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Lumps, Bumps and Lid Lesions ♪ ♪ Know when to hold them & know when to fold them ♪ ♪
COPE #39670-SD
Robert E. Prouty, O.D., FAAOSpecialty Eye Care
Parker, [email protected]
Disclosures
� Financial disclosures:• Speakers Bureaus/Consultant:
� Alcon� Allergan� Optovue� Zeiss-Meditec� VSP� B&L� Ivantis
• I have no personal financial interests in any of these companies
Cancer
� Definitions:– A group of diseases characterized by
uncontrolled growth and spread of abnormal cells
– American Cancer Society. Cancer Facts & Figures 2008. Atlanta: American
Cancer Society; 2008
– Any of various malignant neoplasms characterized by the proliferation of anaplastic cells that tend to invade surrounding tissue and metastasize to new body sites
– www.dictionary.com
Cancer
� Characteristics:
– Can affect any tissue or organ at any age
� ~77% of all cancers occur in patients > 55 yo
– All cancers begin with a defect in a single cell (monoclonal)
– This is followed by unrestrained growth
� Benign tumors may damage localized tissue by occupying space but they do not spread
Cancer
� Characteristics:
– Malignant tumors invade surrounding tissue and may metastasize
� A one cm tumor contains one billion cells
� One trillion cells usually means a lethal tumor
– Cell division is controlled by genes that promote it and genes that suppress it
� Cancer is the result of some combination of defects in this genetic functioning
History
� Duration
� Bleeding
� Discharge
� Change in size
� Change in color
� History of skin cancer
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Cancer
� Risk factors:
– Only ~5% of cancers are strongly hereditary
– Environmental factors account for 75%-80%
� Tobacco
� Poor nutrition
� Obesity
� Infectious agents
� Sunlight/Radiation
� Carcinogens
� The 5 leading non-skin cancers in the U.S.– Prostate
– Lung (90% in tobacco use)
– Breast
– Colo-rectal
– Urinary/bladder
� Cancer accounts for 25% of the deaths in the U.S.– 25% of people will be personally
affected in their lifetime
Cancer
Cancer
� Basal Cell Carcinoma (BCC)– The most common malignancy in humans
– 50% of all U.S. cancer, is skin cancer� 80% of that is BCC!
– Greater risks exist for BCC & SCC in patients:
� White– 19X greater whites:blacks
� Light colored eyes & hair
� Freckle easily and tan poorly
� Increases with UV exposure– Tanning beds = 1.5X relative risk
Cancer
� Basal Cell Carcinoma (BCC)
– 80% of BCC cases are on the head & neck
� 15% on the trunk
– Greater risk of recurrence of BCC on eyelids (lower), nose & ears
– There is no precursor to BCC
Cancer
� Basal Cell Carcinoma (BCC)
Cancer
� Basal Cell Carcinoma (BCC)
– 20% of all eyelid neoplasms
� 90% of all malignant eyelid neoplasms – Spread is by local invasion (almost exclusively)
Nodular
• Morpheaform
Superficial
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Cancer
� Basal Cell Carcinoma (BCC)
– 20% of all eyelid neoplasms
� 90% of all malignant eyelid neoplasms – Spread is by local invasion (almost exclusively)
Cancer
� Basal Cell Carcinoma (BCC)
– 20% of all eyelid neoplasms
� 90% of all malignant eyelid neoplasms – Spread is by local invasion (almost exclusively)
16 weeks of Erivedge®
(Vismodegib)
Source: Yin VT, Pfeiffer ML, Esmaeli B: Targeted therapy for orbtial and periocular basal cell carcinoma and squamous cell carcinoma.
Ophthalmic Plastic and Reconstructive Surgery 2013;29(2):87-92
Basal Cell Nevus Syndrome (Gorlin-Goltz Syndrome)
16 weeks of Tarceva® (Erlotinib)
Source: Yin VT, Pfeiffer ML, Esmaeli B: Targeted therapy for orbtial and periocular basal cell carcinoma and squamous cell carcinoma.
