the risk of epithelial and stromal damage. Deionized water is known to induce a swelling response that is greater at the central cornea than at the periphery.5 With the use of deionized water and a bandage contact lens, we were able to eliminate the wrinkles without having to stretch or iron the corneal flap even when severe folds were present. The wrinkles did not disappear immediately after hydration, probably because it takes some time to soften the adherences inside the folds. Although transient epithelial edema developed, no epithelial defects were produced by the use of deionized water. Deionized water may offer advantages over isotonic solutions to induce a swelling response of the flap and to weaken the forces implicated in the persistence of flap wrinkles after LASIK. REFERENCES
1. Probst LE, Machat J. Removal of flap striae following laser in situ keratomileusis. J Cataract Refract Surg 1998;24:153–155. 2. Steinemann TL, Denton NC, Brown MF. Corneal lenticular wrinkling after automated lamellar keratoplasty. Am J Ophthalmol 1998;126:588 –590. 3. Pannu JS. Incidence and treatment of wrinkled corneal flap following LASIK. J Cataract Refract Surg 1997;23:695– 696. 4. Pannu JS. Wrinkled corneal flaps after LASIK. J Refract Surg 1997;13:34. 5. Ling T. Osmotically induced central and peripheral corneal swelling in the cat. Am J Optom Physiol Opt 1987;64:674 – 677. FIGURE 1. (Top) Biomicroscopic examination shows multiple wrinkles radiating from the superior edge of the hinge. (Bottom) Twenty-four hours after treatment with hydration with deionized water and a bandage contact lens, the cornea is smooth and free of wrinkles.
Conjunctival Intraepithelial Neoplasia Presenting as Corneal Ulcer Mittanamalli S. Sridhar, MD, Santosh G. Honavar, MD, Geeta Vemuganti, MD, and Gullapalli N. Rao, MD To report a case of conjunctival intraepithelial neoplasia presenting as corneal ulcer. METHOD: Case report of a 28-year-old man who presented with sudden onset of pain, redness, and watering in the right eye. Examination of right cornea revealed deep stromal infiltrate inferonasally. Adjacent to the infiltrate and straddling the inferonasal limbus, a reddish welldefined sessible lesion with prominent blood vessels was seen. After corneal scraping for microbiological evaluation, the patient was treated with frequent instillation of ciprofloxacin hydrochloride 0.3% eyedrops. PURPOSE:
FIGURE 2. Videokeratography demonstrates no residual irregular astigmatism 7 days after LASIK. Accepted for publication August 3, 1999. From the Cornea Service (M.S.S., G.N.R.), Oncology Centre (S.G.H.), and Pathology Centre (G.V.), LV Prasad Eye Institute, Hyderabad, India. Inquiries to Mittanamalli S. Sridhar, MD, Cornea Service, LV Prasad Eye Institute, LV Prasad Marg, Banjara Hills, Hyderabad 500 034, India; fax: 91-40-3548271; e-mail:
[email protected]
ing.1,3,4 For severe wrinkles, cutting the hinge at one edge to relieve the tension of the flap has also been reported.4 All these maneuvers involve flap manipulation and carry 92
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Corneal scraping revealed no microorganisms. Infiltrate resolved promptly after excision of the lesion. Histopathologic evaluation of the excised lesion revealed conjunctival intraepithelial neoplasia. CONCLUSIONS: This case highlights the fact that conjunctival intraepithelial neoplasia at the limbus may present as corneal ulcer. This ulcer could have occurred secondary to a dellen formation and epithelial breakdown predisposing to a corneal ulcer. (Am J Ophthalmol 2000;129:92–94. © 2000 by Elsevier Science Inc. All rights reserved.) RESULTS:
S
QUAMOUS NEOPLASIA OF THE OCULAR SURFACE PRE-
sents in a variety of ways, ranging from benign dysplasia to invasive squamous cell carcinoma.1 Conjunctival intraepithelial neoplasia and squamous cell carcinoma are difficult to distinguish on clinical presentation alone. The tumor can be relatively translucent to pearly white, varying in configuration from an ill-defined gelatinous to a well-defined papillomatous growth located in the interpalpebral bulbar conjunctiva near the limbus.2 Most patients with smaller lesions are asymptomatic, and larger and keratinized lesions may produce ocular irritation, pain, or rarely blurred vision.3 We report a young patient with conjunctival intraepithelial neoplasia at the limbus presenting with corneal ulcer. A 28-year-old man with sudden onset of pain, redness, and watering in the right eye was referred with a primary diagnosis of corneal infiltrate with pterygium. He had been treated with topical gentamicin 0.3% eyedrops for 2 weeks. On examination, best-corrected visual acuity was 20/20 in both eyes. Eyelids were edematous, and bulbar conjunctiva was diffusely congested in the right eye. An area of epithelial defect with deep corneal stromal infiltrate was located inferonasally, measuring 2.5 ⫻ 2.5 mm with endothelial exudates and surrounding stromal edema. Adjacent to the infiltrate, straddling the inferonasal limbus, and extending on to the bulbar conjunctiva, was a well-defined, sessile, reddish-grey lesion
