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MRIMS Journal of Health Sciences 2016;4(2)
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pISSN: 2321-7006, eISSN: 2321-7294
Original Article
Clinical behaviour of ocular surface squamous neoplasia (OSSN) in HIV
positive patients
P. Padmavathi 1, D. Padma Prabha 2, Mohd. Ather 3, T. Kavitha 4, M. Padma 5
1, 2 & 5
Assistant professor of Ophthalmology, Sarojini Devi Eye Hospital, Osmania Medical College, Hyderabad
3
Professor I/C of Ophthalmology, Gandhi Medical College, Hyderabad
4
Assistant Professor of Pathology, Osmania Medical College, Hyderabad
Corresponding Author:
Dr. P. Padmavathi
E-mail- [email protected]
Abstract:
Background: A lot of Ocular Surface Squamous Neoplasia(OSSN) may go unnoticed as they are asymptomatic and usually slowgrowing. The prevalence of OSSN is more in tropical region and varies from 12 cases /million/ year in Uganda to 0.3 cases /
million/ year in United States of America, possibly related to sunlight exposure. Objective: To study the clinical behaviour of
Ocular Surface squamous neoplasia (OSSN) in HIV positive patients. Methods: This is a retrospective study done at the
department of the oculoplastics and orbital diseases, Sarojini Devi Eye Hospital Hyderabad over a period of three years from
February 2012 to January 2015. 26 cases of HIV positive patients with OSSN were included in the study and non HIV cases were
excluded. Results: In our study of 26 cases 17 were males and 9 were females and average age of presentation was 34 years 10 to
15 years younger than non HIV cases. Histopathologically 18 cases were squamous cell carcinoma, 5 cases were carcinoma in situ
and 3 cases were with moderate to severe dysplasia. Recurrence was seen in 8 cases (32.1%). Conclusion: OSSN presents at a
younger age in HIV positive patients with aggressive behaviour clinically and histopathologically with more chances of
recurrence.
Keywords: OSSN; HIV association; Clinical profile; Recurrence
INTRODUCTION:
The term Ocular Surface Squamous Neoplasia [OSSN] is
first described by Lee and Hirst in 1995 and it refers to the
entire spectrum of dysplastic, pre-invasive and malignant
squamous lesions of the conjunctiva and cornea1. A lot of
them may go unnoticed as they are asymptomatic and usually
slow-growing. The prevalence of OSSN is more in tropical
region and varies from 12 cases /million/ year in Uganda2 to
0.3 cases / million/ year in United States of America3,
possibly related to sunlight exposure. The two main risk
factors are UV- B light and Human Papilloma Virus4. The
other risk factors are exposure to petroleum products, heavy
cigarette smoking and Infection with HIV is now emerging as
a major risk factor 5, 6. The following are the clinical
varieties.




Gelatinous- Most common type.
Nodular type- Rapidly growing and diffuse type is
slow growing and mimics chronic conjunctivitis
Leukoplakic- Usually pre-invasive represents
secondary hyperkeratosis
Papilliform- Typically exophytic, strawberry like,
with
a
stippled
red
appearance
Corneal OSSN is usually an extension of conjunctival
squamous neoplasia. SCC is the final stage of this tumour
where dysplastic epithelium invades beyond the basement
membrane to the conjunctival substantia propia or corneal
stroma. An advanced lesion or mass that is immobile and
fixed to the globe should be suspected for invasion. First site
of extra ocular involvement is regional lymph nodes, but
metastases are rare. Management includes surgery by “No
touch technique” proposed by Sheilds et al is a widely
accepted surgical approach as the conjunctival component
MRIMS Journal of Health Sciences, Vol. 4, No. 2, April-June 2016
Page 114
Padmavathi P et al. Clinical behaviour of OSSN in HIV positive patients
along with Tenon’s fascia are excised followed by double
freeze thaw Cryotherapy at the conjunctival margin and
alcohol epitheliectomy for the corneal component followed
by MMC 0.04% four times a day for 4 weeks1,7,8,9,10 .
differentiated in 7cases and poorly differentiated carcinoma
in 2 cases (TABLE 1)
MATERIAL AND METHODS
This is a retrospective study conducted at the department of
the oculoplastics and orbital diseases, Sarojini Devi Eye
Hospital Hyderabad over a period of three years from
February 2012 to January 2015. 26 cases of HIV positive
patients with OSSN were included in the study and non HIV
cases were excluded. All cases were evaluated thoroughly by
detailed examination under slit lamp, recorded visual acuity
and subjected for basic haematological investigations.
Anterior segment OCT and Computed Tomography (CT)
were ordered wherever required.
