1. Conjunctival mass
AP. 정소향 / R3 김나현

2. Case 1. 26379843 김 O 석 M/67 C.C ) Dec. VA(OS) onset) 2 days ago
상환 내원 1주일전부터 좌안 충혈 주소로 local 내원, 결막염 진단하에
안약 점안 중 증상 호전 없고 2일전부터 시력 저하되어 재내원,
큰병원 진료 권유받고 내원
DM/HBP (-/+): for 14 yrs(p.o medi)
Thrombolytics(+)
Ocular op/trauma(-/-)
Gls (-) Eye drop (+) : O-TOB x 4, O-FM x 4/OS
A 67-year-old man without significant ocular history presented
complaining of worsening of vision in his left
Eye for 2 days. According to him, he had a symptom of redness about 1wkago, so he visited local clinic and kept applying topical antibiotics and steroid eyedrops but symptome didn’t improve at all.

3. Physical examination VA OD 0.5 (1.0) OS 0.16 (N-C)
IOP OD 10 mmHg OS uncheckable
EOM Straight at 1' position by ACT, No LOM(OU)
Orbit No exophthalmos(OU)
Lid No swellling(OU)
Conj. OU mild injected
Cornea OD slightly elevated, well dermacated translucent corneal clouding(+) at inferior nasal side
OS diffuse, ill defined bordered, and coarsed epithelium(+)
AC OD deep & cell(-)
OS deep & cell(-)
Pupil OU round & nl sized, NVI(-/-) LR(+/+), RAPD(-/-)
Lens OU mild nucleosclerosis
Clinical examination disclosed that his best corrected visual acquity was 0.16 which was not correctable in lt. eye. intraocular pressure was normal. Slit-lamp biomicroscopy showed

4. OD OS
Cornea OD slightly elevated, well dermacated translucent corneal clouding(+) with nodule(+) at inferior nasal side OS diffuse, ill defined bordered, and coarsed epithelium(+)

5. Impression Plan R/O CIN (OS>OD) Start Topical Interferon α (OD)
CIN en bloc resection with cryotherapy (OS)
Orbit CT(enhance)  W.N.L

6. Op. record Dx. : Corneal CIN (OS)
Op. title : Corneo-scleral mass en-bloc
dissection+Cryotherapy(OS)
Op. procedure
: % 알콜을 각막에 묻혀 peel off 시행함
2. corneo-conjunctivo-scleral mass en-bloc 으로 절제함
3. conjunctiva에 cryotherapy 2회 시행함
4. conjunctival suture 시행함

8. Bx. Results [GROSS DESCRIPTION]
Two irregularly shaped transparent membranous fragments,
measuring 0.8 x 0.4 cm, is totally embedded after serial
sections. (Block 2 개)
[DIAGNOSIS]
Cornea, left, biopsy;
Epithelial hyperplasia.
b) Chronic inflammation with elastic degeneration and
calcification in the subepithelial stroma.

9. Follow up (POD#1) Plan Start Topical Interferon α (OU)
VA OS 0.16 
Cornea : peeled epithelium c visible margin
Plan
Start Topical Interferon α (OU)
The patient improved on hyperosmotic drops 4 times a day
(Adsorbonac; Alcon, Fort Worth, TX) to 20/22 visual acuity, and the
symptoms of halos were alleviated, which was the primary
therapeutic advantage.
The patient
will be monitored periodically for signs of corneal compensation due
to a possible further reduction
OD  for primary Tx.
OS  for adjuvant Tx.

