessand 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 in the limbal stem cells might be the reason for the limbal location) § The lesion may be § Flat/ elevated § Localised/ diffuse § Varying degrees of surface keratin § Feeder vessels and or intrinsic vascularity § Pearly grey to pinkish red in colour with varying patterns of pigmentation
- 24. § Based onthe 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 § Lesionsexhibit 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 squamous cell carcinoma (SCC) § The basement membrane of the epithelium is breached and the subepithelial tissue of the conjunctiva is invaded § Show surface keratinisation with cellular pleomorphism, hyperplastic and hyperchromatic cells, dyskeratosis, keratin pearls, loss of cellular cohesiveness and atypical mitotic figures.
- 27. § Slit lampexamination
- 28. § Rose Bengalstain- 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 with increased N: C ratio, well border between neoplastic and normal epithelium and loss of sub basal corneal nerves § Characteristic “starry sky” appearance § Ultrasound biomicroscopy § Helps in determining the thickness of the lesion and the extent of introcular invasion when present § Orbital imaging § By CT or MRI in cases with forniceal involvement to rule out any orbital extension
- 31. The different modalitiesavailable 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 quadrantsof 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 aday (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