Abstract
Introduction
Intraocular localization of conjunctival squamous cell carcinoma (SCC) is due to scleral or corneal invasion. Herein, we describe the clinical and histopathological findings in four cases of SCC complicated by intraocular invasion, and we review cases reported in the literature and their management. We retrospectively collected and analyzed clinical characteristics, histopathology, management, and follow-up data from 4 patients with conjunctival SCC complicated by intraocular invasion. We reviewed the literature and summarized cases of intraocular invasion by conjunctival SCC reported over the last 30 years.
Case Presentations
Two patients presented with intraocular invasion by conjunctival SCC at diagnosis. The two others developed intraocular invasion as recurrence of conjunctival SCC, previously treated with excisional biopsy and adjuvant radiotherapy. All 4 cases had a previous history of conjunctival surgery, but no history of intraocular surgery. Three patients were managed with modified enucleation, including one that required adjuvant orbital radiotherapy. One patient required orbital exenteration. Histopathology analysis showed a well-differentiated conjunctival SCC in all cases. None developed distant localization after at least 2.5-year follow-up.
Discussion/Conclusion
Intraocular invasion is a rare complication of conjunctival SCC. Appropriate treatment in a tertiary center and long-term follow-up are highly recommended.
Keywords: Conjunctiva, Squamous cell carcinoma, Anterior chamber, Enucleation, Radiotherapy
Introduction
Conjunctival squamous cell carcinoma (SCC) is an ocular surface malignancy arising from the conjunctival epithelium affecting mostly adults, with a predominance in middle-aged and elder individuals. It is most often located in the interpalpebral area of the perilimbal conjunctiva. It clinically appears as a nodule or a conjunctival fleshy and gelatinous thickening. Excisional biopsy is necessary to determine whether the neoplasm is intraepithelial (in situ SSC) or invades the underlying stroma (infiltrative SSC). In the latter, treatment should be completed with local irradiation, by either brachytherapy, external photon therapy, or proton-beam therapy according to tumor localization, and availability of the techniques that differ across centers [1, 2].
Intraocular invasion may exceptionally complicate infiltrative conjunctival SSC [3–6]. The intraocular invasion is either present at diagnosis of conjunctival SSC or usually develops during the first year after the initial excisional biopsy.
Here, we describe 4 cases of conjunctival SCC that have progressed to intraocular invasion and were treated in our tertiary center, summarized in Table 1. Of these cases, two occurred with a delayed onset (up to 14 years) after excisional biopsy and local adjuvant radiotherapy.
Table 1.
Summary of 4 cases of intraocular invasion by conjunctival squamous cell carcinoma
| Case | Age | Sex | Previous surgery | Clinical data | Histo-pathologic analysis | Conjunctival size, mm | Treatment | Interval between SCC notification and intraocular invasion | Follow-up and survival |
|---|---|---|---|---|---|---|---|---|---|
| #1 | 86 | F | Yes (excision biopsy) | Temporal limbus; adjacent white mass of the anterior chamber and retrocorneal precipitates | Well-differentiated squamous cell carcinoma | No conjunctival tumor clinically visible | Modified enucleation | 14 years | 3 years Mt− |
| #2 | 78 | M | Yes (suspected pterygium) | Nasal limbus retrocorneal precipitates | Well-differentiated squamous cell carcinoma | No conjunctival tumor clinically visible | Modified enucleation | 2 years | 7 years Mt− |
| #3 | 68 | F | Yes (suspected pterygium) | Nasal limbus anterior chamber inflammation, corneal edema, white mass in iridocorneal angle | Well-differentiated squamous cell carcinoma | ND | Modified enucleation + radiotherapy | <2 months (2 years of presumed previous evolution) | 3 years Mt− |
| #4 | 49 | M | Yes (suspected pterygium) | Nasal limbus; no sign of intraocular invasion | Well-differentiated squamous cell carcinoma | D = 20 | Exenteration | <6 months (2 years of presumed previous evolution) | 2.5 years Mt− |
D, diameter; F, female; M, male; Mt, metastasis; ND, no data.
