A Novel Technique to Diagnose and Follow up Conjunctival and Corneal Intraepithelial Neoplasia Using Ultra High Resolution Optical Coherence Tomography Mohamed Abou Shousha, MD, Carol L. Karp, MD, Victor L Perez, MD, Rodrigo Hoffmann, MD, Roberta Ventura, MD, Victoria Chang, BS, Sander R Dubovy, MD, Jianhua Wang, MD, PhD ________________________________________________ Bascom Palmer Eye Institute, University of Miami, Miller School of Medicine, FL, USA The authors have no financial interest in the subject matter of this poster.

Purpose To report a novel diagnostic technique and a case series of conjunctival and corneal intraepithelial neoplasia (CCIN) diagnosed and followed using prototype ultra high resolution optical coherence tomography (UHR-OCT).

Methods  Retrospective, non-comparative, interventional case series.  6 eyes of 6 consecutive patients with CCIN treated using topical interferon alfa-2b or 5-fluorouracil.  UHR-OCT was used to image the ocular surface at primary diagnosis of CCIN and during the follow up period until resolution of the lesion.  UHR-OCT Images were correlated to clinical picture and histopathological specimens. UHR OCT Wavelength: 840nm Axial resolution: ~2 µm Methods

Pretreatment SLE Pretreatment Specimen Pretreatment UHR-OCT a b X100 Patient 1: Superior gelatinous CCIN Patient 1: Superior gelatinous CCIN Post-treatment UHR-OCT Post-treatment SLE Post-treatment specimen Post-treatment UHR-OCT image and post-treatment biopsy specimen: After 2 months of treatment disclose a normal limbus and confirm the resolution of the tumor (stain, hematoxylin–eosin) Pretreatment Slit lamp photograph (SLE) : Shows a superior gelatinous CCIN. Post-treatment SLE : Showing resolution of CCIN lesions post- treatment X100 Pretreatment UHR-OCT image: Discloses a severely thickened limbal hyper-reflective epithelial lesion (a). A plane of cleavage between the lesion and the underlying tissue is noted (b). Pretreatment incisional biopsy specimen From the lesion discloses mucosal epithelium that displayed faulty epithelial maturational sequencing extending up to full thickness, with no invasion of the underlying tissue, consistent with carcinoma in situ and confirming the diagnosis of CCIN (stain, hematoxylin–eosin) Topical interferon alfa-2b 1 million IU/ml 4 times per day Topical interferon alfa-2b 1 million IU/ml 4 times per day

Pretreatment SLE: Shows a temporal conjunctival (a) and corneal (b) intraepithelial neoplasia. Pretreatment UHR-OCT image: Discloses a thickened hyper-reflective epithelial layer (a) with abrupt transition from normal to hyper-reflective epithelium (b). The conjunctival epithelium is seen as a discreet layer (c). Underlying opaque layer (d) is seen under the lesion that could be correlated with fibrous episcleral tissue. Follow up SLE Shows the clinically improved temporal CCIN lesion. Slight congestion of conjunctival vessels and mild residual corneal blood vessels are noted. The conjunctival lesion (a) and the opalescent corneal tumor (b) appeared resolved. Follow up UHR-OCT Shows persistence of residual CCIN in the form a thickened hyper-reflective epithelial layer (a). Topical treatment was therefore continued according to the findings of the UHR-OCT for 2 more months. Post-treatment SLE and UHR-OCT: Discloses the resolution of the lesion as the epithelium returns back to normal (a). Patient 1: Temporal CCIN lesion : Patient 1: Temporal CCIN lesion : UHR-OCT image identified residual subclinical CCIN avoiding premature termination of therapy Follow-up UHR-OCT shows residual CIN Post-treatment SLE: After treatment continuation. Follow up SLE shows clinical resolution v Pretreatment SLEPretreatment UHR-OCT Post-treatment UHR-OCT confirms resolution

a a c b Patient 1: Inferior CCIN lesion: Patient 1: Inferior CCIN lesion: Pretreatment SLE Pretreatment UHR-OCT Post-treatment UHR-OCT Post-treatment SLE Pretreatment SLE: Shows an inferior CCIN. Post-treatment SLE: Showing resolution of CCIN lesions post-treatment Pretreatment UHR-OCT image: Discloses the thickened hyper-reflective epithelial layer (a) with abrupt transition from normal to pathological epithelium (b). Bowman’s layer (c) appears intact. Post-treatment UHR-OCT image: Confirms the resolution by disclosing normal epithelial configuration (a).

a c b a a b X100 Patient 2: Inferior gelatinous CCIN: Patient 2: Inferior gelatinous CCIN: Pretreatment SLE Pretreatment UHR-OCT Post-treatment UHR-OCT Post-treatment SLE Pretreatment Slit lamp photograph (SLE) : Shows an inferior gelatinous limbal CCIN lesion. Post-treatment SLE: Showing resolution of the resolution Post-treatment UHR-OCT image Confirms the resolution of the lesion. It discloses normal epithelium (a) with a subepithelial opaque layer (b) that is attributed to subepithelial fibrous tissue and post-treatment corneal pannus. Pretreatment specimen Pretreatment incisional biopsy specimen Discloses mucosal epithelium that displayed faulty epithelial maturational sequencing extending up to full thickness, with no invasion of underlying tissue. Note the abrupt transition (a) between normal and affected epithelium (stain, hematoxylin–eosin) Pretreatment UHR-OCT image: Discloses a severely thickened hyper-reflective epithelial inferior limbal lesion (a). Abrupt transition between the normal and affected hyper-reflective epithelium is evident (b). A plane between the lesion and the underlying tissue is noted (c). The thickened lesion is casting slight shadow over the underlying tissue. Topical interferon alfa-2b