Ophthalmic Plastic and Reconstructive Surgery 2013;29(2):87-92
Cancer
� Squamous Cell Carcinoma (SCC):
– SCC is increasing in incidence
� Greater rate of increase for SCC vs BCC– 200% for SCC vs 80% for BCC
– Estimated BCC:SCC = 4:1
� SCC is most common skin cancer in blacks (30%)
– 60% of cutaneous SCC occurs on the head & neck (sun-exposed)
� 90% of head & neck cancer = SCC
Cancer
� Squamous Cell Carcinoma (SCC):
– 2nd most common eyelid malignancy
� 10% of all eyelid malignancy
– Demographics
� Older population
� Fair complexion, sun damage
– Intraepithelial spread or deep invasion with
potential rare regional lymph node metastasis
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Cancer
� Squamous Cell Carcinoma (SCC):
– Risks:
� Cumulative UV-B exposure is the primary risk factor– UV-A is less indicated but data is unclear
� Smoking = 2X risk
� Tanning beds = 2.5X risk
� Born in high UV exposure area = 3X risk
� Light skin & hair = 2-5X risk
� Outdoor occupation = 5X risk
� SCC vs BCC:
– SCC grows faster, ulcerates, bleeds & scabs more than BCC
– SCC recurs more frequently that BCC
� Since SCC extends deeper (not local), more severe
� Lesions on the ear & lips are at greater risk for recurrence
– Scalp, forehead, temple, eyelid, nose and hands are close behind
Cancer
� SCC vs BCC:
– SCC grows faster, ulcerates, bleeds & scabs more than BCC
– SCC recurs more frequently that BCC
� Since SCC extends deeper (not local), more severe
� Lesions on the ear & lips are at greater risk for recurrence
– Scalp, forehead, temple, eyelid, nose and hands are close behind
Cancer
� SCC vs BCC:
– SCC grows faster, ulcerates, bleeds & scabs more than BCC
– SCC recurs more frequently that BCC
� Since SCC extends deeper (not local), more severe
� Lesions on the ear & lips are at greater risk for recurrence
– Scalp, forehead, temple, eyelid, nose and hands are close behind
Cancer
SCC- Conjunctival
•Unrelated to sun exposure
•Commonly misdiagnosed as conjunctivitis
•Higher incidence of metastatic disease if lesion extends into fornix
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� Solar lentigo
– Benign sun-induced area of darkening pigmentation
� Commonly referred to as “Liver Spot”
� Easily mistaken for melanoma
Cancer Cancer
� Seborrheic keratosis
– Common benign skin lesion in older adults
– Proliferation of epidermal cells occurring on sun exposed areas of skin
Cancer
� Seborrheic keratosis
– Common benign skin lesion in older adults
– Proliferation of epidermal cells occurring on sun exposed areas of skin
� Variable pigmentation– Pink – brown – dark brown – black
� Can transition to solar lentigo
– Usually begin as flat, brown, circumscribed areas that can increase in size and thickness
� Causes suspicion for melanoma
Cancer
� Malignant Melanoma (MM):
– Increasing incidence (~6% per year)
� Greatest incidence increase amongst neoplasms
� ½ the incidence of MM is between 35-65 ages– 80% of cases occurring between 20-74 ages
� Survivability has improved– 60% in 1960’s
– >89% in 1990’s
� Median age of diagnosis is 57
Cancer
� Malignant Melanoma (MM):
– Risks:
� FHx offer 10% increase risk
� Dysplastic nevus syndrome can increase risk 100-500X – ~25% of nevi develop to MM
� Blondes = 2X risk
� Red heads = 4X risk
� Sun sensitive or inability to tan = 2X risk
� Freckling = 2X risk
� Whites = 10X risk vs blacks/Asians/Hispanics
Cancer
� Malignant Melanoma (MM):
– Risks:
� Sunlight exposure is primary risk factor– Past sunburn at ANY age = 2X risk
• Childhood sunburns increase risk
– Tanning beds = 1.25X risk
– Living near equator increases risk
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Cancer
� Malignant Melanoma (MM):
– ABCDE rule:
� Asymmetry, Border irregularity, Color abnormality & Diameter (>6mm)
� E has now been added:– Evolving = change in size, shape, surface (bleeding) or
symptoms (itching or tenderness)
Cancer
� Dermal Melanoma
Now to the tour…..
