Diagnosis of ocular surface lesions using ultra-high-resolution optical coherence tomography

Abstract

Purpose: To assess the use of ultra-high-resolution (UHR) optical coherence tomography (OCT) in the diagnosis of ocular surface lesions.

Design: Prospective, noncomparative, interventional case series.

Participants: Fifty-four eyes of 53 consecutive patients with biopsy-proven ocular surface lesions: 8 primary acquired melanosis lesions, 5 amelanotic melanoma lesions, 2 nevi, 19 ocular surface squamous neoplasia lesions, 1 histiocytosis lesion, 6 conjunctival lymphoma lesions, 2 conjunctival amyloidosis lesions, and 11 pterygia lesions.

Intervention: Ultra-high-resolution OCT imaging of the ocular surface lesions.

Main outcome measures: Clinical course and photographs, UHR OCT image, and histopathologic findings.

Results: Ultra-high-resolution OCT images of all examined ocular surface lesions showed close correlation with the obtained histopathologic specimens. When clinical differential diagnosis of ocular surface lesions was broad, UHR OCT images provided optical signs indicating a more specific diagnosis and management. In cases of amelanotic melanoma, conjunctival amyloidosis, and primary histiocytosis and in 1 case of ocular surface squamous neoplasia, UHR OCT was instrumental in guiding the diagnosis. In those cases, UHR OCT suggested that the presumed clinical diagnosis was incorrect and favored a diagnosis that later was confirmed by histopathologic examination.

Conclusions: Correlations between UHR OCT and histopathologic findings confirm that UHR OCT is an adjunctive diagnostic method that can provide a noninvasive means to help guide diagnosis and management of ocular surface lesions.

Financial disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Figure 1

Ultra high resolution optical coherence tomography image of the limbus of a normal subject. Normal corneal epithelium (1A-a) appears hypo-reflective. Note Bowman’s layer (1A-b), corneal stroma (1A-c) and Descemet’s membrane (1A-d). Conjunctival epithelial appears hypo-reflective (1A-e). Note the underlying substantia propria (1A-f).

Figure 2

Slit lamp photograph (2A) of primary acquired melanosis (PAM). Ultra high resolution optical coherence tomography (UHR-OCT) image (2B) in the area of the black dotted arrow disclosed normal thickness epithelium (2B-a) with regular, intense hyper-reflectivity of the basal epithelial layer (2B-b). No invasion of the underlying tissue was seen. Histopathology (2C) confirmed the diagnosis of PAM with moderate atypia (stain, hematoxylin–eosin; original magnification, X200).

Figure 3

Slit lamp photograph (3A) of a raised, reddish, non-pigmented conjunctival lesion referred as a possible squamous neoplasia. Ultra high resolution optical coherence tomography (3B) in the area of the black dotted arrow disclosed a subepithelial lesion (3B-a) beneath a normal thickness epithelium (3B-b). The lesion was casting a significant shadow (3B-c) on the underlying tissue. Foci of epithelial cleavage (Fig 3B-d) and moderate hyper-reflectivity of the epithelium were noted. Histopathologic examination (3C) confirmed the diagnosis of melanoma. (stain, hematoxylin–eosin; original magnification, X200).

Figure 4

Slit lamp photograph (4A) of a pigmented conjunctival lesion (4A). Ultra high resolution optical coherence tomography (4B) in the area of the black dotted arrow disclosed a well circumscribed hyper-reflective lesion in the epithelium (4B-a) and substantia propria (4B-b) with shadowing (4B-c). Cystic structures were noted (4B-d). Histopathologic examination (4C) revealed nevus cells within the epithelium and substantia propria. Epithelial lined cysts were present in the superficial substantia propria (4C-a). Pathologic diagnosis confirmed a compound cystic nevus. (stain, hematoxylin–eosin; original magnification, X100).

Figure 5

Slit lamp photograph (5A) of a gelatinous pigmented conjunctival lesion referred as a possible melanoma. Ultra high resolution optical coherence tomography image (5B) in the area of the black dotted arrow revealed severely thickened hyper-reflective epithelium (5B-a). Abrupt transition between unremarkable and thickened hyper-reflective epithelium was noted (5B-b) as well as a plane of cleavage between the lesion and the underlying tissue (5B-c), all suggestive of an ocular surface squamous neoplasia (OSSN). Histopathological examination of the excised specimen (5C) confirmed the diagnosis of OSSN (stain, hematoxylin–eosin; original magnification, X200).

Figure 6

Slit lamp photograph (6A) of an elevated gelatinous corneal-conjunctival lesion with tufts of blood vessels. Ultra high resolution optical coherence tomography (UHR-OCT) image (6B) in the area of the black dotted arrow disclosed an unremarkable epithelium (6B-a) and a lesion (6B-b) confined to the subepithelial layer (6B-c). The mass was composed of small dots; which may represent cellular infiltration (6B-b). Note oval hypo-reflective areas that represent blood vessels (6B-c). Histopathologic examination of the excised specimen (6C) confirmed UHR-OCT findings of cellular infiltration, in this case of CD68 positive histiocytes (6C-a) underneath an intact appearing epithelium (6C-b), suggesting a diagnosis of conjunctival histiocytosis. (stain, hematoxylin–eosin; original magnification, X200).

Figure 7

Slit lamp photograph (7A) of a salmon pink conjunctival lesion. Ultra high resolution optical coherence tomography (7B) indicates a normal epithelium (7B-a) and a lesion in the substantia propria (7B-b) formed of stippled dots. The lesion was hyporeflective and homogeneous in nature. Histopathologic examination (7C) discloses a monomorphous population of small to moderate sized blue cells located within the substantia propria. Flow cytometry and gene rearrangement results confirmed the diagnosis of extranodal marginal zone lymphoma. (stain, hematoxylin–eosin; original magnification, X200).

Figure 8

Slit lamp photograph (8A) and ultra high resolution optical coherence tomography (UHR-OCT) in the area of the black dotted arrow demonstrate conjunctival lymphoma, a lesion that was formed by small cellular like dots (8B-a) on UHR-OCT. Histopathologic examination (8C) along with flow cytometry and gene rearrangement confirmed the diagnosis of extranodal marginal zone lymphoma. The lesion resolved after a 20 days course of external beam radiation (8D). A follow up UHR-OCT image (8E) confirmed resolution. (stain, hematoxylin–eosin; original magnification, X100).

Figure 9

Slit lamp photograph (9A) of a yellow-pink conjunctival lesion that was thought to be conjunctival lymphoma. Ultra high resolution optical coherence tomography in area of black dotted arrow (9B) disclosed a normal epithelium (9B-a) and hypo-reflective lesion (9B-b) present diffusely in the substantia propria intermixed with hyper-reflective linear areas (9B-c). Histopathological examination (9C) revealed paucicellular material located diffusely within the substania propria that was PAS, congo-red positive and demonstrates an apple green-birefringence (9C) with polarized light. Flow cytometry and gene studies were negative. A diagnosis of conjunctival amyloidosis was made. (stain, hematoxylin–eosin; original magnification, X100).

Figure 10

Slit lamp photograph (10A) demonstrates a pterygium. Ultra high resolution optical coherence tomography (UHR-OCT) in the area of the black dotted arrow disclosed a moderately hyper-reflective epithelium (10B-a) and a highly hyper-reflective fibrillary subepithelial lesion (10B-b). Hypo-reflective areas may correspond to blood vessels (10B-c). Histopathological examination (10C) demonstrated an unremarkable epithelium with solar elastosis within the substantia propria confirming the diagnosis of pterygium (stain, hematoxylin–eosin; original magnification, X200).