We reviewed cases of intraocular invasion by conjunctival SCC published over the past 30 years (from 1992 to 2022). We summarized their clinical characteristics, management, and evolution during follow-up in Table 2.
Table 2.
Literature review of cases of conjunctival squamous cell carcinoma with intraocular invasion, from 1992 to 2022
| Publication, case # | Age | Sex | Previous surgery | Clinical data | Histopathologic analysis | Conjunctival size (mm if not specified) | Treatment | Interval between SCC diagnosis and intraocular invasion | Follow-up and survival |
|---|---|---|---|---|---|---|---|---|---|
| Char et al. [7] (1992) | |||||||||
| #1 | 58 | F | Yes (excision biopsy and scleral graft) | Temporal limbus; white mass in the anterior chamber adjacent to the conjunctival tumor | SCC | ND | sclera-iris-ciliary body resection | 6 months | 3 years Mt− |
| Gündüz et al. [8] (1998) | |||||||||
| #1 | 89 | F | Yes (excision biopsy and discovering of a wound leak through scleral dehiscence) | Nasal limbus; intraocular inflammation and mass in the posterior chamber | Mucoepidermoid carcinoma | Clock hours involved: 2 h–4 h | Excisional biopsy, cryotherapy, and plaque radiotherapy then modified enucleation then, exenteration (recurrence) | 5 months | 2 years Mt− |
| Pan-American Lecture, Shields et al. [3] (1999) | |||||||||
| #1 | 51 | M | Yes (previous SCC) | Nasal limbus, sign of iridocyclitis and adjacent white mass in the anterior chamber, and glaucoma | Well-differentiated SCC | D = 8*8; T = 5 | Exenteration | 12 months | 1 year Mt− |
| #2 | 72 | M | Yes (conjunctival dysplasia) and cataract surgery | Nasal limbus; intraocular inflammation, glaucoma, clumps of yellow-white cellular material | SCC | No conjunctival tumor clinically visible | Modified enucleation | <8 months | 7 years Mt− |
| #3 | 55 | F | Yes (suspected pterygium, no histological analysis) | Nasal limbus; uveitis, glaucoma, opacification of the nasal third of the cornea | SCC | Diffuse thickening of the conjunctiva nasal | Modified enucleation | 5 years | 5 years Mt− |
| #4 | 89 | F | Yes (excision biopsy) | Nasal limbus: intraocular inflammation, intraocular mass | Mucoepidermoid carcinoma | ND | Modified enucleation then exenteration | 3 months | 3 years Mt− |
| #5 | 58 | M | Yes (squamous dysplasia) | Nasal limbus; conjunctiva; glaucoma, white mass in the anterior chamber angle nasally | SCC | ND | Modified enucleation | 8 months | 1 year Mt− |
| Char et al. [9] (2002) | |||||||||
| #1 | 31 | ND | No | Treated for scleritis with oral corticosteroids; nasal sup limbus, OG; white in the anterior chamber angle | SCC | Clock hours involved: 8 h–2 h 30 | Enucleation (failure of iris-ciliary body-choroidal resection) | ND | Mt− |
| #2 | 80 | ND | Yes (several “atypical pterygium” surgery) | Temporal limbus and cornea, OD; scleral thinning with peaked pupil | Mucoepidermoid conjunctival carcinoma | Clock hours involved: 6 h–10 h | Sclera-iris-ciliary body resection | ND | Mt− |
| Ramonas et al. [10] (2006) | |||||||||
| #1 | 91 | F | Yes (cataract surgery) | Nasal limbus; white mass in the anterior chamber nasally, satellite tumor nodules on the iris | Moderate to well-differentiated SCC | Clock hours involved: 1 h–5 h 30 | Proton-beam therapy | ND | 9 months Mt− |
| Tulvatana and Tirakunwichcha [11] (2006) | |||||||||
| #1 | |||||||||