Tissues of the conjunctiva
� Epithelium
– Stratified layers
� Basal�Wing�Surface
� Melanocytes
� Langerhahn’s cells� The sentry cells
– Signal the immune system
� NOT in the cornea!– They stimulate the system to cause scarring
Tissues of the conjunctiva
� Epithelium
– Stratified layer
� Melanocytes
� Langerhahn's cells
� Goblet cells
Tissues of the conjunctiva
� Epithelium
– Stratified layers
� Melanocytes
� Langerhahn's cells
� Goblet cells
� Fibroblasts
� Nerve cells
� Lymphatics
– Not IN the eye but in the conj & lids
– This allows for lymphatic related spread of disorders
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Tissues of the conjunctiva
� Blood vessels
� Mast Cells
– At BV wall
– Degranulate in allergy
� Itch
� Erythema
� Edema
Early Phase AllergySensitized Mast Cell
Histamine
Endothelial Gaping ���� fluid leakage =
Other Mediators: Tryptase
Heparin
Prostaglandins
Vasodilation @ 5-10 min =
H1 nerve stimulation
@ 3-5 min =
Itching!
Nerves
Antigen
Blood Vessel
Fluid
Blood Vessel
Redness!
Swelling!
Tissues of the conjunctiva
� Limbal stem cells– Thickened area of conjunctiva
� Source of replenishment of corneal epith
– A highly mitotic & immunologic area
– Explains why the limbal area can be the source of so many disorders
Limbal
stem
cells
Tissues of the conjunctiva
� Goblet cells– Mucus producing cells
– Distribution of goblet cells in the conj is notuniform
� Greater density away from the limbus toward fornix
� Greater nasally then temporally
Palpebral conjunctiva
Clinical Identification tips
� Conjunctival lesions– Limbal Dermoids
� Congenital choristoma– Definition:
• Choristoma is a congenital lesion composed of types of normal tissue that would not normally be found at that location of the body
• Hamartoma is a congenital lesion of an abnormal density of normal tissue that would be found at that location
- Freckle/nevus = hamartoma of pigment
- Hemangioma = hamartoma of blood
vessels
Clinical Identification tips
� Conjunctival lesions
– Limbal Dermoids
� Congenital choristoma– White – solid lesion
– Usually seen in children (rarely seen by ODs as a new lesion)
– Can consist of fat tissue-hair follicles-teeth
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Clinical Identification tips
� Conjunctival lesions
– Limbal Dermoids
� Differentiate for Goldenhar’s Syndrome– Oculoauriculovertebral syndrome
• Facial asymmetry (FLK): Usually unilateral
• Scoliosis
So to differentiate, look at the ear as well
as the eye!
Clinical Identification tips
� Conjunctival lesions
– Limbal phlectenule
� Located at the limbus
� Similar to marginal infiltrate (staph) but no clear zone at the limbus
� Possible association with TB (if regionally at risk)
� Very responsive to topical steroids
Clinical Identification tips
� Conjunctival lesions– Salzman’s nodular degeneration� May develop from any chronic surface disease– Common after chronic phlectenulosis – HSK – etc.
� Bluish-gray color to avascular lesion– Epith intact but thinned
� Not overly inflamed
� Often needs graft
Clinical Identification tips
� Conjunctival lesions
– Bitot’s spot
� Squamous Metaplasia– Mucosal tissue change in response to chronic dryness as protection
• Keratinization
– Reversible!