10. Follow up – POD# 1mon
VA OD/OS (0.8)/(0.5+2)
Cornea : clear
before

11. Follow up – POD# 3mon
VA OD/OS 0.63/1.0
Cornea : clear
Before
After

12. Case 2. 9552471 장경수 M/68 C.C ) Redness c irritation(OS) onset) 1wk ago
상환 내원 1주일전 부터 지속된 우안 충혈과 불편감으로
이에 대한 evaluation 위해 내원
DM/HBP (-/-)
Ocular op/trauma(+/-)
5-6년 전 BULB at PS
양안 하안검 지방제거술
우안 안검 재수술
Gls (-) / Eye drop (-)

13. Physical examination VA OD 1.0 (1.0) OS 0.8 (1.0) IOP OD 10 OS 11 mmHg
EOM Straight at 1' position by ACT, No LOM(OU)
Orbit No exophthalmos(OU)
Lid No swellling(OU), ectropion(+)(OD)
Conj. OD mod. injected esp. nasal area
OS not injected
Cornea OD slightly elevated, well dermacated translucent corneal clouding(+) with vascularization at nasal side
OS clear
AC OD deep & cell(-)
OS deep & cell(-)
Pupil OU round & nl sized, NVI(-/-) LR(+/+), RAPD(-/-)
Lens OU mild nucleosclerosis

14. Cornea OD. slightly elevated, well dermacated translucent corneal
Cornea OD slightly elevated, well dermacated translucent corneal clouding(+) with vascularization at nasal side

15. Impression Plan R/O CIN (OD)
CIN en bloc resection c Cryotherapy with AMT (OD)

16. Op. record Dx. : Corneal CIN (OD)
Op. title : Corneo-scleral mass en-bloc
dissection+AMT(OD)
Op. procedure
: Routine draping & painting was done
en-bloc resection was done at nasal & temporal side.
Excisional biopsy was done.
conjunctival suture was done.
AMT was done at nasal side.
Routine dressing was done.
T-lens applied

17. Bx. Results
[GROSS DESCRIPTION] 1. An irregularly shaped pale brown tissue fragment, measuring 1.5 x 0.5 cm, is totally embedded. 2. An irregularly shaped pale brown tissue fragment, measuring 0.5 x 0.2 cm, is totally embedded. [DIAGNOSIS] 1. Conjunctiva, nasal, right, excision(#1); Squamous dysplasia, mild. 2. Conjunctiva, temporal, right, excision(#2); Epithelial hyperplasia with solar elastosis.

18. Follow up (POD#1wk) Plan Orbit MRI OPD F/u
Bx. Results : Squamous dysplasia, mild.
VA OS 1.0
Cornea : peeled epithelium c visible margin
Plan
Orbit MRI
No remarkable finding in both orbits.
OPD F/u

19. Follow up – POD# 1wk
VA OD/OS 1.0/1.0
Cornea : clear
Before
After

20. Case 김 O 희 F/70
C.C ) Dec. VA(OS) onset) for 3months ( )
상환 내원 3개월 전부터 좌안 시력저하 있어 주소로 local 내원하여 r/o
limbal cell deficiency, r/o conjunctival tumor 의심되어
큰 병원 진료 권유 받고 내원
DM/HBP (-/-)
Ocular op/trauma(+/-) : Ex.(OS) at local
Gls (-) Eye drop (+) : O-LVF x 4, O-0.3HUM x prn, O-FM x 2/OS

21. Physical examination VA OD 1.0 OS 0.5 (N-C) IOP OD 14 mmHg OS 15 mmHg
EOM Straight at 1' position by ACT, No LOM(OU)
Orbit No exophthalmos(OU)
Lid No swellling(OU)
Conj. OU not injected
Cornea OD clear
OS Elevated papilliform, irregular margins and accompanied by feeding blood vessels at the corneoscleral limbus nasally.
keratinization(+)
AC OD deep & cell(-)
OS deep & cell(-)
Pupil OU round & nl sized, NVI(-/-) LR(+/+), RAPD(-/-)
Lens OU mild nucleosclerosis

22. Impression Plan R/O CIN (OS)
En bloc sclera-conjunctival mass Ex. and Bx.+ CryoTx(OS)

23. Op. record (2009.3.10) Dx. : R/O Corneal CIN (OS)
Op. title : En bloc sclera-conjunctival mass Ex.
and Bx.+ CryoTx(OS)
Op. procedure
1. Absolute alcohol 바른 후 cornea mass 제거 – 병리
2. En bloc sclera-conjunctival mass 제거 – 병리
3. Crotherapy on conjunctival edge
4. Temporal atypical melanosis 제거 –병리
5. Peritomy 후 conjunctival suture

