Role of high resolution optical coherence tomography in diagnosing ocular surface squamous neoplasia with coexisting ocular surface diseases

Abstract

Purpose: Coexistence of an ocular surface disease can mask the typical features of ocular surface squamous neoplasia (OSSN). The purpose of this study was to evaluate high resolution optical coherence tomography (HR-OCT) as an adjunct in the detection and differentiation of OSSN within coexisting ocular surface pathologies.

Methods: Retrospective study of 16 patients with ocular surface disease and lesions suspicious for OSSN that were evaluated with HR-OCT. HR-OCT images of the lesions were taken to look for evidence of OSSN. Biopsies were performed in all cases, and the HR-OCT findings were compared to the histological results.

Results: Of the 16 patients with OSSN and a coexisting ocular surface disease, 12 were found to have OSSN by HR-OCT and all were subsequently confirmed by biopsy. Two patients had OSSN with rosacea, one with pingueculum, two within pterygia, one with Salzmann' nodular degeneration, six with limbal stem cell deficiency (LSCD)/scarring. In all 12 cases HR-OCT images revealed classical findings of hyper-reflective, thickened epithelium and an abrupt transition from normal to abnormal epithelium. OSSN was ruled out by HR-OCT in four cases (2 Salzmann's, 1 mucous membrane pemphigoid, and 1 LSCD). Negative findings were confirmed by biopsy. HR-OCT was used to follow resolution of the OSSN in positive cases, and it detected recurrence in 1 case.

Conclusions: While histopathology is the gold standard in the diagnosis of OSSN, HR-OCT can be used to noninvasively detect the presence of OSSN in patients with coexisting ocular conditions.

Keywords: Conjunctiva; Cornea; Lymphoma; Melanoma; Ocular surface squamous neoplasia (OSSN); Optical coherence tomography (OCT); Pterygium; Tumor.

Figure 1

(a) A 76-year-old male with longstanding scarring, trichiasis and chronic inflammation. An inferior leukoplakic opacification (black arrow) appeared suspicious. (b) HR-OCT (custom device, white line scan in a) demonstrated hyper-reflective thickened epithelium (above arrow heads) with an abrupt transition from normal to abnormal (white arrow). (c) A 67-year-old female with ocular surface inflammation and a suspicious area of elevation at the 5 o’clock position (black arrow). (d) HR-OCT (custom device, white line scan in c) demonstrated hyper-reflective thickened epithelium (above arrowheads) with an abrupt transition from normal to abnormal (white arrow). OSSN confirmed by biopsy in both cases.

Figure 2

(a) A 37-year-old male boat captain with a longstanding conjunctival lesion presented with a subtle area of leukoplakia (black arrow) at the corneal margin of the lesion. (b) HR-OCT image (commercial device, white line scan in a) demonstrated hyper-reflective thickened epithelium (above arrow heads) and an abrupt transition zone (white arrow). (c) Similarly, a subtle opacification and elevation was noted at the head of a longstanding pterygium of a 64-year-old male (black arrow). (d) HR-OCT (commercial device, white line scan in c) revealed the anatomy of the folded pterygium tissue (P) with normal epithelium (E), and an adjacent area of thickened epithelium (above arrow heads, T), with two abrupt transition zones (white arrows) suspicious for OSSN. Biopsy confirmed OSSN in both cases.

Figure 3

(a) A 76-year-old male seen with an opacity (area within bracket) adjacent to a long standing nodule (black arrow). (b) HR-OCT (custom device, white line scan in a) showed the subepithelial opacities (long white arrow) consistent with Salzmann’s nodular changes but also subtle adjacent epithelial thickening (T) and a transition zone (short white arrow) consistent with OSSN. Biopsy confirmed OSSN. (c) A 57-year-old female referred for a corneal opacity thought to be OSSN (black arrow). (d) HR-OCT (commercial device, white line scan in c) demonstrated thin, dark epithelium (above the arrowheads) with a hyper-reflective subepithelial lesion (black arrow) consistent with Salzmann’s, which was confirmed by biopsy.

Figure 4

(a) A 73-year-old male with a history of OSSN in the lateral canthus 7 years prior to presentation developed Stage III MMP (Foster classification) with symblepharon formation (black arrow) and presented for possible OSSN recurrence at the limbus. (b) HR-OCT (commercial device) along the white line, however, demonstrated thin epithelium (above arrowheads) with a subepithelial hyper reflectivity consistent with scarring (S) and no OSSN. Biopsy was negative for OSSN.

Figure 5

(a) A 66-year-old female with history of lipid keratopathy, stem cell deficiency and a prior history of OSSN was referred for possible OSSN recurrence. (b) HR-OCT (commercial device, white line scan in a) demonstrated a uniform, only mildly thickened epithelium (above white arrow tips) but without a transition zone and a diffuse subepithelial scar (above black arrow heads) and stromal scar (black arrow) ruling out OSSN. Biopsy was negative for OSSN. (c) A 28-year-old male with diffuse corneal scarring presumed to be herpetic keratitis. The opacity had a whirling opalescent appearance (black arrows). (d) HR-OCT (commercial device, white line scan in c) revealed hyper-reflective epithelial thickening (above arrow heads) with an abrupt transition from normal epithelium (white arrow) suggestive of OSSN, which was confirmed on biopsy.

Figure 6

(a) A 35-year-old male with HIV, vernal keratoconjunctivitis, and extensive LSCD with chronic epithelial defects presented for evaluation of possible OSSN. (b) HR-OCT (custom device, white line scan in a) demonstrated epithelial thickening (above arrow heads), an abrupt transition (arrow) and subepithelial scarring (below arrow heads) consistent with OSSN, which was confirmed by biopsy. (c) Slit lamp photograph showing resolution after treatment with topical interferon and (d) HR-OCT (commercial device) demonstrating thin, normalized epithelium on OCT (white arrowheads). (e) A 43-year-old female who presented with neovascularization and opacification of her penetrating keratoplasty implant. A subtle gelatinous change was noted in the limbal conjunctiva (black arrows) suspicious of OSSN. (f) HR-OCT (commercial device, white line scan in e) was consistent with OSSN showing a thickened mildly hyper reflective epithelium (above arrow heads) and a transition zone (white arrow). Biopsy confirmed OSSN.

Figure 7

(a) 61-year-old male with LSCD presented with a gray lesion (black arrow). (b) HR-OCT (custom device, white line scan in a) revealed thickened and hyper reflective epithelium (above arrow heads) consistent with OSSN. A band of scar/inflammation was seen (between Bowman’s and arrowheads). Biopsy confirmed the OSSN. (c) Nineteen months after resolution, a new opacity was detected at the 4 o’clock area. (d) HR-OCT (custom device, white line scan in c) revealed epithelial thickening, hyper reflectivity (above arrow heads) and a visible transition zone (white arrow) suggestive of OSSN recurrence. OCT finding was confirmed on biopsy.