Sir,

A 68-year-old male was evaluated for redness of the right eye, which had been present for 3 months. The visual acuity was 20/40 and 20/20. A nodular growth, 6 × 5 × 3 mm in size, was observed at the temporal limbus overriding the cornea for about 2 mm (Figure 1a) with circumferential corneal extension for 120° from 0700 to 1100 hours (Figure 1b). Preoperative treatment with 0.04% mitomycin eye drops four times a day (1 week on 1 week off cycle) was initiated following insertion of punctal plugs. Marked reduction in size of the conjunctival tumour was observed by the end of two cycles (Figure 1c) with complete clearing of all corneal involvement and its replacement by normal epithelium (Figure 1d). The patient tolerated the therapy well. Following additional cycle of treatment, excision of the residual conjunctival tumour and double freeze thaw cryotherapy to the conjunctival margins was performed. Histopathology of the residual conjunctival lesion confirmed CCIN with mild dysplasia (Figure 1e). The margins were clear of dysplastic tissue. There was no evidence of tumour recurrence at 12-month visit (Figure 1f).

Figure 1
figure 1

(a) Fleshy nodular growth at the temporal limbus. (b) Circumferential corneal extension for 120° (arrowheads). (c) Appearance following two cycles of mitomycin C (MMC) therapy. Marked reduction in size of the conjunctival tumour was observed. (d) Appearance following two cycles of mytomycin C (MMC) therapy. Note complete clearing of all corneal involvement. (e) Histopathology of the residual conjunctival tumour reveals CCIN with mild dysplasia. Note large hyperchromatic nuclei containing nucleoli (arrows, hematoxylin and eosin). (f) Appearance at 12 months postoperative visit.

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Comment

Conjunctival epithelial tumours represent a spectrum ranging from mild dysplasia to invasive squamous cell carcinoma involving the conjunctiva as well as the cornea, and are grouped as ocular surface squamous neoplasia (OSSN).1, 2, 3 More than 20 years ago, Fraunfelder and Wingfield reported improved tumour control when excision was combined with cryotherapy as compared to excision or cryotherapy performed alone.4, 5 The limitation of surgical excision is a potential for partial excisions and possibility of stem cell failure when large areas of limbal epithelium are excised.

In recent years, topical chemotherapy with mitomycin has been advocated for postoperative usage in cases where tumour excision is incomplete, both for primary and recurrent tumours while accepting risk of reversible keratoconjunctivitis.6, 7, 8, 9 By using topical neoadjuvant chemotherapy the advantages of surgical excision and of chemotherapy can be exploited in the most effective way. The surgical excision is limited, histopathologic diagnosis can be confirmed, the risk of keratoconjunctivitis is minimized, and the risk of postoperative tumour recurrence may be reduced.7