Britishournal ofOphthalmology, 1992,76, 123-125

Resection of intraocular squamous cell carcinoma

D H Char, J Brooks Crawford, E L Howes Jr, A J Weinstein

AbstractA patient with recurrent squamous cellcarcinoma ofthe conjunctiva was referred with20/20 vision in an eye with obvious intraocularextension. A modified iridocyclochoroidec-tomy was performed and the tumour wasremoved. Three and a half years later thepatient's vision is 20/30 and there is no recur-rence. This is the first case in which an eye hasbeen successfully salvaged with documentedintraocular squamous cell carcinoma of theconjunctiva.

Squamous cell carcinoma of the conjunctivausually remains superficial, localised, and can becured at that stage with resection and adjunctivecryotherapy or radiation.' Rarely the tumourinvades either into the orbit or the globe.Approximately 60 cases of intraocular invasionhave been reported.5-9 Usually this complicationoccurs in patients with either neglected or recur-rent tumours. In a 60 year retrospective reviewfrom the Mayo Clinic there were two of 22 casesof invasive squamous cell carcinoma of theconjunctiva invaded into the globe.8 In a series of104 epithelial tumours reported by Irvine, onehad intraocular invasion; similarly one of 27invasive carcinomas reported from the WilmerInstitute had intraocular penetration. 16 20

Intraocular invasion from squamous cellcarcinoma of the conjunctiva can have a numberof clinical manifestations. We have noted it as anundiagnosed corneal perforation, anterior seg-ment inflammation, a combined orbital andintraocular mass, a non-specific broad peripheralanterior synechiae, an apparently solitary intra-ocular mass, or a sheet of cells growing onto theiris surface,' other presentations have included anecrotising scleritis.2' Nicholson and Herschlerdescribed a patient who presented with apparentanterior chamber inflammation in whom the

Ocular Oncology Unit,Department of RadiationOncology, and theFrancis I ProctorFoundation, Universityof CaliforniaD H Char

Eye PathologyDepartment, Universityof CaliforniaJ Brookes CrawfordE L Howes

Private practice,New MexicoA J WeinsteinCorrespondence to:D H Char, MD, OcularOncology Unit, PO Box 0730,UCSF, San Francisco,CA 94143, USA.Accepted for publication27 June 1991

PFgure I External photograph demonstrates the appearanceofthe intraocular tumour. The patient had previouslyundergone a scleral graft. The intraocular tumour is visiblebetween 7 and 9 o'clock (arrow).

correct diagnosis of squamous cell carcinomawas confirmed with aqueous paracentesis. II

The ocular prognosis for patients with intra-ocular invasion from conjunctival carcinoma hasbeen dismal. All reported cases have requiredeither enucleation or exenteration.2-20 We reporta patient with recurrent squamous cell car-cinoma that invaded the globe in whom we wereable to successfully salvage both the eye andvision.

Case reportA 58-year-old female was referred with a recur-rent right conjunctival squamous cell carcinomawith intraocular invasion. The patient wasinitially examined in January 1987 by her localophthalmologist for an atypical area of solardamage at the right temporal limbus. In Feb-ruary 1987 this was resected and pathologicalexamination revealed a squamous cell car-cinoma. The tumour recurred 6 weeks later anda second resection was performed in April 1987.An en bloc excision of the tumour and theunderlying 50% thickness sclera was performed.Adjunctive cryotherapy was delivered to theremaining scleral fibres and the edges of theresection. The area was closed primarily withouta graft. The neoplasm recurred within 1 monthin the same area and a third resection wasperformed in May 1987 with placement of a10 mm diameter scleral allogeneic patch graft.Pathology sections demonstrated that allmargins were clear.Two months later in July 1987 intraocular

invasion was noted (Fig 1) and the patient wasreferred to us for further management.On our examination at that time the visual

acuity was 20/20 in each eye. The left anteriorsegment and fundus were unremarkable exceptfor areas of lattice degeneration without retinalbreaks. The intraocular pressure was 14 mm Hgin the right eye and 16 mm Hg in the left.

In the right eye there was a large scleral graft atthe temporal limbus. The cornea was clear. Theiris and ciliary body were involved with anamelanotic mass from 7 to 9 o'clock. There wasno pupillary distortion. There was trace flarewithout cell in the anterior chamber. Examina-tion of the right fundus with both scleral depres-sion and three mirror contact lens examinationwas unremarkable.

Ultrasonography demonstrated a mass involv-ing the lens and ciliary body. The tumour wasapproximately 7 mm thick on standardised Ascan.

