Ocular surface squamous neoplasia (OSSN)- A Case report Dr. Vijay Pratap Singh MLB MEDICAL COLLEGE JHANSI

1. Case presentation
Dr. Vijay Pratap Singh
JR-3
Dept. of Ophthalmology, MLBMC, Jhansi
(U.P.)

2. Personal information
• Name- Gendarani
• Age- 65 year
• Sex- Female
• Add- Kochabhawanr, navabaad, Jhansi u.p.
• MRD No.- 35799

3. Chief complains
• Flashy mass growing towards cornea right eye Х 2 Months
• Redness (RE) Х 2 Months

4. History of present illness
• According to patient’s she was apparently asymptomatic 2
month back when she developed flashy mass growing towards
cornea on right eye which was gradual onset, rapid progressive
and painless in nature and associated with DOV, redness and
F.B. sensation in right eye.
• She also complains on and off and mild to moderate grade
fever not associated with chills, rigor and rashes.
• There is no history of trauma, discharge, watering, and other
ocular complains

5. Past history
• Past history- No history of DM, HTN, TB, and any other
chronic illness.
• No history of significant weight loss.
• No history on Chemo-radiation exposure.

6. Family history
• No significant family history

7. Personal history
• Strict vegetarian by diet.
• Non alcoholic, non-smoker.
• Bladder, bowel habit -N

9. General examination
Inspection-
• Patient well oriented, conscious, no neurological deficit
seen.
• No skin lesions seen.
Palpation-
• Abdomen –soft, non-tender
• No organomegaly noticed.
• No palpable lymph nodes or skin lesions seen

10. Vitals
• Pulse rate- 92/ min
• Respiratory rate- 19/min
• Temperature- 37.4 c
• BP- 140/100 mm of Hg

11. Ocular examination
• Head- centrally placed.
• Forehead – B/L symmetrical.
Right eye Left eye
Vision 6/60 6/18
Perception of light + +
Projection of light Present in all quadrant Present in all quadrant
Orbital margin Intact on palpation Intact on palpation
Eye lid and lashes WNL WNL
Ocular movement WNL in all direction WNL in all direction
Conjunctiva and sclera Flashy mass growing
from Upper fornix and
covering over upper half
of the cornea
Muddy
Cornea Clear
AC ND ND

12. Right eye Left eye
Iris Seems to normal colour
and normal pattern
Normal colour and normal
pattern
Pupils R/R/R R/R/R
Lens Grayish white reflex Grayish white reflex
Fundal glow Poor Poor
Fundus Could not be assessed due
to hazy media
Media hazy
Disc-wnl
FR- dull
Rest wnl
BCVA (Pre-op.) 6/24 6/12

13. Investigation
• Slit lamp- A flashy mass arising from bulbur conjunctiva and
enchoroding over upper half of the cornea with high
vascularity.
• USG B-scan- echogenic lens with vitreous deneration
no sign of intraocular masses both eye
• Chest X-ray- No significant abnormality seen

14. Blood investigations
Hb 12.7 gm/dl
TLC 11000 cells/mm3
Platelet count 69000 cells/mm3
DLC N-65 L-30 E-04 M-01 B-00
PLATELET COUNT 3.29 Lac cells/ mm3
ESR 18 mm/1st hour (wintrobe)
BT & CT 2:10 min, 3:40 min
RBS 85 mg/dl
Serum urea 19.4 mg/dl
Serum creatinine 0.93 mg/dl
HbsAg NR
HIV NR

15. Provisional diagnosis
• On behalf of history, examination and investigation – Ocular
surface squamous neoplasia (OSSN)

16. Differential diagnosis
The differential diagnosis of OSSN includes :-
• Pannus
• Actinic disease
• Vitamin A deficiency
• Benign intraepithelial dyskeratosis
• Pinguecula
• Pterygium
• Pyogenic granuloma
• Keratoacanthoma
• Pseudoepitheliomatous hyperplasia
• Malignant melanoma and nevi

17. Treatment
• Medical management-
Immunosuppressant drugs like Mitomycin-c and Cyclosporine.
• Surgical management-
excision biopsy
Outcome -
3rd post-op. day BCVA- 6/12

18. OSSN
Ocular Surface Squamous Neoplasia (OSSN) was a term given
by Lee and Hirst which has three grades :-
I. Benign dysplasia
• Papilloma
• Pseudotheliomatous hyperplasia
• Benign hereditary intraepithelial dyskeratosis
II. Preinvasive OSSN
• Conjunctival/corneal carcinoma in situ
III. Invasive OSSN
• Squamous carcinoma
• Mucoepidermoid carcinoma

19. Imaging modalities
• Optical coherence tomography (OCT) has been employed as an in
vivo diagnostic modality in the detection of OSSN. There are distinctive
features of OSSN, such as hyper reflectivity, thickened epithelium, and abrupt
transition from normal to abnormal tissue seen on ultra high resolution OCT
that differentiates it from other conjunctival lesions such as pterygia.
• Impression cytology have been reported in the literature as a noninvasive
method to diagnose and clinically monitor patients with OSSN. However, it can
only assess superficial tissue and is unable to discern the depth of involvement.
• Confocal microscopy has also been reported to be helpful in guiding treatment
since it is able to reveal cellular details. Its disadvantages include difficulty of
use and limited field of view.
• High frequency ultrasound may be helpful in determining the extent of invasion
into the eye in cases of SCC.

20. Prognosis
• The recurrence rate of OSSN after surgical excision can occur
in over half of cases and may occur years later. The rate of
recurrence is substantially higher in the setting of positive
surgical margins. Even if the surgical margins are negative, up
to one- third of eyes may experience a recurrence within 10
years. The conjunctival lesions that tend to fare the worst
involve over half of the limbal stem cells.
• A recurrent OSSN can grow rapidly and be more invasive, and
thus needs to be treated with aggressive medical, surgical, or
combination therapy. The conjunctival lesions that tend to fare
the poorest involve over half of the limbal stem cells. Overall,
SCC is generally associated with local invasion rather than
wide- spread systemic metastases.

21. • The overall prognosis in OSSN is good. Modern treatment
strategies are effective with local recurrence rates reported to
be 5% and regional lymph node metastasis at <2%. Aggressive
variants like muco-epidermoid and spindle cell carcinoma and
OSSN in immunocompromised patients have a worse
prognosis.