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.

面对进口品牌当道的美妆市场，国产品牌应利用新兴营销方式，灵活营销，相对于外资品牌的营销手段，国产品牌宣传不到位，营销理念较落后，对消费者的教育缺乏，从主力产品到成分再到包装都毫无创新也是其中一个重要的原因。

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

增强营销队伍素质是管控电力营销风险的必然要求。电力营销任务“新、快、多、杂”的特点决定了必须要提升营销人员素质，优化营销队伍结构，只有这样才能更好更快的接受新的理念，提升工作积极性，及时提醒和处理电力用户遇到的问题，从而向用户提供更加优质的服务。同时高素质的营销队伍可以更高效的促进管理水平，增强自我纠错和风险防控。

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表示怎样的含义？7×0.1，15×0.1呢？此环节设计的目的是让学生学会用乘法分配律的性质将小数运算变形，进而去理解小数乘法多方面的意义.同时习得此方法，将其运用到任意的小数乘法.

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种：（1）等值线追踪法，被美国NOAA采用，具体原理为：由数字高程模型DEM（TIN或GRID），再通过等值线跟踪法提取潮汐基准面所对应的等值线；（2）二值法，将DEM分割成水陆二值图像，通过图像处理方法提取海岸线。分析对比优缺点，选取最适合海岸线的提取方法[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.