Various therapeutic options were discussedwith the patient and her family and it wasdecided to proceed with a scleral resection and amodified iridocyclectomy. The area around thescleral graft was explored and obvious tumourextension along both surface and under the graft

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Char, Brooks Crawford, Howes, Weinstein

Figure 2AFigure2 (A)Lowpowerphotomicrographofanteriorportionofresected tissue (H and E, x 10). (B) Higher powerphotomicrograph showing invasive squamous cell carcinomaarisingfrom the conjunctival surface. Note the hyperkeratosisand keratosis on the surface ofthe conjunctiva, and theinvasion ofa scleral canal (arrow) (H and E, x40). (C)Higher powerphotomicrograph ofthe ciliary body invaded bysquamous cell carcinoma, some ofwhich hasformedkeratinising pearls (H and E, x40).

was confirmed on frozen section. A large scleralresection approximately 17 x 12 mm in diameterwas performed and the contiguous iris, ciliarybody, and choroid were removed en bloc. Frozensections of the margins were clear. A free

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allogeneic scleral graft was used to reconstructthe eye. Double freeze thaw adjunctive cryo-therapy to adjacent sclera and conjunctiva wasdelivered in a standard manner. Microscopicexamination of the resected tissue showed akeratinising squamous cell carcinoma arisingfrom the conjunctiva and extending throughscleral canals into the ciliary body (Figs 2 A,B,C).

Postoperatively the patient slowly developedincreasing lens opacity over the next year. Shesubsequently had an extracapsular cataractextraction and the implantation of an intraocularlens by her referring ophthalmologist in August1989. A YAG laser capsulotomy was performedand on her last visit in August 1990 her visualacuity was 20/30. There was no evidenceof tumour recurrence and the pressure was14mmHg.

DiscussionThere are at least three important risk factorsfor intraocular extension of squamous cellcarcinoma of the conjunctiva, neglectedmalignancy, recurrent tumours, and histologictumour type.' 9 1016 Our case had repeat excisionswith apparently clear margins but eventuallydeveloped intraocular penetration. The disparitybetween the apparently clear surgical marginsand recurrence emphasises the limitations ofstandard frozen section control of tumour mar-gins. While that histological technique is quiteaccurate to delineate horizontal tumour spread,especially with a small surgical specimen, itsefficacy for sampling the deep surface is poor.We have had one other conjunctival tumourpatient with clear frozen section margins whodeveloped a recurrence because of inapparenttumour at the deep surgical line. These limita-

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Resection ofintraocular squamous cell carcinoma

tions with frozen section technique have led us touse adjunctive cryotherapy both to the base aswell as the horizontal resection lines in all cases. I

Intraocular penetration and metastases fromsquamous cell carcinomas of the conjunctiva arerare.' 816 In most series fewer then 2% of caseshave intraocular penetration, and only twopatients in the United States have had docu-mented metastatic disease. In 10 patientsreported from Saudi Arabia with advanceddisease seven had intraocular invasion.22Mucoepidermoid and, possibly, spindle cellvariants of squamous cell carcinoma are morelocally aggressive and have a higher recurrencerate; each histological subtypes account for fewerthan 5% of squamous cell carcinomas of theconjunctiva.9' l 23Very few surgeons have attempted to salvage

an eye with intraocular penetration of squamouscell carcinoma of the conjunctiva; all previouscases have required either enucleation orexenteration. Li and co-workers reported twopatients who had modified en bloc resections;however both had positive margins and wereenucleated within 1 day and 1 week of the initialsurgery.'9 It is uncertain how many patients withintraocular proliferation of squamous cell car-cinoma are candidates for a modified irido-cyclochoroidectomy. We have examined fivepatients with intraocular extension from thistumour, and this was the only case in which wefelt that this approach was indicated. Usuallyintraocular penetration by this malignancy is notamenable to local resection with ocular salvagebecause the tumour is too diffuse. Since 1903 anumber of investigators have demonstrated thatintraocular invasion is usually associated withdiffuse spread in both the suprachoroidal spaceand the uvea.'8 Often the tumour is sufficientlyfriable to seed cells into the anterior chamber andsimulate inflammation."' In some cases there isextensive orbital spread contiguous with theocular involvement. In a minority of patientswith apparently localised intraocular tumour amodified eyewall resection is a reasonablealternative.

This work was supported in part by NIH grant EYO 7504, and by

unrestricted grants from That Man May See and Research toPrevent Blindness.

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