24. Bx. results
[GROSS DESCRIPTION] #1. Two irregularly shaped pale brown soft tissue fragments, measuring up to 0.5 x 0.5cm, are totally embedded. #2. An irregularly shaped pale brown soft tissue fragment, measuring 0.7 x 0.3cm, is totally embedded. #3. An irregularly shaped pale brown soft tissue fragment, measuring 1.0 x 0.3cm, is totally embedded. [DIAGNOSIS] 1. Cornea, left, biopsy (#1); Squamous cell carcinoma, moderately differentiated. 2. Conjunctiva, left, biopsy (#2); Squamous dysplasia, severe. 3. Conjunctiva, left, `atypical pigmentation`, biopsy (#3); a) Mild epithelial hyperplasia with squamous metaplasia. b) Hyperpigmentation of the basal cells.

25. Follow up – POD# 1wk (2009.3.17) Plan VA OD/OS 0.8/(0.32)
IOP OS 18 mmHg
Conjunctiva : well approximated wound
Cornea: clear
AC: deep & cell(-)
Plan
Start topical 0.02  0.04% MMC (OS)
Systemic evaluation
PET-CT
Orbit MRI

26. Orbit MRI About 6x9 mm sized, nodular enhancing lesion in the
medial corneal region, left orbit.
R/O) Cornea squamous ca.
2. No evidence of L orbital
globe or adjacent skin.
3. No abnormality in both retrobulbar regions.

27. PET CT

28. Plan recur?! Improved!! (POD#2mon) Topical 0.04% MMC for 1mon
VA OD/OS 1.0/0.5
Topical 0.04% MMC
for 1mon
VA OD/OS 1.0/0.5
(POD#2mon)
Improved!!

29. Follow up – After MMC 4 cycles (POD#3m 2wks)
VA OD/OS 1.0/0.63 Cornea OS whorl-like pigmentary epithelium proliferation at superior-temporal limbus, Dye pooling(+)
(one cycle of treatment¼1 week on+one
week off)

30. Follow up – After MMC 4 cycles (POD#4m)
VA OS 0.1 (0.32 x -2.00Dc Ax 150’) Cornea OS Decreased whorl-like pigmentary epithelium proliferation at superior-temporal limbus, dye pooling(+) Localized limbal cell dysfunction at sup.

31. Impression Plan R/O recurred CIN c limbal deficiency (OS)
Ex of medial tenal tissue c Mitomycin C application+AMT c glue(OS)
Superficial keratectomy

32. No nodular mass was found.
Op. record ( )
Dx.: Corneal squamous cell carcinoma(OS)
Op. title :
Ex of medial tenal tissue c Mitomycin C application+AMT c glue(OS)
Superficial keratectomy (OS)
Op. procedure
1. routine draping을 시행함.
2. subtenon space로 2% lidocaine을 주입함.
3. 95% alcohol을 각막 표면에 도포후 epithelial layer을 벗겨내 biopsy 시행
4. medial area의 exploration 시행함.
5. thickening된 tenal tissue 들을 biopsy 시행함.
6. medial rectus muscle을 확인하고 exploration을 중단함.
7. Mitomycin을 apply함. (2min)
8. Tissel glue을 이용하여 biopsy로 인한 conj defect 부위에 AMT 시행함.
9. 양막과 sclera와 주변 conj에 anchoring suture를 시행함.
10. T-lens apply함.
11. Routine dressing을 시행함.
No nodular mass was found.
Bx. was done at the site of abnormal thickening of tenal tissue in medial rectus muscle.

