Spontaneous rupture of ocuIar surface squamous neopIasia-a case report

Ocular surface squamous neoplasia (OSSN) typically occurs adjacent to limbus or in inter-palpebral fissures,over a preexisting pinguecula.The term OSSN includes mild dysplasia at one end of its disease spectrum and invasive squamous cell carcinoma at the other and is the most common non-pigmented malignancy of the ocular surface.The tumor can involve tarsal conjunctiva or it can be associated with other conditions,and these presentations can make correct diagnosis challenging.However,spontaneous rupture of OSSN is rare,and no previous report has been issued in Korea.Herein,we describe a case of active bleeding associated with spontaneous rupture of OSSN.

面對進口品牌當道的美妝市場，國產品牌應利用新興營銷方式，靈活營銷，相對于外資品牌的營銷手段，國產品牌宣傳不到位，營銷理念較落后，對消費者的教育缺乏，從主力產品到成分再到包裝都毫無創新也是其中一個重要的原因。

This case study was conducted in accordance with the Declaration of Helsinki.Written informed consent was obtained from the patient for publication of this case report with any accompanying images.

CASE REPORT

增強營銷隊伍素質是管控電力營銷風險的必然要求。電力營銷任務“新、快、多、雜”的特點決定了必須要提升營銷人員素質，優化營銷隊伍結構，只有這樣才能更好更快的接受新的理念，提升工作積極性，及時提醒和處理電力用戶遇到的問題，從而向用戶提供更加優質的服務。同時高素質的營銷隊伍可以更高效的促進管理水平，增強自我糾錯和風險防控。

An 87-year-old Korean male patient presented with a protruding ocular mass and ptosis in his right eye of several months duration.External photograph revealed a tumor 5×4 cmsized tender,lobulated cystic mass and restricted extraocular movements (Figure 1A).Slit lamp examination demonstrated adome-shape,non-movable,and protruding ocular surface mass,originating from superior bulbar conjunctiva and limbus in his right eye.The patient also had Alzheimer dementia,lobar pneumonia,a newly developed splenic infarction,and pulmonary artery thromboembolism.He had a nasogastric tube because of his cognitive and functional status.He was a retired veteran who served in Korean War and Vietnam War.There was no other lesion suspicious of human papillomavirus (HPV) infection including common warts,genital or anal wart by physical examination and medical history.Preoperative serologic test revealed leukocytosis,elevated C-reactive protein,erythrocyte sedimentation rate,elevated liver enzyme and creatinine above 2.9 mg/dL (estimated glomerular filtration rate,eGFR=22 mL) due to systemic illness.And routine preoperative human immunodeficiency virus (HIV) antibody testing revealed the negative result.

The management of OSSN includes surgical resection with topical chemotherapy,topical/local interferon alpha-based immunomodulation,cidofovir,and/or photodynamic therapy.A “no touch” technique is preferred to avoid the potential risk of seeding and to provide a tumor-free margin.In the present case,the patient had several severe systemic diseases.The palliative surgical treatment strategy employed achieved a relatively favorable result.

OSSN is typically characterized by epithelial thickening,a prominent “corkscrew” vascular pattern,or a gelatinous or leukoplakic surface,indicative of surface keratinization.In particular,adjacent conjunctiva might contain a lesion feeder vessel.However,in the described case,the initial presentation was a protruding ocular mass without the typical characteristics of OSSN,and thus,accurate diagnosis was challenging before histopathologic evaluation.Recently,technical developments such asconfocal microscopy and anterior segment optical coherence tomography (OCT)can provide additional information about superficial dysplastic lesions,but they cannot be used to assess the potential invasive growth of lesion or protruding nature.In our patient,after spontaneous OSSN rupture,the surface of the tumor exhibited the typical characteristics of OSSN.Active bleeding associated with spontaneous rupture,as was observed in this case,is rare and has not been previously reported in Korea.The etiology of OSSN appears to be multifactorial,and likely involves a variety of environmental factors in a susceptible host.These multifactorial etiologies include exposure to ultraviolet radiation,chemical carcinogen,mutation of tumor suppressor gene p53,and viral infections including human papilloma virus and HIV infection associated with immunosuppression.In this patient,chronic sun exposure(ultraviolet) associated with his occupation (retired soldier),and current immunosuppressive condition related to general illness may contribute to the risk of malignancy.

DISCUSSION

Histopathologic examinations showed full-thickness cell atypia,loss of polarity,prominent mitotic figures and malignant epithelial cells in substantia propria forming“keratin pearls”,which suggested OSSN (Figure 2A,2B).OSSN was managed by wide surgical excision under local anesthesia;it was followed by adjuvant topical chemotherapy with mitomycin-C (MMC) 0.04% to reduce residual tumor.We planned the 4 cycles of postoperative MMC (0.04% four times daily regimen),each cycle consisting of 1wk on and 1wk offtreatment.After 2cycle of adjuvant chemotherapy,the tumor was markedly reduced (Figure 2C).However,the patient was lost to follow-up due to his systemic conditions and did not complete planned chemotherapy.

④ 按照以上方法，7×0.5表示怎樣的含義？7×0.1，15×0.1呢？此環節設計的目的是讓學生學會用乘法分配律的性質將小數運算變形，進而去理解小數乘法多方面的意義.同時習得此方法，將其運用到任意的小數乘法.

Thus,palliative surgery was planned for biopsy and tumor size reduction.Two days after the first visit to the ophthalmic clinic,he came back due to active bleeding associated with spontaneous rupture of the tumor (Figure 1B).Although magnetic resonance imaging (MRI) is usually preferred to evaluate soft tissues and intraocular involvement,we performed the computed tomography (CT) scan considering his general condition and economic status.A contrast enhanced-CT axial cut demonstrated an ocular surface lesion with homogenous enhancement and no visible intraocular invasion (Figure 1C).Under the sub-Tenon anesthesia with 2% lidocaine,we performed the palliative surgery.Under the surgical microscope,the tumor was located at or near the limbus (overhanging conjunctivo-corneal mass) and demonstrated fleshy lobulated characteristics,engorged feeder vessels,and was immobile and firmly fixed to underlying episcleral or scleral tissues (Figure 1D).We removed almost all visible protruding ocular surface mass and left most of the lesion in a bare sclera state without ocular surface reconstruction such as conjunctival flap or other donor graft tissues.To minimize exposure of extraocular muscles,we performed minimally sliding conjunctival advancement for superior conjunctiva at 12 o'clock direction using 8-0 vicryl anchoring suture.

使用的方法主要有2種：（1）等值線追蹤法，被美國NOAA采用，具體原理為：由數字高程模型DEM（TIN或GRID），再通過等值線跟蹤法提取潮汐基準面所對應的等值線；（2）二值法，將DEM分割成水陸二值圖像，通過圖像處理方法提取海岸線。分析對比優缺點，選取最適合海岸線的提取方法[1]。

To the best of our knowledge,this case is the first case report issued of spontaneous OSSN rupture in Korea.Our experience highlights that initial presentation of OSSN may not exhibit typical characteristics of a “corkscrew” vascular pattern or a gelatinous or leukoplakic surface,and that active bleeding associated with OSSN rupture might occur in elderly patients on anticoagulants.

ACKNOWLEDGEMENTS

Supported by a VHS Medical Center research grant,Republic of Korea (No.VHSMC 22017).

None;None.