| Zhang et al. [12] (2007) | |||||||||
| #1 | 66 | F | No (anti-inflammatory drugs) | Nasal limbus; white flaky mass. Iris invasion on UBM | SCC | D = 8*6 | Exenteration | 0 | Mt− |
| Rootman et al. [13] (2012) | |||||||||
| #1 | 72 | M | Yes (combined cataract and pterygium surgery) | Intraocular inflammation and white mass in ciliary body, secondary glaucoma | Moderately differentiated SCC | ND | Enucleation | 3 weeks | ND |
| #2 | 85 | M | Yes (cataract 4 years before and pterygium surgery) | Intraocular inflammation and white mass in the iris | Well-differentiated SCC | ND | Enucleation | 5 months | ND |
| Arepalli et al. [14] (2014) | |||||||||
| #1 | 74 | M | ND | ND | SCC | D = 8; T = 3 | Excisional biopsy, cryotherapy+ plaque radiotherapy | 0 | 96 months Mt− |
| #2 | 63 | M | ND | ND | SCC | D = 20; T = 4 | Excisional biopsy, cryotherapy+ plaque radiotherapy | 0 | 70 months Mt− |
| #3 | 76 | M | ND | ND | SCC | D = 10; T = 4 | Excisional biopsy, cryotherapy+ plaque radiotherapy | 0 | 12 months Mt− |
| Cano-Suarèz et al. [15] (2017) | |||||||||
| #1 | 70 | M | Yes (excision biopsy) | Temporal limbus;anterior uveitis and corneal edema | Well-differentiated SCC | D = 17 × 15; T = 3.4 | Enucleation (after failure of excisional biopsy + plaque therapy) | 6 weeks | ND |
| Meel et al. [5] (2019) | |||||||||
| #1 | 35 | M | Yes (corneoscleral patch graft) | Choroidal mass | Well-differentiated SCC | D = 7*5; T = 3.5 | Enucleation | ND | 30 months Mt− |
| #2 | 62 | M | No | Uveal show, pupillary peaking | Moderately differentiated SCC | D = 14*10; T = 4.5 | Enucleation+ radiotherapy | ND | 7 months Mt+ |
| #3 | 51 | M | Yes (excision biopsy) | Corneal melt | Well-differentiated SCC | Diffuse | Exenteration | ND | 32 months Mt− |
| #4 | 50 | M | Yes (excision biopsy) | Ciliary body invasion on UBM | Well-differentiated SCC | D = 10*12; T = 5.5 | Enucleation | ND | 20 months Mt− |
| #5 | 80 | M | No | Anterior segment and ciliary body invasion on UBM | Moderately differentiated SCC | D = 12*16; T = 6.5 | Exenteration | ND | 16 months Mt− |
| #6 | 40 | M | Yes (excision biopsy) | Anterior segment and ciliary body invasion on UBM | Well-differentiated SCC | D = 18*12; T = 6.9 | Enucleation | ND | 18 months Mt− |
| #7 | 52 | F | Yes (excision biopsy) | Anterior segment and ciliary body invasion on UBM | ND | D = 25*12; T = 3.5 | Lost to follow-up before treatment | ND | ND |
| Kaliki et al. [16] (2020) | |||||||||
| 23 patients | 48 | M = 70%; F = 30% | 16 (excision biopsy), 2 (intraocular surgery) | HIV infection in 8 | Well-differentiated: 17 | D = 17; T = 4, diffuse in 9 | Modified enucleation: 8 | 7 months | Distant localization: 2 (regional lymph nodes |
| Moderately differentiated: 5 Poorly differentiated: 1 | Exenteration: 15 | No follow-up | |||||||
| Mucoepidermoid carcinoma: 1 | |||||||||
| Feizi and Esfandiari [17] (2022) | |||||||||
| #1 | 87 | M | Yes (excision biopsy + topical erythropoietin following sclera necrosis) | Nasal limbus conjunctival bulge with areas of keratin. Corneoscleral thickening, ciliary body, and iris mass on UBM | Well-differentiated SCC | D = 5.5*4.0 | Enucleation preconized, not followed by # | 4 months | Mt− |
SCC, squamous cell carcinoma; D, diameter; F, female; M, male; Mt, metastasis; ND, no data; T, thickness; UBM, ultrasound biomicroscopy (high-frequency ultrasonography).