Pretreatment SLE: Shows an infero- temporal conjunctival and corneal intraepithelial neoplasia (CCIN, white arrows). Pretreatment UHR-OCT image: Discloses discloses a thickened hyper-reflective epithelial layer (a). Abrupt transition from normal to abnormal, hyper-reflective epithelium (b) and Bowman’s layer (c) are evident in the UHR-OCT. Follow up SLE: Shows the clinically resolved CCIN lesion. Follow up UHR-OCT: Shows the persistence of residual CCIN in the form a thickened hyper-reflective epithelial layer (a). Accordingly, the patient was advised to continue on the topical treatment Post-treatment SLE and UHR-OCT: Discloses the resolution of the lesion as the epithelium returns back to its normal configuration (a). Patient 3: Infero-temporal CCIN : Patient 3: Infero-temporal CCIN : UHR-OCT image discloses a residual lesion that was missed clinically avoiding premature termination of therapy Follow-up UHR-OCT shows residual CIN Post-treatment SLE: After treatment continuation. Follow up SLE shows clinical resolution v Pretreatment SLEPretreatment UHR-OCT Post-treatment UHR-OCT confirms resolution Topical interferon alfa-2b 1 million IU/ml 4 times per day

Pretreatment SLE Shows infero- nasal conjunctival and corneal intraepithelial neoplasia (CCIN, white arrows). Pretreatment UHR-OCT image Discloses a thickened hyper-reflective epithelial layer (a), Bowman’s layer (b) as well as the abrupt transition from normal to hyper-reflective epithelium (c). Follow up SLE After 3 month of treatment, the lesion appeared significantly resolved. Follow up UHR-OCT UHR-OCT image, however, shows the persistence of residual CCIN in the form a thickened hyper-reflective epithelial layer (a). The patient was advised to continue on topical treatment Post-treatment SLE and UHR-OCT Discloses the resolution of the lesion as the epithelium returns back to its normal configuration (a). Patient 4: Infero-temporal CCIN : Patient 4: Infero-temporal CCIN : UHR-OCT image discloses a subclinical lesion avoiding premature termination of therapy Post-treatment SLE: After treatment continuation. Follow up SLE shows resolution v Pretreatment SLEPretreatment UHR-OCT Post-treatment UHR-OCT confirms resolution Follow-up UHR-OCT shows residual CIN Topical interferon alfa-2b 1 million IU/ml 4 times per day

a Pretreatment SLE Pretrea tment UHR- OCT a b Patient 5: Annular CCIN Post-treatment UHR-OCT: Shows residual temporal mass (a). Post-treatment SLE Post-treatment UHR-OCT image: Confirms the resolution of the tumor nasally and inferiorly, with the persistence of the temporal lesion (a). Pretreatment SLE : Shows an annular gelatinous limbal CCIN. Post-treatment SLE: Shows resolution of the CCIN lesion inferiorly and the persistence of a small temporal limbal mass. Pretreatment UHR-OCT image: Discloses a thickened hyper- reflective epithelial lesions(a), abrupt transition between the normal and affected hyper- reflective epithelium (b) and a plane between the lesions and the underlying tissue (c) in the nasal, temporal and inferior scans. Nasa l Temporal Inferior a a a b c c b b c Pretreatment SLE Pretreatment UHR-OCT Nasal Temporal Nasa l Temporal Inferior Nasal Temporal Inferior Topical interferon alfa-2b 1 million IU/ml 4 times per day

9A a b a c Patient 6: Temporal Papillomatous CCIN : Patient 6: Temporal Papillomatous CCIN : Post-treatment SLE Pretreatment SLEPretreatment UHR-OCT Post-treatment UHR-OCT confirms resolution Pretreatment SLE: Shows a temporal papillomatous CCIN lesion. Post-treatment SLE: Showing resolution of CCIN lesions post-treatment after 3 cycles of treatment Pretreatment UHR-OCT image Discloses thickened hyper-reflective epithelial layer (a), a well defined inferior border (b) as well as the abrupt transition (c) from normal to hyper-reflective epithelium Post-treatment UHR-OCT image: Confirms the resolution by disclosing normal epithelial configuration (a). Topical 1% 5-fluorouracil 4 times daily for 7 days per cycle for 3 cycles

o UHR-OCT is a novel non-invasive technique to diagnosis and manage medically treated CCIN. o Using UHR-OCT to guide medical treatment could prevent premature termination of topical treatment in the presence of subclinical disease. o Larger sample size will be needed for further validation of its sensitivity and specificity. Conclusions