Conjunctival Squamous Cell
Carcinoma with Massive
Intraocular Invasion
Fiona Roberts, Glasgow
BAOP, Manchester
7-8th April, 2011
Clinical History
• 75 year old male
• 15 month history of left limbal mass
• Biopsied
Clinical History
• Invasive poorly differentiated squamous cell
carcinoma
• Excision was considered best treatment
However
• Not a good 75 year old and generally frail
• Decision to treat with topical mitomycin C
• Review in 3 months
3 Month Review
• Condition significantly deteriorated.
• Struggling to open the left eye.
• Vision had decreased from 6/24 to hand
movement.
• Mass had increased in size with dystopia
• Rubeosis, posterior synechiae and an anterior
uveitis.
• No fundal view.
• Pressure in the left eye was slightly raised
Pathology
CK14
Pathology Summary
• Squamous cell carcinoma of the conjunctiva
• Extensive intraocular spread
– anterior chamber with malignant epithelial
downgrowth and invasion of trabecular meshwork
– Ciliary body
– Choroid with mass forming posteriorly
• Secondary effects of raised intraocular
pressure
Conjunctival
Squamous Cell Carcinoma
• Relatively uncommon worldwide
• Geographical variation in incidence of 0.02 to
3.5/100,000
• Part of the spectrum of ocular surface squamous
neoplasia (OSSN)
• Occurs in sun-damaged ocular surface usually at
the limbus in elderly males
• Also associated with immunosuppression (AIDS,
Transplant etc.)
Intraocular Invasion of
Conjunctival SCC
• Reported to be rare (2 to 13% of cases)
• Char et al. BJO, 1992 identified approximately
60 reported cases of intraocular invasion
• Since then around a further 18 cases (13 as
part of several series and 5 case reports)
• Even been reported in a 12 year old Haflinger
gelding
Kaps et al. Veterinary Ophthalmology, 2005
Intraocular Invasion - Features
• Most commonly in older patients with one or 2
recurrences
Shields et al. 1999
• Tumour usually located near corneoscleral
limbus
• Heralded by onset of low-grade inflammation
and secondary glaucoma
• A white mass generally was observed in the
anterior chamber angle
• Most cases reported to date confined to anterior
chamber and ciliary body and extension
posteriorly is unusual
Risk Factors 1
• Neglected primary malignancy
– Did failure to excise primary tumour in this case
equate with neglect ?
– Topical mitomycin C is recognised as an effective
treatment of SCC of the conjunctiva
– Thin tumours less than 4mm can show complete
regression even if extensive
– Larger/thicker tumours may show only a partial
response
– Mitomycin C for chemoreduction prior to surgery
Shields et al., Arch Ophthamol, 2005
Risk Factors 2
• Recurrent tumours/Inadequate primary
excision
– 73 year old male who had conjunctival SCC with
intraocular invasion removed by corneoscleral
resection with iridocyclectomy
– Initial excision showed clear margins
– Recurrence one year later in iris and trabecular
meshwork well away from primary tumour
Glasson et al., Arch Ophthalmol, 1994
Risk Factors 3
• Histological tumour type
– Mucoepidermoid carcinomas
• Lacour et al. J Fr Ophthalmol, 1991
• Seitz & Henke, Klin Monbl Augenheilkd, 1995
• Gunduz et al. Ophthalmology, 2000
– Spindle cell squamous carcinoma
• Shields et al., Cornea, 2007
– Both regarded as more locally aggressive and to have
a higher recurrence rate
– However, each histological subtype accounts for few
than 5% of squamous cell carcinomas of the
conjunctiva
Summary
• Intraocular invasion from conjunctival
squamous cell carcinoma is uncommon
• Usually occurs in elderly males with mass at
the limbus
• Involves anterior chamber with signs of
inflammation and raised intraocular pressure
• Extension posteriorly is uncommon
• Ocular prognosis is poor but survival is good