Case Reports
From 1995 to 2022, among patients diagnosed, treated, and followed in our center for conjunctival SSC, we identified four cases who developed intraocular extension of SSC. None of these patients underwent intraocular surgery, but all four had a history of previous conjunctival surgery. Two of them were initially treated for infiltrative conjunctival SCC without intraocular invasion at diagnosis and presented a delayed intraocular relapse. The two other cases presented with intraocular invasion of conjunctival SSC at diagnosis. The 4 cases are summarized in Table 1. The presence of distant localization was evaluated by chest, abdomen, and pelvis CT scans for each patient.
Case 1
An 86-year-old woman presented in 2003 with a conjunctival juxtalimbal temporal lesion of the left eye. It was treated by excisional biopsy under local anesthesia, and the histopathological analysis revealed an infiltrative conjunctival SCC with tumor-free surgical margins. No adjuvant therapy was administered. There was no recurrence over the following 11 years, but in 2014 she was referred again for local recurrence (Fig. 1a). The recurrent lesion was removed by excisional biopsy and she received adjuvant photon-beam radiotherapy (52 Gy in 16 fractions). Three years later, the patient presented again with a conjunctival lesion suggesting another local recurrence. Visual acuity was 20/200 and intraocular pressure was 35 mm Hg. Slit-lamp biomicroscopy revealed a conjunctival thickening located temporally, associated with an adjacent white mass within the anterior chamber, and retrocorneal precipitates (Fig. 1b, c). These findings were suggestive of intraocular invasion by recurrent SSC. The patient underwent left eye enucleation with removal of the temporal bulbar conjunctiva. Histopathological analysis confirmed the diagnosis of intraocular invasion by infiltrative SSC. The lesion’s largest diameter was 27 mm and its thickness was 4 mm. Mitotic index was 8 mitoses per 10 fields (highest magnification). Tumor emboli were observed. There was full-thickness scleral infiltration, and infiltration of ciliary body, iris, iridocorneal angle, and corneal stroma. Additional perilesional conjunctival samples were tumor-free (Fig. 1d).
Fig. 1.
Case 1, clinical and histopathological aspect. a Local recurrence in 2014. b Local recurrence in 2017 with anterior chamber localization of the SCC. c Gonioscopy in 2017 showing angle invasion and multiple retrocorneal and iris nodules. d Histopathological analysis. Black arrow: infiltrated sclera. Yellow arrow: intraocular localization of SCC. Head arrow: extraocular localization of SCC.
Photon-beam radiotherapy was performed on the orbit to reduce the risk of local recurrence due to the histopathological characteristics of the tumor. After a 3-year follow-up, the patient is alive without local or distant recurrence.
Case 2
A 69-year-old man presented in July 2011 with an ulcerative conjunctival and limbal lesion of the right eye, located nasally (Fig. 2a). It was initially presumed to be a pterygium and was surgically removed by his attending ophthalmologist under local anesthesia. The histopathological analysis revealed an invasive well-differentiated conjunctival SSC. The patient was referred to our tertiary center for treatment. Because of focal corneal thinning estimated at 80% on slit-lamp biomicroscopy, adjunctive treatments, such as radiation therapy or topical chemotherapy, were contraindicated. Thirteen months later, in September 2012 he presented with a painful and red right eye. Biomicroscopy showed anterior chamber cells, episcleritis, and conjunctival thickening in the nasal sector (Fig. 2b). A conjunctival biopsy was performed and confirmed the local recurrence of SSC. The patient received adjuvant proton-beam therapy (60 Gy in 8 fractions). In May 2013, anterior segment inflammation had resolved, but he presented with hyphema and nasal corectopia, suggestive of an intraocular recurrence of the SCC in the context (Fig. 2c). Gonioscopy revealed a focal whitish infiltration of the iridocorneal angle adjacent to the treated nasal area, and multiple white spots scattered over the iris surface (Fig. 2d, e). Visual acuity was light perception, and intraocular pressure was 4 mm Hg. High-frequency ultrasonography visualized a 9.2 × 2.1-mm mass invading the ciliary body and an advanced focal scleral thinning. The patient was treated by modified enucleation. Histopathological evaluation confirmed the diagnosis of intraocular invasion by a recurrent conjunctival SSC. Mitotic activity was low, but infiltration of the iridocorneal angle, ciliary processes, choroid, and sclera was observed. With a 7-year follow-up, the patient is alive and did not experience local or distant recurrence.