� Leukoplakia– = White plaque
� Vitamin-A deficiency– ERG to r/o night blind
Clinical Identification tips
� Conjunctival lesions
– Conjunctival Intraepithelial Neoplasia (CIN)
� Was Carcinoma in situ
� Collective term for ALL Ocular Surface Squamous Neoplasms (OSSN)
Ocular Surface Squamous Neoplasia
*Ocular Surface
Squamous Neoplasia
*Melanocytic
*Non-Melanocytic
*Melanosis
*Malignant Melanomas
*Papillomas
*Corneal Intraepithelial
Neoplasia (CIN)
*Squamous Cell Carcinoma
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Clinical Identification tips
� Conjunctival lesions
– Conjunctival Intraepithelial Neoplasia (CIN)
Clinical Identification tips
� Conjunctival lesions
– Conjunctival Intraepithelial Neoplasia (CIN)
� Once the lesion reaches the limbus, it likes the high mitotic area so it works around the limbusinstead of marching across (like a pterygium)
Clinical Identification tips
� Conjunctival lesions
– Conjunctival Intraepithelial Neoplasia (CIN)
� Once the lesion reaches the limbus, it likes the high mitotic area so it works around the limbus instead of marching across (like a pterygium)
� Once the lesion breaks through to the underlying conjunctival stroma (invasive), it is termed a Squamous Cell Carcinoma (SCC)– One step beyond CIN
� Basal Cell Carcinoma (BCC) is unheard of in the conjunctiva!– On skin think BCC 1st but conj think SCC !
Clinical Identification tips
� Conjunctival lesions
– Conjunctival Intraepithelial Neoplasia (CIN)
� Conjunctival Gelatinous Polypoid Squamous Cell Carcinoma– Will cross the cornea!
– HPV-16 often found but NOT considered the cause
Clinical Identification tips
� Cystic lesions
– Epithelial Inclusion Cyst (EIC)
� Use optic-section beam to “light up’ the lesion
– Formation:
� Epithelial cells are driven below the surface
Clinical Identification tips
� Cystic lesions
– EIC Formation Sequence
� Epith. Cells are designed to separate 2 environments from each other– Base toward stroma and top should be away from stroma
– Since it can only divide, they make a wall/chain until a new space is inside and the base is to stroma
– Once they achieve a separated space, they go back to their function and secret fluid = cyst
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Clinical Identification tips
� Cystic lesions
– EIC Formation Sequence
� Epith. Cells are designed to separate 2 environments from each other
Clinical Identification tips
� Cystic lesions
– EIC
� Fornix lesions are cloudy due to mast or goblet cell secretions
Clinical Identification tips
� Cystic lesions
– Lymphangiectasis
� May be linear or multi-lobular
Clinical Identification tips
� Cystic lesions
– What is it?
Clinical Identification tips
� Lid lesions
– Transition Areas
� Generally, in areas where one epithelium transitions from one type to another, is prone to viral induced lesions– Lid conj to palpebral conj (Lid Margin)
– Bulbar conj to cornea (Limbus)
Clinical Identification tips
� Lid lesions
– Molluscum Contagiosum
� Characteristics:– Sessile papillomatous lesion
– Viral induced
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Clinical Identification tips
� Lid lesions
– Molluscum Contagiosum
� Characteristics:– Sessile papillomatous lesion
– Viral induced
• Chronic follicular conjunctivitis
Molluscum bodies
Clinical Identification tips
� Lid lesions
– Molluscum Contagiosum
� Characteristics:– Sessile papillomatous lesion
– Viral induced
� A small “prick” of the surface to draw a bit of blood may involute the lesion
Clinical Identification tips
� Lid lesions
– Differentiate lesions
� History
� Onset timing
� Biopsy?
SCC
BCC
Melanoma
� Differentiate from HSK lid lesions
Clinical Identification tips
Masquerade Presentations
� Many eyelid tumors spread in a manner that involves different tissue planes at a microscopic level
� As a result, the process does not present as a discrete lesion and is often misdiagnosed as a benign inflammatory lesion
Clinical Identification tips
� Lid lesions
– Sebaceous Cell Carcinoma
� Often masks as persistent/recurrent chalaziaor unresponsive blepharitis
� Note lash line alteration!