33. Follow up – POD# 1wk(2009.7.30) Plan
Biopsy results : Tenan tissue  mild chronic inflammation VA OS 0.5 Cornea good wound apposition
Plan
Keep eyedrops
F/U 2wks

34. Orbit MRI - F/U

35. Follow up – POD# 6mon after 2nd operation(2010.3.3)
VA OS (0.63) Cornea OS epithelial irregularity at limbus, dye pooling(+)
Plan
Limbal transplantation(OS)

36. Follow up – POD# 2mon for Limbal cell transplantation
VA OS (0.63) Cornea good limbal cell transplantation state

37. Case 4. 26437811 김 O 봉 M/64 C.C Conj. mass(OS) onset) 11 yrs ago
상환 내원 11년전부터 상기 증상 있었으나 크기 감소 소견 없어
이에 대한 proper management 위해 내원
DM/HBP (-/+): for 6~7 yrs(p.o medi)
Ocular op/trauma(-/-)
Gls (-) Eye drop (+) : O-FM x 4/OS

38. Physical examination VA OD 1.0 OS 1.0 IOP OD 10 OS 15 mmHg
EOM Straight at 1' position by ACT, No LOM(OU)
Orbit No exophthalmos(OU)
Lid No swellling(OU)
Conj. OD mild injected
OS mild injected c solid mass at temp. side
Cornea OD clear
AC OD deep & cell(-)
OS deep & cell(-)
Pupil OU round & nl sized, NVI(-/-) LR(+/+), RAPD(-/-)
Lens OU mild cortical opacity

39. Impression Plan Conjunctival mass Ex. & Bx. (OS)
Conjunctival mass (OS)
R/O Ductal cyst (OS)
Plan
Conjunctival mass Ex. & Bx. (OS)
AS-OCT showed clearly that
The transverse cross-section
is presented

40. Bx. Results
[GROSS DESCRIPTION] An irregularly shaped pale brown tissue fragment,measuring 1.3 x 0.5 cm, is totally embedded. [DIAGNOSIS] Conjunctiva, left, biopsy; Findings consistent with Ductal cyst.

41. Follow up Plan O-GAF x 4, O-FM x 4 F/U
VA OS 1.0 Conj. Well approx. Wx.
Plan
O-GAF x 4, O-FM x 4
F/U

42. Management of Conjunctival tumor

43. Introduction Ocular surface squamous neoplasia(OSSN)
 the third most common ocular tumor after melanoma and lymphoma
1. squamous dysplasia
2. squamous cell carcinoma in situ [CIN]
3. invasive squamous cell carcinoma

44. Introduction - Conjunctival and corneal intraepithelial neoplasia (CIN)
- the abnormal epithelium can be limited to the conjunctiva, the cornea, or involve both
- common, slowly growing lesions that
may evolve to squamous cell carcinoma
although they carry only a small risk of
malignancy
- most common neoplasms of the ocular surface

45. Introduction - invasive squamous cell carcinoma
an extension of abnormal epithelial cells
through the basement membrane to gain access to the conjunctival stroma.
- more elevated than CIN
Gekatinous, nodular, flat diffuse

47. Risk factors Certain patient characteristics
: light hair and ocular pigmentation
: British Isles, Austria, or Switzerland
White populations at latitudes closer to the
equator
Men > women
Age ↑ (an average age of 56 years)
UV exposure
HIV & HPV
Exposure to petroleum products
Heavy cigarette use & contact lens wear
causing the formation of pyrimidine
dimers. These dimers distort the DNA strand and result in failure or
delay in repair.

48. Risk factors

49. Clinical presentations
foreign body sensation, Redness or irritation
decrease in vision with corneal involvement.
growth on the ocular surface
: slightly elevated, well demarcated, and
accompanied by feeding blood vessels at the
corneoscleral limbus temporally or nasally
: diffuse with ill-defined borders
opalescent, gelatinous surface

50. Clinical presentations
Typically involve the limbus
Elevated papilliform, leukoplakic, or
gelatinous with characteristic tufts of blood vessels
Corneal involvement consists of a gray, opaque, thickened epithelium
An area of translucent corneal clouding
Duration of symptoms
: can range from 2 weeks to 8 years (aver. 3 mo)

51. Differential diagnosis
Pterygium
keratinization of the corneal epithelium
Pannus
Dermoid
Anterior basement membrane dystrophy
malignant melanoma

52. Treatment wide excision of the tumor combined with cryotherapy
External beam radiation, phototherapeutic
keratectomy with the excimer laser, and
photodynamic therapy
Topical therapy with immune modulators
or chemotherapeutic agents, such as
interferon and mitomycin C, and
immunotherapy

53. Tx. - surgery Excision with a 2 to 3mm margin
Incompletely excised lesions have a recurrence rate between 53% and 69%
Biopsies from the 4 quadrants
(pathologically to rule out diffuse dysplastic disease)
AMT or a limbal stem cell graft
(depending on the extent and location of ex.)

