PMC10176191_01
Series of ocular photographs of the affected right eye. a A preoperative patient photograph of the right eye, highlighting the original nasal conjunctival lesion (image provided by patient, only preoperative image available). The mass is large, gelatinous, and opaque. Additionally, it appears to cross the limbus onto the cornea. b-d Slit-lamp examination photos of the right eye taken at postoperative evaluation. Pronounced nasal conjunctival injection and edema are seen, extending from the conjunctiva to the sclera. Additionally, a small bleb on the nasal conjunctiva is visible in (b, c) (black arrows). d Image highlighting the large, white opacity occupying the nasal half of the A/C.
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F1
Two months before referral to our institution, the patient presented to an emergency room with a nasal conjunctival lesion involving the cornea (Fig. 1a), endorsing pain and irritation of the right eye; the patient first noticed the conjunctival mass several months prior. The right conjunctiva had significant nasal injection with a visible bleb and thin sclera (Fig. 1b, c). A/C examination OD revealed a large, white plaque with scattered pigment occupying the nasal half of the chamber (Fig. 1d).
Imaging of the right eye. a An ultrasound biomicroscopy image of the right A/C, notable for irregular A/C morphology and a highly reflective mass in the inferonasal component (red arrow). This mass appears to be rooted in the angle with possible ciliary body involvement. Thickened and elevated conjunctiva with low reflectivity is seen, suggesting possible scleral excavation (green arrow). b An anterior segment optical coherence tomography image of the nasal lesion, emphasizing the nasal conjunctival irregularity. Focal inner scleral thinning is seen with an adjacent inner mass that traces along the endothelium (red arrow).
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F2
A/C involving the ciliary body, thickened conjunctiva, and an area of low reflectivity, suggesting possible scleral invasion (Fig. 2a). Anterior segment optical coherence tomography of the right eye showed focal, inner scleral thinning with an adjacent inner mass along the endothelium (Fig. 2b).
Histopathologic specimen from the enucleated right eye. a The nasal limbal full-thickness open defect, partially plugged by keratinous debris (black arrow), with focal mild dysplastic change in the surface epithelium along the wound edge. Eosinophilic material partially fills the anterior chamber (A/C). Epithelial cells line the posterior corneal (c) surface, the angle area, and the anterior iris (I) surface. The sclera (s) is disrupted and infiltrated by chronic inflammatory cells, which are also present in the ciliary body (cb) and iris (x2). b The nasal limbal defect; at the bottom of the photo, a cluster of tumor (t) cells invading the iris is seen, and tumor cells cover the inner corneal surface, iris surface, and ciliary body (black arrows) (x4). In (c), tumor is seen invading the sclera and ciliary body (x4). d Tumor cells on the iris pigment epithelium (IPE) and along the ciliary epithelium (x10). e Tumor cells on the opposite ciliary process (cp), in the posterior chamber admixed with neutrophils, and growing on lens (L) anterior surface. In (f), malignant tumor cells can be seen on anterior iris surface, crawling around the pupillary edge of the iris and into the posterior iris surface. Keratinized and degenerated cells are visualized in A/C with dystrophic calcifications (black arrow) (x10). g A higher magnification image of the tumor cells on the iris surface (x20). Polygonal tumor cells have large nuclei with prominent nucleoli, moderately abundant dense eosinophilic cytoplasm, and intercellular bridges indicating squamous differentiation. Degenerating keratinized cells and keratinous debris admixed with neutrophils are present in the A/C (top of photo). h A higher magnification of the tumor cells along the corneal edge (x20); this defect is presumably one entry point of the tumor cells. All images are stained with H&E.
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F3
Microscopic pathology diagnosed moderately differentiated squamous cell carcinoma of the conjunctiva with extensive intraocular invasion including the sclera, posterior corneal surface, trabecular meshwork, iris, ciliary body, and lens (Fig. 3). Notably, a full-thickness nasal limbal defect was identified, plugged by keratinous debris (Fig. 3a).