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Chronic Conjunctivitis
� “The patient is non-compliant”
� “I haven’t found the right drop yet”
Chalazion
� Recurrent chalazion, same/multiple locations
Dermatitis
� Allergic dermatitis, chronic eczema, scleroderma
Ectropion
� Cicatricial LL ectropion, LL retraction
Entropion
� Trachoma, OCP
Blepharitis
� Non-compliant patient, poor hygiene
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Facial numbness or paralysis
� “It’s just a Bells palsy”
Clinical Identification tips
� Lid lesions
– Sebaceous Cell Carcinoma
� Often masks as persistent/recurrent chalaziaor unresponsive blepharitis
Clinical Identification tips
� Lid lesions
– Sebaceous Cell Carcinoma
� Pagetoid spread– Can significantly complicate the surgical management of this disease
Clinical Identification tips
� Lid lesions
– Sebaceous Cell Carcinoma
� Lash Margin could be best clinical clue
– Very rare but VERY bad cancer:
� 8%-25% die from this cancer (even at this early stage)
Clinical Identification tips
� Pink-colored lesions
– Pyogenic granulomas
� Neither pyogenic nor granulomatous!
� Ocular causes: – Post-op complication of tissue malpositioning
– May also occur in response to a retained foreign material
– May occur if a chalazion/hordeloum ruptures through the tarsus to the conjunctival surface and spontaneously drains
Clinical Identification tips
� Pink-colored lesions
– Pyogenic granulomas
Retained suture
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Clinical Identification tips
� Pink-colored lesions
– Pedunculated papillomas
� Viral induced
Clinical Identification tips
� Pink-colored lesions
– Sessile papillomas
� Difficult to differentiate!– Note “feeder” vessel(s)
� Pox virus induced– HPV 6 & 11 have been associated
Clinical Identification tips
Viral
Children/Adolescents
Often Bilateral
Often Multiple
Pedunculated in fornix
No inflammation
Resolve in 2 yrs
Neoplastic
Adults
Unilateral
Solitary
Sessile, at limbus
Inflammation
Do not resolve
Clinical Identification tips
� Pink-colored lesions
– Lymphoma
� Mucosa Associated Lymphoid Tissue (MALT)– Less aggressive
– Most common
� Mantle– Malignant-behaving
MALT Mantle
Clinical Identification tips
� Pigmented lesions
– Iris Nevus
� Melanoma transition & metastasis is rare
� Management of nevi is photos and monitor for:– Growth
– TM invasion
– Watch for
sentinel vessel
July ‘07 March ‘08
Clinical Identification tips
� Pigmented lesions
– Nevus at the caruncle
� Caruncle is usually very quiet
� More suspicious for development of melanoma
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Clinical Identification tips
� Pigmented lesions
– Conjunctival Nevus
� Focal, movable, congenital hamartoma
� May darken in puberty
� Always sample/biopsy if inflamed
Clinical Identification tips
� Pigmented lesions
– Conjunctival Nevus
� Focal, movable, congenital hamartoma
� May darken in puberty
� Always sample/biopsy if inflamed
Clinical Identification tips
� Pigmented lesions
– Ocular Melanosis
� Blue, gray or brown pigmentation
� Does NOT move
Clinical Identification tips