Histopathological
variant
Well differentiated SCC
Surgical excision of lesion with 4 mm of normal conjunctiva
and cryoapplication to scleral bed was done
[TABLE/FIGURE 2A &2B] for 25 patients and one patient
who presented with massive swelling and ocular myiasis
[TABLE/FIGURE 5] was treated conservatively in view of
her emaciated status and sent to MNJ cancer hospital for
palliative treatment after confirming diagnosis by biopsy and
histopathological examination. All surgically excised lesions
were sent for HPE. All cases were treated postoperatively
with 4-6 cycles of topical Mitomycin C 0.04% drops , which
is used 4 times a day for 4days with 3days off in a week for
4-6weeks. Patients were followed for a maximum of 9
months and were lost for follow up after that. The patients
with recurrences were investigated by taking OCT and CT to
know the involvement of the coats of the eye ball. Two
patients with invasion into ocular coats were advised
Enucleation. Six cases which presented with recurrence were
subjected for resurgery with a similar technique and kept on
topical Mitomycin drops for 8weeks.
RESULTS
A total of 26 HIV positive cases were studied. Among these
17 cases were males and 9 cases were females. Average age
of presentation was 34 years 10 to 15 years younger than non
HIV cases. Males were presenting at an younger age (mean
age for females 37.9 and for males 32.52) Out of 26 patients
21 knew they had HIV infection and 5 patients were found to
be HIV positive after they were investigated when presented
with OSSN.
The lesions were larger in size compared to non HIV cases.
(FIGURE 3] All the lesions were having feeder vessels. Two
lesions presented with pigmentation. FIGURE 2] Complete
surgical excision with 4 mm of normal conjunctiva (no touch
technique) and cryo application for scleral bed (double freeze
thaw technique) was done for 25 cases and specimens sent
for histopathological examination. Post operatively all cases
were prescribed topical MMC drops 0.04 percent QID for 4-6
weeks. Recurrences were seen in 8 cases (32%) in one case
as early as two weeks.
HPE reports have shown 18 cases of SCC, 5 cases of CIS, 3
cases of moderate to severe dysplasia. In 18 cases of SCC
well differentiated carcinoma was seen in 9 cases, moderately
Table1 Distribution of histopathological variant of OSSN
Percentage
Number
34.61%
9
Moderately
Differentiated SCC
Poorly
differentiated
SCC
Carcinoma in situ
26.92%
7
7.69%
2
19.23%
5
Moderate
dysplasia
–
severe
11.53%
3
DISCUSSION:
In the present study, we observed that Males were affected
predominantly which was observed in various other studies
done on OSSN11. In a study done in Sub-Saharan population
females were more commonly affected than males 12.
Average age of presentation was 34 years. 10 to 15 years
younger than non HIV cases. Males were presenting at an
younger age (mean age for females 37.9 and for males 32.52
). A similar trend was observed in other studies where OSSN
has become more prevalent and aggressive with young
people being affected mostly13,14,15,16,17. About 20% of
patients had OSSN as their first manifestation of HIV
infection.
Histopathological data showed higher grade of malignancy
[CIS+all grades of SCC] [FIGURE 5 &6] in around 88% of
study subjects, a similar prevalence which was also noted in
other studies of HIV infected OSSN population 4, 12, 18.
Recurrences in our study were seen in 8 cases constituting
32%, a similar rate of higher recurrence was also observed
in studies done in Sub-Saharan Africa by Nkomazana O
et.al.19, and Khokhar S et.al.20
CONCLUSION:
Any young patient presenting with OSSN should be
investigated for HIV as OSSN could be the first
manifestation of HIV infection and followed up frequently
as recurrences are common in patients with HIV and treated
aggressively
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Figure 1
Figure 1 A. LESION WITH FEEDER VESSELS
1B. FOUR WEEKS AFTER EXCISION OF LESION
Figure 2
RAISED PIGMENTED LESION
MRIMS Journal of Health Sciences, Vol. 4, No. 2, April-June 2016
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Padmavathi P et al. Clinical behaviour of OSSN in HIV positive patients
Figure 6
Figure 3
WELL DIFFERENTIATED SCC
A LARGE LESION ENCROACHING THE CORNEA
Figure 5
Figure 4 MASSIVE TUMOUR WITH ORBITAL EXTENSION
CARCINOMA IN-SITU
Cite this article as: Padmavathi P, Padma Prabha D,
Mohd. Ather, Kavitha T, Padma M. Clinical
behaviour of ocular surface squamous neoplasia
(OSSN) in HIV positive patients. MRIMS J Health
Sciences 2016;4(2):114-117.
Source of Support: Nil. Conflict of Interest: None.
MRIMS Journal of Health Sciences, Vol. 4, No. 2, April-June 2016
Page 117