Fig. 2.
Case 2, clinical and histopathological aspects. a Ulcerative lesion after excisional biopsy, July 2011. b Local recurrence in September 2012. c Exclusively intraocular recurrence in May 2013 manifesting by asymmetrical pupil, without lesion on the conjunctiva. d, e Gonioscopy showing anterior chamber invasion. f Histopathological analysis. Black arrow: infiltrated sclera. Yellow arrow: intraocular localization of SCC in the ciliary body.
Case 3
A 68-year-old woman presented with a nasal conjunctival and limbal lesion of the right eye, that she had first noticed 2 years before. Because of the clinical suspicion of pterygium, the lesion was surgically removed by her attending ophthalmologist in September 2019 under local anesthesia with peribulbar injection, followed by reconstruction with amniotic membrane. Histopathological analysis revealed a well-differentiated conjunctival SSC. She was referred to our tertiary center for adjuvant management. Visual acuity was 20/50 and intraocular pressure was 10 mm Hg. Slit-lamp examination showed anterior chamber inflammation, corneal edema, and a white mass occupying the nasal sector of the iridocorneal angle (Fig. 3a). Ultrasound biomicroscopy (UBM, high-frequency ultrasonography) visualized an intraocular mass invading the iris root and ciliary body (Fig. 3b). A biopsy using 25-Gauge forceps (Grieshaber Revolution, Alcon®, Fort Worth, TX, USA) retrieved whitish material, identified by cytological analysis as SSC invading the anterior chamber. A modified enucleation removing the overlying nasal conjunctiva was performed. Histopathology revealed a well-differentiated conjunctival SSC with intraocular extension, invading the sclera, iris, and ciliary body. The lesion largest diameter was 5 mm and its thickness was 4 mm. The patient received adjuvant photon-beam therapy of the orbit (60 Gy in 30 fractions). She has not presented local recurrence or metastasis after 3 years of follow-up.
Fig. 3.
Cases 3 (a, b) and 4 (c, d), clinical and histopathological aspect. a Case 3, clinical aspect at first visit, after pterygium surgery, with anterior chamber localization of SCC. b Case 3, UBM image with intraocular mass dimensions. c Case 4, clinical aspect. d Case 4, histopathological analysis. Black arrow: infiltrated sclera. Yellow arrow: intraocular localization of SCC.
Case 4
A 49-year-old immunosuppressed patient under tacrolimus due to a liver transplant in 2013, had a nasal bulbar conjunctival lesion removed in 2016 without histopathologic analysis, due to the presumed diagnosis of pterygium. In 2019, he presented a recurrence of this lesion that was biopsied in January 2020, showing a non-invasive low-grade squamous-cell lesion. He was referred to our Center for Management in April 2020. The visual acuity was 20/250. The slit-lamp biomicroscopy examination revealed an ulcerated conjunctival thickening of the bulbar conjunctiva nasally (Fig. 3c). The anterior chamber was free of cells or suspect nodules. Dilated fundus examination showed no intraocular extension. The anterior chamber angle was widely open nasally and the lesion was purely conjunctival on UBM. Orbital MRI showed no visible posterior extension. Infiltrative SCC was confirmed on several biopsies. There was no metastasis. Due to the size of the tumor and the impossibility to obtain oncologically safe surgical margins with conjunctival removal, an exenteration was performed. Histopathologic analysis revealed a 20-mm diameter well-differentiated conjunctival and corneal SCC with intraocular extension, invading the iris, the ciliary body, and the choroid (Fig. 3d). Because of his immunosuppressed status, the patient received adjuvant photon-beam radiotherapy on the orbit and cervical lymph nodes (50 Gy in 25 fractions). After 2.5 years of follow-up, the patient was alive without local or distant relapse.