� Pigmented lesions
– Ocular Melanosis
� Associated with Nevus of Ota (Hori’s Nevus)– Most frequently in Asians
– Male:Female = 1:4.8
– 50% present at birth
– Second peak at adolescence
– Rare ocular melanoma
but incr uveal melanoma
Clinical Identification tips
� Pigmented lesions
– Primary Acquired Melanosis (PAM)
� 35% develop melanoma
Classification of Conjunctival PapillomasConjunctival
NevusCongenital Ocular
Melanosis
Primary Acquired
Melanosis (PAM)
Onset Congenital-may darken
Congenital Acquired-middle age
Structure Discrete Diffuse Diffuse
Color Brown Blue/slate gray Brown
Cysts 50% of compound nevi
None None
Pigmentation Variable Always Always
With conj movement
Lesion moves Lesion does NOT move
Lesion moves
Growth Stationary Stationary Waxes and wanes
Uvea Not involved Heterochromia Not involved
Skin Not involved May be involved
(Nevus of Ota)
Not involved
Malignant Potential
Conjunctival melanoma
Skin or uveal, rarely conjunctival
Conjunctival melanoma
Adapted from Thomas Freddo, O.D., Ph.D, FAAO, Univ of Waterloo
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Clinical Identification tips
� Pigmented lesions
– Conjunctival Melanoma
� 10% develop de-novo
� 20% from pre-existing nevus
� 60%-70% from spreading PAM
� Mortality = 25%– 40%-44% if from PAM
– Spreads to PA node or Sub-mandibular nodes
Clinical Identification tips
� Pigmented lesions
– Conjunctival Melanoma
Clinical Identification tips
� Pigmented lesions
– Lid MelanomaCase:
Ah… those suspicious lumps & bumps
HG
� 67 yowf
� CC: Raised limbal lesion OS
� MHx: Neg (Smoker!)
� OHx: Neg
� Meds: None
� FHx: Neg
� VASC: 20/20 OU
HG
� Pupils: PERRL - APD
� EOM: full range of motion
� Tapp: 15 OU
� SLE: - OD: WNL
- OS: Temporal raised gelatinous
vascularized lesion X 6+ months
� DFE: c/d 0.3 OU Mac/vessels/periph WNL
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HG HG
� Diagnosis:
– Pterygium
– Pinguecula
– Corneal intraepithelial neoplasm (CIN)
– Squamous cell carcinoma (SCC)
– I don’t know, that is why I called YOU!
HG
� Management:
– Topical antibiotics
– Mitomycin-C 0.002% (MMC)
– Surgery
– No treatment necessary
– Monitor
HG
� Lesion was biopsy positive SCC and referred to us for a second opinion:– Enucleate
– Other options
� No association with HPV
� No evidence of AC invasion, TM involvement or cataract.
HG
� What is the most identifying characteristic of these lesions?
– Gelatinous appearance
– Location on the cornea
– Vascularization
– Raised lesion
– Persistence &/or changes over time
HG
� What is the most identifying characteristic of these lesions?
– Gelatinous appearance
– Location on the cornea
– Vascularization
– Raised lesion
– Persistence &/or changes over time
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HG
� Management:– Option #1:
� Lamellar keratectomy with conjunctivectomy and sclerectomy
� Cryo of the margins
– Option #2:� Topical Mitomycin-C 0.002% (MMC)
� Head and Neck oncologists start systemic chemo of Fluoruracil and Cisplatin (X two cycles)
MMC Tx example
6/21/00 6/28/00
7/17/00 12/13/00
Is it reasonable to monitor CIN?
Not all will need MMC!
