CLINICAL SCIENCES

SURGEON’S CORNER

Pterygium and Associated Ocular

Surface Squamous Neoplasia
Lawrence W. Hirst, MD, MPH; Roy A. Axelsen, BSc, MD, FRCPA; Ivan Schwab, MD

Objective: To measure the rate of histopathologically sequential pterygium specimens.

identified ocular surface squamous neoplasia (OSSN) in
pterygium specimens. Conclusions: This rate of unsuspected OSSN suggests
that all specimens of pterygium should be submitted for
Methods: All pterygium specimens collected from con- histopathologic examination and that patients in whom
secutive patients between April 8, 2003, and February OSSN is noted should be examined at more frequent in-
6, 2008, were submitted for histopathologic examina- tervals so any clinical OSSN that develops can be iden-
tion, and the rate of OSSN was calculated. tified at an early stage.

Results: The rate of OSSN was 9.8% (52 of 533) in Arch Ophthalmol. 2009;127(1):31-32

P
TERYGIUM IS A COMMON OCU- tions, 4 µm thick, were cut. Three or 4 sec-
lar surface disease in Austra- tions stained with hematoxylin-eosin were
lia, with a prevalence of 7.3% mounted on each slide, and 4 slides were ex-
in a population-based study amined per specimen. One pathologist (R.A.A.)
examined all the specimens in an open man-
in Blue Mountains, New
ner because the interpretations were made and
South Wales, Australia.1 A pathology- documented during the initial pathologic ex-
based incidence study2 of ocular surface amination for routine diagnosis of the submit-
squamous neoplasia (OSSN) in the state ted specimens. If a patient had a pterygium re-
of Queensland demonstrated a rate of 1.9 moved from the opposite eye, it was considered
new cases per 100 000 residents. Because to be a separate event; if a nasal pterygium and
both of these ocular surface conditions are a temporal pterygium were excised from 1 eye,
strongly related to sunlight exposure,3,4 it only the first pterygium removed was in-
could be expected that both might occur cluded in this study. Findings of OSSN were
in the same individual. We examined this reported as mild dysplasia, moderate dyspla-
sia, severe dysplasia, and carcinoma in situ ac-
hypothesis by using histopathologic ex-
cording to an accepted classification.5
amination to identify OSSN in pterygium All the patients were followed up for at least
tissue samples removed during surgery. 1 year after pterygium surgery. The possible dif-
ference in OSSN incidence between primary
METHODS and recurrent pterygium specimens was tested
using a ␹2 test. This study was approved by the
This retrospective study examined the patho- Human Research Ethics Committee of Prin-
logic results of excised tissue from all patients cess Alexandra Hospital.
with pterygium who underwent surgery con-
sisting of excision and autoconjunctival trans-
plantation. The procedures were all per- RESULTS
formed by 1 of us (L.W.H.) between April 8,
Author Affiliations: 2003, and February 6, 2008. The indications Five hundred thirty-three consecutive pte-
Queensland Eye Institute and for surgery were primarily the presence of pte- rygium specimens were excised from pa-
Princess Alexandra Hospital, rygium greater than 3 mm on the cornea, vi-
sion loss attributable to pterygium, and, in some
tients between April 8, 2003, and Febru-
University of Queensland
(Drs Hirst and Schwab); patients, a concern about the appearance of the ary 6, 2008. In 3 patients, there was some
IQ Pathology (Dr Axelsen), eye. All specimens were submitted for routine slitlamp evidence of clinical OSSN ex-
Brisbane, Australia; and pathologic examination in formalin fixation, pressed as well-demarcated corneal epi-
University of California, Davis which involved paraffin embedding of the en- thelial clouding emanating from the head
(Dr Schwab). tire pterygium specimen. Multiple serial sec- of the pterygium. Otherwise, there was no

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clinical suspicion of OSSN. The male to female distribu- This high rate of OSSN in patients with pterygium is
tion of patients was 1.82:1.0, the mean (SD) age was 50 sufficient justification for a pathologic audit of all pte-
(12.8) years (range, 18-85 years), and the ratio of right rygium specimens so that patients can be warned of the
to left eyes was 0.93:1.00. There were no significant dif- possible recurrence of OSSN at a later time. The results
ferences in any of these variables in patients with pte- of this study also suggest that routine examination of pa-
rygium and no evidence of OSSN compared with the tients with pterygium and histopathologically diag-
group with histopathologic evidence of OSSN. nosed OSSN should probably occur at more frequent in-
Fifty-two specimens (9.8%) revealed OSSN, of which tervals than might otherwise be undertaken. No data, at
33 (63.5%) were graded as mild dysplasia, 10 (19.2%) present, indicate whether nonclinical OSSN will ulti-
as moderate dysplasia, 5 (9.6%) as severe dysplasia, and mately result in clinical disease; however, at least 1 pa-
1 (1.9%) as invasive squamous cell carcinoma. In 3 speci- tient in the present series had invasive squamous cell
mens, dysplasia was ungradable. None of the OSSN- carcinoma, which suggests that severe consequences
positive specimens were from bilateral pterygium exci- could result.
sions. Forty-six of 437 primary pterygium specimens
(10.5%) and 6 of 96 recurrent pterygium specimens Submitted for Publication: April 22, 2008; final revi-
(6.3%) revealed OSSN. There was no significant differ- sion received July 10, 2008; accepted August 11, 2008.
ence between these groups (relative risk, 1.68; 95% con- Correspondence: Lawrence W. Hirst, MD, MPH, Queens-
fidence interval, 0.74-3.83; P = .20; ␹12 = 1.63). No OSSN land Eye Institute, 41 Annerley Rd, South Brisbane,
was evident in any patients via slitlamp evaluation dur- Queensland, Australia 4101 ([email protected]).
ing the 1-year follow-up. Author Contributions: Dr Hirst had full access to all the
data in the study and takes responsibility for the integ-
COMMENT rity of the data and the accuracy of the data analysis.
Financial Disclosure: None reported.
We investigated the frequency of association of OSSN with Funding/Support: This study was supported by the
pterygium specimens. To our knowledge, there have been Prevent Blindness Foundation through Viertels Vision
no reports of this association. A population-based study2 (Dr Hirst).
has identified a rate of 1.9 new cases of OSSN per 100 000
residents per year, but this was thought to be a gross un- REFERENCES
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©2009 American Medical Association. All rights reserved.