Discussion
In this case series, we presented four cases of intraocular invasion by SCC, with a maximum delay between the diagnosis of SCC and intraocular invasion of 12 years, which is, to our knowledge, the longest delay reported in literature. Moreover, we have summarized in Table 2 the clinical and pathological features, management and follow-up of 48 cases reported in the literature over the past 25 years.
The mean age of our 4 patients was 68 years, and the sex ratio was 1/1. One patient was immunosuppressed. For 2 cases, the intraocular invasion was delayed and was detected during follow-up after 2 and 11 years, respectively. For the two other cases, the intraocular localization was present at diagnosis, but with a history of recurrent pterygium beginning at least two-to-four years before. All 4 patients had a history of previous ocular surface surgery, but no history of intraocular surgery. Noticeably, three of them were initially misdiagnosed as pterygium, inducing delayed and inappropriate management of the initial tumor and possibly focal damage of the sclera during the initial procedure. Three patients presented signs of intraocular invasion such as inflammation or white nodules inside the anterior chamber, and one had high intraocular pressure (35 mm Hg, case 1). The fourth patient required exenteration due to orbital involvement, and the intraocular localization was discovered upon histopathological analysis. None of the patients had fundus abnormalities. On histopathology analysis, all cases had typical SCC without sebaceous, adenosquamous, or mucoepidermoid features.
Based on our institutional database, the annual rate of cases treated for invasive SCC at our center is ∼30 cases/year. Hence, over a 28-year period (1995–2022), ∼27 × 30 = 840 cases with invasive SCC have been managed and the rate of intraocular invasion could be estimated at ∼0.5%.
In the literature, the rate of intraocular invasion varies from 2 to 13%. The high proportion of 13% [4] was reported on a series of 60 patients with SCC, managed without adjuvant radiotherapy. It may be possible that the use of radiotherapy after excision biopsy in selected cases lower this percentage. An important proportion of cases with intraocular extension of SCC could be due to a delayed initial visit and the local evolution of SCC. In our series, no patient had an initial tumor thickness of more than 5 mm, whereas in the literature, many patients had a massive conjunctival tumor (Table 2). However, in all 4 patients from our series, the duration between prior excision biopsy and intraocular invasion was long, from 2 to 14 years. No duration of more than 12 months between initial treatment and intraocular invasion is reported in literature (except for 1 patient from the Pan-American lecture series by Shields et al. [3], who developed intraocular localization of a SCC 5 years after undergone excision of a suspected pterygium. No histological analysis was performed at that time).
At least 36 out of 48 (75%) patients underwent previous ocular surgery. Cases reporting history of superficial surgery for recurrent atypical pterygium, or one or several excision biopsies for conjunctival SCC may be explained by multifactorial mechanisms, such as scleral or limbal microarchitecture perturbation, local inflammation, weakening and thinning of the sclera and/cornea leading to easier invasion by the SCC through the eye wall. History of intraocular surgery had been reported in a few cases [10, 13, 17–19], usually performed in the case of misdiagnosed or subclinical conjunctival SCC. In those cases, intraocular invasion may have occurred by direct intraocular insemination of tumor cells by surgical instruments.
