A 62-year-old woman was referred with chronic redness, irritation and photophobia of the left eye for several months. She had no prior history of eyelid surgery or trauma. Her past medical history was significant for hypothyroidism. Multiple treatment regimens, including artificial tears, topical corticosteroids and bandage contact lens, had been tried. On examination, the best-corrected visual acuity was 20/20 in both eyes. Her left superior bulbar conjunctiva was injected with engorged and tortuous episcleral vessels . In addition, there was a single filament present on the superior corneal surface but no epithelial leukoplakia was noted. The diagnosis was felt to be SLK on clinical grounds and treatment with fluorometholone 0.1% ophthalmic ointment four-times daily was started. At the 3-week follow-up, her symptoms improved and the superior limbus and conjunctiva had not changed. Prednisolone acetate 1% eyedrops three-times daily was added and, 1 month later, she reported resolution of her symptoms and had decreased superior conjunctival injection. Over the next 3 months, she was treated for sporadic recurrence of her symptoms with tapering doses of corticosteroid drops and ointment. Within a few weeks of tapering the topical corticosteroids, she had recurrence of her symptoms. At this point, the superior bulbar conjunctival lesion developed an elevated, fibrinous appearance that extended onto the corneal epithelium . This area of superior limbus was also associated with limited peripheral corneal neovascularization. Because of the evolving clinical appearance and the frequency and severity of her symptoms, excisional biopsy of the left superior conjunctiva was performed.
Superior conjunctival lesion with thickening, injection and prominent episcleral vessels
Figure 2 Pathology showing acanthotic, nonkeratinized epithelial layer. Dysplasia is noted 2/3 of the way through the specimen. Artificial separations are noted in the tissue from processing. The basement membrane is intact. Chronic inflammation is noted in the (more ...)
Close up view of the superior limbus highlighting peripheral neovascularization and limbal leukoplakia
Pathologic examination with standard hematoxylin and eosin stains revealed diffuse thickening of the epithelium, with focal areas of dyskeratosis, atypia, pleomorphism, prominent nucleoli and clumped chromatin . These changes extended to 50–80% of the epithelial thickness and there was no penetration of the epithelial basement membrane. A diagnosis of OSSN of the conjunctiva was made and the patient was started on mitomycin C 0.02% three-times a day for 3 weeks. On follow-up, the superior corneal epithelium showed persistent leukoplakia and treatment was changed to interferon alfa 2b (IFNα2b) eyedrops (2 million IU/ml) four-times daily, with resolution of clinical findings over 2 months.
Slit lamp photograph showing resolution of the ocular surface squamous neoplasia