A newer biopsy technique
� Impression Cytology
– Non-invasive technique that allows ID of cell types to classify a lesion
Impression Cytology Procedure
� Instructions for patient specimen collection:– The Biopore membrane device (Millicell-CM 0.4 µm PICM 02550, Millipore Corp, Bedford, MA, USA) comes in a sealed sterile package
� The filter disc is 8 mm in diameter and is attached to a small plastic tube which is held during collection of the specimen
– Before collecting a sample, three protruding plastic legs must be snapped off from the base of the tube with a pair of Spencer–Wells forceps
– Topical proparacaine 0.5% eye drops are then instilled onto the ocular surface/lower fornix
– Cytology specimens are obtained from the conjunctiva or cornea
– The membrane device is firmly pressed against the area to be sampled for 10-20 seconds (until the membrane becomes translucent)
– Lastly, the device is immediately transferred into a 10 ml container of 95% ethanol without air drying
� Be sure to fully immerse the membrane in the solution
Impression Cytology Procedure
� Instructions for patient specimen collection:
– We use the Univ. of Colorado Denver Dept. of Anatomic Pathology/Cytology Lab at The Anschutz Center
� There are national labs that accept overnight delivery for assessment
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Impression Cytology Procedure
� Codes:
– Benign Neoplasm of eye = 224.00
� Conjunctiva = 224.30
� Cornea = 224.40
� Eye lid = 216.10
– Carcinomas (in situ) = 234.00
� General code for eye – cornea or conjunctiva
� Excludes lid– Eye lid = 232.10
Limitations & Disadvantages
� Tissue Biopsy and Surgical Excision– Can cause disorganization of the specimen during
– Can often miss tumor margins in the tissue collection
– Longer recovery time
– More invasive procedure for the patient
– Recurrence rate near 52%
– Can cause scarring
– Removes limbal stem cells with each surgical procedure
� Impression Cytology– Sample depth is only first few superficial layers
– Inconsistent reliably to distinguish invasive SCC or epithelium carcinoma in situ from minimally invasive disease
– Keratinizing dysplasias may yield no or few atypical cells on impression cytology
Impression Cytology What is that bump?
� OSSN lesions have been routinely ID’ed by surgical biopsy
– P/op stem cell deficiency concerns
� Impression cytology is a less invasive diagnostic option
References� 1. Yanoff M, Duker J. Ophthalmology. 2nd ed. St. Louis, MO Mosby; 535-541� 2. McKelvie P. Ocular Surface Impression Cytology. Adv Anat Pathol 10;6:328-337� 3. Nolan G, Hirst L, Bancroft B. The Cytomorphology of Ocular Surface Squamous Neoplasia by
Using Impression Cytology. Cancer (Cancer Cytopathol) 2001;93:60–67� 4. Tananuvat N, Lertprasertsuk N, Mahanupap P, et al. Role of impression cytology in diagnosis of
ocular surface neoplasia. Cornea. 2008;3:269-274� 5. Tole D, McKelvie P, Daniell M. Reliability of impression cytology for the diagnosis of ocular
surface squamous neoplasia employing the Biopore membrane. Br J Ophthalmol 2001;85:154-15� 6. Chen C, Louis D, Dodd T, et al. Mitomycin C as an adjunct in the treatment of localized ocular
surface squamous neoplasia. Br. J. Ophthalmol. 2004;88;17-18� 7. McKelvie P, Daniell M. Impression cytology following mitomycin C therapy for ocular surface
squamous neoplasia. Br J Ophthalmol 2001;85:1115–1119� 8. Thatcher R, Darougar S, Jones B. Conjunctival impression cytology. Arch Ophthalmol. 1977;95:678–
681� 9. Egbert P, Lauber S, Maurice D. A simple conjunctival biopsy. Am J Ophthalmol. 1977;84:798–801� 10. Singh R, Joseph A, Umapathy T, et al. Impression cytology of the ocular surface. British Journal of
Ophthalmology 2005;89:1655-1659� 11. Mathew A, Stumpf T, McGhee C. Impression cytology: implications for ocular surface squamous
neoplasias. British Journal of Ophthalmology 2008;92:157-158� 12. Sun E, Fears T, Goedert J. Epidemiology of squamous cell conjunctival cancer. Cancer Epidemiol Bio
Prevent 1997; 6: 73–77� 13. Yamamoto N, Ohmura T, Suzuki H, et al. Successful Treatment with 5-Fluorouracil of Conjunctival
Intraepithelial Neoplasia Refractive to Mitomycin-C. Ophthalmology 2002;109:249–252� 14. Mahar P, Nwokora G. Role of mitomycin C in pterygium surgery. British Journal� of Ophthalmology 1993;77:433-435� 15. Hirst L, Randomized Controlled Trial of Topical Mitomycin C for Ocular Surface Squamous
Neoplasia. Ophthalmology 2007;114:976–982
Thank You!
Grand Tetons, Wyoming