The histopathological type of SCC could also modulate the risk of anterior chamber invasion. Surprisingly, the 4 patients from our series presented well-differentiated SCC, presumably less aggressive than moderate to non-differentiated SCC. However, well-differentiated SCC may also be more resistant to radiotherapy treatment. Aggressive variants of SCC at higher risk for intraocular invasion were identified in the literature search, such as mucoepidermoid [20], spindle-cell [21], and nodulo-ulcerative carcinoma [22].
Immunosuppression, an established risk factor for SCC, could also favor intraocular invasion, especially in patients under immunosuppressive therapy, or with HIV or tuberculosis [11, 16]. However, a study comparing the incidence of intraocular extension of SCC between HIV-positive and HIV-negative patients showed no differences between both groups [23].
In most cases reported in the literature, intraocular invasion was suspected on clinical examination. In some instances, UBM was a helpful tool to detect intraocular localization [9, 12, 24, 25]. However, UBM did not show any images of intraocular invasion for our patient 4, probably because of a low intraocular tumor volume at the time of the UBM exploration, and a subsequent rapid tumor growth.
All 4 patients from our series were treated without conservation of ocular globe, in order to obtain safe surgical margins and to avoid local and distant recurrences. Similarly, in the literature most reported cases required enucleation or exenteration. A few patients were treated with excisional biopsy, cryotherapy, and plaque brachytherapy [8, 14, 15] or with iris-ciliary body-choroidal resection [7, 9]. One reported patient was treated with excisional biopsy and no adjuvant treatment because of scleral necrosis. Topical erythropoietin had been instilled on the corneal scaring, and according to the authors, may have favored subsequent intraocular invasion [17]. However, conservative treatments do not allow safe oncologic surgical margins, and recurrences occurred in ∼50% of cases managed by both techniques, that ultimately required enucleation. A treatment with proton-beam therapy only after excisional biopsy has also been reported, without recurrence over a short follow-up of 9 months [10]. In our series, the 4 cases were not eligible to primary irradiation (by brachytherapy, proton therapy, or external photon therapy) due to the impossibility to assess the exact microscopical limits of intraocular spread, and because we usually indicate irradiation to treat microscopic residual disease, and believe that the delivered dose would have not been sufficient to control macroscopic disease before surgical removal.
The overall prognosis seems to be favorable once the intraocular invasion is diagnosed and managed appropriately, as none of our patients and only three of the 48 cases described in literature have developed distant relapses. Only 1 case presented systemic metastasis at 7 months of follow-up and died from it after refusing treatment [5], and two cases developed cervical lymph node invasion [16].
In conclusion, intraocular invasion is a rare complication of SCC due to multiple causes, such as a relatively long evolution of SCC, its histopathological type, immunosuppression, history of multiple procedures and inappropriate management after initial misdiagnosis – often as pterygium. After clinical suspicion of SCC, rapid management in a tertiary center, if possible, is recommended. Strict surgical rules should be followed, and histopathological analysis must be performed on every excised specimen even if a pterygium is initially suspected. For invasive SCC, adjuvant radiation therapy should be administered on the tumor site to reduce the risk of local or distant recurrence. Long-term follow-up is mandatory to detect local, distant, or intraocular relapses.
Statement of Ethics
Ethical approval is not required for this study in accordance with national guidelines. All subjects have given their written informed consent to publish their case, including images.
Conflict of Interest Statement
The authors have no conflicts of interest to declare.
Funding Sources
No funding was received for this study.
Author Contributions
Ysé Borella wrote the manuscript, Ysé Borella, Livia Lumbroso, Christine Lévy, Sophie Gardrat, Jerzy Klijanienko, Denis Malaise, Rémi Dendale, Nathalie Cassoux, and Alexandre Matet participated in collecting, analyzing the results. Livia Lumbroso, Nathalie Cassoux, and Alexandre Matet reviewed the manuscript.
Funding Statement
No funding was received for this study.
Data Availability Statement
All data generated or analyzed during this study are included in this article. Further inquiries can be directed to the corresponding author.
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Associated Data
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Data Availability Statement
All data generated or analyzed during this study are included in this article. Further inquiries can be directed to the corresponding author.