1. Conjunctival Squamous Cell Carcinoma with Massive Intraocular Invasion Fiona Roberts, Glasgow BAOP, Manchester 7-8 th April, 2011

2. Clinical History 75 year old male 15 month history of left limbal mass Biopsied

8. 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

9. 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

16. Pathology

27. CK14

32. 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

33. 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.)

34. 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

35. Kaps et al. Veterinary Ophthalmology, 2005

36. 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 Schlote et al., Klin Monbl Augenheilkd, 2001

37. 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

38. 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

39. 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

40. 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