54. The conjunctival incision is made approximately
Absolute alcohol is applied by a cotton tip applicator to the involved cornea to allow for controlled corneal epitheliectomy
The corneal epithelium is scrolled off using a controlled sweeping motion with a beaver blade
The localized corneal epitheliectomy is performed by saturating a cotton-tipped applicator with absolute alcohol and gently applying this to the affected corneal epithelium adjacent to the conjunctival tumor
2. A margin of 2mm of normal surrounding corneal epithelium
is also treated. The exposed cells are devitalized with the application and the treated epithelium becomes
slightly opaque and gray. Using a No.57 Beaver blade, the epithelium containing the tumor and the tumorfree
margin is then gently rolled like a scroll off the Bowman membrane
The conjunctival incision is made approximately
4 mm outside the tumor margin.
A beaver blade is used to create a thin lamella of tumor-free sclera underlying the limbal portion of the tumor.

55. underlying sclera and limbal corneal epithelium.
The conjunctival malignancy is removed, along with tumor-free margins, including
underlying sclera and limbal corneal epithelium.
- The depth of this incision should be about 0.2 mm (about 20% the thickness of the sclera)
Cryotherapy is applied to the conjunctiva at the site of resection.
Using a fresh No. 57 Beaver blade, a semicircular superficial
groove is then made in the exposed sclera 2 mm posterior to the tumor
margin. The depth of this incision should be about 0.2 mm (about 20%
the thickness of the sclera).
double freeze-thaw cryotherapy to the margins of the exposed bulbar conjunctiva The tip of
the cryoprobe is placed on the underside of the conjunctival edge, lifting the conjunctiva with forceps to
avoid freezing the sclera or ciliary body
Closure of the conjunctiva with absorbable sutures is performed.

56. Cryotherapy an important adjuvant therapy
destroys cells and obliterates circulation causing ischemic infarction of normal and cancerous cells
Potential risks
: iritis, change in intraocular pressure, corneal edema and scarring, and iris atrophy

57. Topical therapy an adjuvant therapy to surgery with or
without cryotherapy or as primary tumor therapy
mitomycin (MMC)
5 fluorouracil (5FU)
interferon alpha 2b (INFa 2b)

58. Interferon alfa-2b
protein molecules that bind to cell receptors and trigger
synthesis of effector proteins that can inhibit viruses,
activate immunocompetent cells, and regulate oncogenes.
a daily dose of 1 million IU/mL until resolution of the
lesion
 up to 1 month beyond tumor resolution,and up to 4
months beyond tumor resolution in various studies.
ideal medication because relatively nontoxic
Side effects
transient keratitis
follicular conjunctivitis but are uncommon

59. MMC a potent alkylating agent that that inhibits the
synthesis of DNA, RNA, and protein.
0.02% to 0.04% applied 3 or 4 times daily given
in cycles of 1 to 2 weeks with MMC-free periods
in between
Start after surface epithelialization is complete
after surgery
side-effects
keratitis, hyperemia, irritation, pain, photophobia, epithelial defect and
less frequently corneal haze, blepharospasm, lid swelling, contact
dermatitis, limbal stem cell deficiency, corneal edema, pseudomembrane,
pannus, and intumescent cataract

62. Prognosis Generally regarded as low-grade malignancy
The more severe grades of OSSN tend to recur at higher rates
Most lesions tend to recur within the first two years
Intraocular invasion and metastasis are uncommon
CIN..
a definite malignant potential albeit low and slow
become invasive in 3% of the cases
Recurrence
Dysplasia < CIN < squamous carcinoma
Regular check-up is recommended

63. Thank YOU FOR listening