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The article by McKelvie et al1 is especially noteworthy as it highlights a number of interesting observations.
In the first instance, the authors highlight that conjunctival squamous cell carcinoma (SCC) is not as uncommon worldwide as reported earlier.2
Recurrence of ocular surface squamous neoplasia (OSSN) is common, with significantly increased risk for older patients, large size, high proliferation index (Ki-67 score), and positive surgical margins (total recurrence being 27%). For control of local disease, exenteration may be the answer. The larger the diameter of the mass, the more accurate is the clinical diagnosis. A high proliferation index increases the predictability of recurrences and serial impression cytology is an extremely useful tool for early detection of recurrences.
Intraocular invasion, corneal and/or corneoscleral invasion, and death due to metastasis are the other important findings.
We have been working in this field since 1977 and managed a large number of eyes at two tertiary eye care centres of developing countries (All India Institute of Medical Sciences, India; 86 in 22 years, BP Koirala Institute of Health Sciences, Nepal; seven in 2 years). We would like to comment on a few aspects that have been reported by the authors.1
We are in agreement with the authors that SCC is not uncommon, which is true even in our part of the world. From the histopathological analysis revealing involvement of the margins in a few cases, it is not clear whether the cases were managed by frozen section controlled excision (FSCE) or not (as one tends to remove all the histopathologically proved lesions if the frozen section facility is available during surgery).
The authors have very rightly documented the risk factors for recurrence. However, by employing FSCE we did not come across a recurrence in any of our patients and we feel that FSCE combined with double freeze-thaw cryotherapy to the surgical margins is a useful tool for tumour management and should become mandatory in all cases. We had a clinical impression of recurrence in three eyes which after removal revealed granulomatous lesions on histopathology. However, as we have operated on a large number of recurrent lesions, our impression is that recurrent tumours have an aggressive look and grow at a rapid pace.
Though we do not have any experience on impression cytology or the proliferation index for these lesions, we appreciate that these two are very sensitive parameters to guide the clinicians regarding recurrences and feel that all ophthalmic departments (at least those of tertiary eye care centres) should have access to these facilities.
We do not agree with the authors’ comment that orbital exenteration may be required for control of local disease. Rather we feel, if there is clinical suspicion of intraocular spread the lesions should be subjected to a 20 MHz high frequency ultrasound assessment to check for intraocular involvement and computed tomography to rule out orbital extension before the decision of exenteration. In our series we could save three eyes with optimal visual preservation by performing local excision in cases where previous exenteration had been advised.3 Further, so far we have not come across the problem of death due to metastasis (and we have followed up some patients over 20 years). However, this is a very important issue and all ophthalmologists should remain alert while managing the SCC, more so for extensive lesions.
Finally, we congratulate the authors for their well documented series which, no doubt, will guide the ophthalmic clinicians dealing with these lesions.