Invasive squamous cell carcinoma of the conjunctiva

A 94 year-old man presented with a rapidly growing mass in the right eye for 2 months. The ophthalmological examination of the right eye showed an exophytic lesion protruding through the lids and involving the eyeball (Figure 1). The left eye was entirely normal. The magnetic resonance imaging of the orbits showed a large heterogeneous anterior lesion, measuring 2.8 * 3.3cm, adjacent to the inner canthus of the right orbit and involving the lacrimal gland (Figure 2). A small excision biopsy was taken from the exophytic lesion and performed a well differentiated squamous cell carcinoma of the conjunctiva. The extension assessment showed local bone Abstract


Introduction
Squamous cell carcinoma is the most common epithelial malignancy of the conjunctiva [1]. The tumor primarily affects middle-aged to elderly male patients [1]. Sun injury, viral infections, and immunocompromised states are known etiological factors. The limbal epithelial cells appear to be the progenitors of this disease [2].
It is generally a low-grade tumor. Invasive squamous cell carcinoma, however, is uncommon, and intraocular extension has rarely been reported [3].
Here, we report an unusual case of invasive squamous cell carcinoma of the conjunctiva with intra-ocular involvement.

Case report
A 94 year-old man presented with a rapidly growing mass in the right eye for 2 months. The ophthalmological examination of the right eye showed an exophytic lesion protruding through the lids and involving the eyeball ( Figure   1). The left eye was entirely normal. The magnetic resonance imaging of the orbits showed a large heterogeneous anterior lesion, measuring 2.8 * 3.3cm, adjacent to the inner canthus of the right orbit and involving the lacrimal gland ( Rarely, late presentation with large orbital tumors and diffuse involvement is seen [2]. Invasion deep in the stroma, in the orbit, or in the eye can result in vision loss [7].
Large exophytic tumor, as we saw in our case, is a rare presentation. To our knowledge, large orbital tumor involving the eyeball as the presenting sign of squamous cell carcinoma has not been previously reported.
The mean delay of diagnosis is usually 7 months after onset [1]. Our patient sought medical attention at 2 months after tumor development, but the mass was aggressive enough to cause blindness.
We postulated that the short interval from the tumor's fi rst appearance to the time the patient seeks medical attention may be explained by rapid growth from strong sunlight exposure in this environment or because of ignorance of the patient at the fi rst appearance of the tumor.
Histopathology is the gold standard for diagnosis [8]. The treatment of conjunctival SCC is wide excision. Enucleation is advised when cornea or sclera has been invaded, and exenteration is recommended in cases of invasion of anterior orbit [9], like in the case of our patient. Exenteration is a radical technique that involves removing all the orbital contents including the periosteum [8].
Metastasis occurs rarely, and commonly parotid or submandibular glands are involved. Even with metastasis, the chance of survival is good [5,10].

Conclusion
Invasive malignancy of conjunctiva is a rare neoplasm.
However, it should be suspected in all aged patients with a conjunctival lesion, particularly with the rapid rate of growth.
Late presentation with large orbital tumours are uncommon.
The possibility of an intraocular diffusion of this tumour must be always evaluated, and the need for prompt surgical treatment considered. Proper management is crucial to improve the visual prognosis.
We are presenting this rare case report to promote awareness about this uncommon malignancy which will help in accurate management in future.

Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given his consent for his images and other clinical information to be reported in the journal.