with patches of leukoplakia on the surface and surrounding episcleral feeder blood vessels (Figure 1, left). We made a clinical diagnosis of squamous cell neoplasia with corneal ulcer in the right eye. Corneal scrapings from the ulcer were negative for microorganisms on Gram stained smear and potassium hydroxide wet mount; cultures were sterile. The density of the infiltrate reduced after our initial treatment with ciprofloxacin hydrochloride 0.3% eyedrops instilled every 30 minutes, atropine sulfate 1.0% eyedrops three times daily, and artificial tears eight times daily. However, the size did not change. The limbal lesion was excised under peribulbar anesthesia once the culture reports were confirmed sterile. Partial lamellar keratoconjunctivectomy was performed by the standard procedure3 with supplemental cryotherapy to the bare sclera and the conjunctival edge. The infiltrate resolved and formed a scar the fourth postoperative day (Figure 1, right). The sections of the excised specimen stained with hemotoxylin and eosin showed corneal epithelium and conjunctival tissue with clear surgical margins. Marked hyperplasia of conjunctival epithelium was evident with loss of polarity and surface maturation; these cells occupied from two thirds to the entire thickness of the epithelium. The basement membrane was intact. These features were consistent with conjunctival intraepithelial neoplasia (Figure 2). Squamous neoplasia of the ocular surface most often presents as a growth on the ocular surface or as foreign body sensation, redness, or irritation.3 We are unaware of previous reports of conjunctival intraepithelial neoplasia presenting as corneal ulcer and could find no reference to it in a computer search using MEDLINE. Corneal ulcer could have occurred in this patient secondary to a dellen (localized thinning of the corneal epithelium, Bowman layer, and superficial stroma). Dellen forms in the peripheral cornea adjacent to a paralimbal lesion and may result in breakdown of the corneal epithelium,4 predisposing in this case to an ulcer. Corneal ulcer could be causally
FIGURE 1. (Left) Squamous cell neoplasia at the inferonasal limbus with extension to bulbar conjunctiva. Note the adjacent corneal ulcer (arrow) and marked leukoplakia. (Right) One week after excision of squamous cell neoplasia, the corneal ulcer has healed with stromal scarring.
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FIGURE 2. Pathology consistent with conjunctival intraepithelial neoplasia showing marked hyperplasia of conjunctival epithelium, loss of polarity, and surface maturation. Basement membrane (arrow) is intact. Subepithelial stroma contains patchy lymphomononuclear cell infiltrates (arrowhead) (hematoxylin and eosin, ⴛ125).
attributed to conjunctival intraepithelial neoplasia in our patient as excision of the limbal lesion was followed by rapid resolution of the ulcer. The case we have presented highlights that conjunctival intraepithelial neoplasia at the limbus may present as corneal ulcer.
PURPOSE: To
investigate a case of an unusual neoplasm of the cornea and limbus. METHODS: A 59-year-old man presented with a highly vascularized, nodular mass involving the left cornea and limbus. An excisional biopsy and, subsequently, a superficial lamellar keratectomy and multiple conjunctival biopsies were performed. At the 6-month follow-up examination, repeat conjunctival biopsies were performed. RESULTS: Histopathologic examination of the corneal specimen showed a high-grade intraepithelial squamous neoplasia (in situ carcinoma) overlying an atypical fibroxanthoma. CONCLUSION: We report the clinical and histologic appearance of a corneal/limbal neoplasm consisting of an intraepithelial squamous neoplasia and an atypical fibroxanthoma. (Am J Ophthalmol 2000;129:94 –96. © 2000 by Elsevier Science Inc. All rights reserved.)
REFERENCES
1. Lee GA, Hirst LW. Ocular surface squamous neoplasia. Surv Ophthalmol 1995;39:429 – 450. 2. Cha SB, Shields JA, Shields CL, Wang MX. Squamous cell carcinoma of the conjunctiva. Int Ophthalmol Clin 1993;33: 19 –24. 3. Waring GO, Roth AM, Ekins MB. Clinical and pathologic description of 17 cases of corneal intraepithelial neoplasia. Am J Ophthalmol 1984;97:547–559. 4. Smolin G. Corneal dystrophies and degenerations. In: Smolin G, Thoft RA, editors. Cornea: scientific foundations & clinical practice, 3rd ed. Boston: Little, Brown & Company, 1994;505.
Combined Intraepithelial Squamous Neoplasia and Atypical Fibroxanthoma of the Cornea and Limbus
Accepted for publication June 30, 1999. From the Department of Ophthalmology (N.E.E., J.G.F., and R.P.Y.) and the Department of Pathology (W.L.W.), Wake Forest University School of Medicine, Winston-Salem, North Carolina. Inquiries to Jerry G. Ford, MD, Wake Forest University Eye Center, Medical Center Blvd, Winston-Salem, NC 27157-1033; fax: (336) 716-7994; e-mail:
[email protected]
Nicholas E. Engelbrecht, MD, Jerry G. Ford, MD, Wain L. White, MD, and R. Patrick Yeatts, MD 94
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