Ocular surface squamous neoplasia (OSSN) in the context of cicatricial disease
B. Test for vitamin A deficiency, with additional conjunctival biopsies for pathologic evaluation and testing for immune deposits
This case demonstrates an atypical presentation of OSSN. The bilateral cicatrizing disease prompted workup for other underlying conditions, such as vitamin A deficiency and ocular cicatricial pemphigoid (OCP). Brimonidine-timolol drops were discontinued because medicamentosa is a common cause of cicatrizing disease.1 Discontinuation of the offending medication is often diagnostic; however, the severity of the keratinization and the bilaterality (brimonidine-timolol drops were used only unilaterally) suggested that medicamentosa alone was not the culprit (choice C). Furthermore, these features were concerning for an underlying life-threatening cicatricial process, such as mucous membrane pemphigoid, making observation inappropriate (choice A).2 It would likewise be inappropriate to perform lesion excision with tissue disposal (choice D). Vitamin A levels returned as normal, and the patient’s medical history did not suggest a nutritional deficiency or malabsorption.