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Referral and warning signs
When to refer
IMMEDIATE URGENT REFERRAL to Ophthalmologist/Eye Hospital (RR/UCI): ANY child with suspected Retinoblastoma (leukocoria, strabismus). Refer ALL suspected cases of conjunctival SCC.
Red flags
- Leukocoria (white pupil) in a child.
- New onset strabismus in a child.
- Proptosis.
- Persistent conjunctival growth, especially if changing or vascularized.
Signs and symptoms
- Retinoblastoma (Children <5 years):
- - Leukocoria: White pupillary reflex ('cat's eye reflex') - MOST COMMON sign.
- - Strabismus: Squint / crossed eye (second most common).
- - Decreased vision (difficult to assess in young children).
- - Red, painful eye (if secondary glaucoma or inflammation).
- - Proptosis (if orbital extension).
- Squamous Cell Carcinoma (SCC) of Conjunctiva (Adults):
- - Fleshy, pink/white growth on conjunctiva (often interpalpebral area near limbus).
- - May appear gelatinous or leukoplakic (white patch).
- - Associated feeder vessels.
- - Irritation, foreign body sensation.
- - Redness.
- - May invade cornea.
- - Slow growing usually.
Risk factors
- Retinoblastoma:
- - Genetic predisposition (RB1 gene mutation - heritable form ~40%).
- - Family history of retinoblastoma.
- SCC of Conjunctiva:
- - Ultraviolet (UV) light exposure (sun exposure).
- - Human Papillomavirus (HPV) infection.
- - HIV infection / Immunosuppression.
- - Older age.
- - Light skin pigmentation.
Diagnosis
Clinical assessment
Retinoblastoma: High suspicion with leukocoria or new onset strabismus in young child. Requires urgent dilated fundus examination by ophthalmologist. SCC: Suspicion based on characteristic appearance of conjunctival growth. Differentiate from pterygium, pinguecula, papilloma, other tumours.
Investigations
- Retinoblastoma:
- - Dilated Fundus Examination (often requires Examination Under Anaesthesia - EUA).
- - Ocular Ultrasound (B-scan): Detect calcification within tumour.
- - CT / MRI Orbit/Brain: Assess for optic nerve invasion, extraocular extension, pinealoblastoma ('trilateral retinoblastoma').
- - Genetic testing.
- SCC:
- - Slit Lamp Examination.
- - Excisional Biopsy: Complete removal of lesion with margin for histopathological confirmation (Gold standard).
Diagnostic criteria
Retinoblastoma: Clinical/imaging findings confirmed by pathology if eye enucleated. SCC: Histopathological confirmation after biopsy.
Management
Pharmacological treatment
- Requires Specialist Management at Tertiary/Cancer Centre (RR/UCI):
- Retinoblastoma: Treatment depends on size, location, laterality, extension.
- - Goal: Save life, preserve eye, preserve vision.
- - Chemotherapy: Systemic or intra-arterial chemoreduction.
- - Local therapies: Laser photocoagulation, Cryotherapy, Brachytherapy (radioactive plaque).
- - Enucleation: Surgical removal of the eye (for large tumours, extensive disease, no visual potential).
- - External Beam Radiotherapy (less common now due to side effects).
- SCC:
- - Surgical Excision: Wide local excision with cryotherapy to margins.
- - Topical Chemotherapy: Mitomycin C or 5-Fluorouracil eye drops (adjuvant or primary for extensive disease).
- - Interferon alpha-2b drops.
- - Radiotherapy (occasionally).
- - Orbital Exenteration (if extensive orbital invasion).
Monitoring
Requires long-term, regular follow-up by specialists. Retinoblastoma: Monitor for recurrence, new tumours (bilateral cases), secondary malignancies. SCC: Monitor for recurrence.
Complications
- Retinoblastoma: Vision loss/blindness, Metastasis (brain, bone marrow, lymph nodes), Secondary cancers (esp. osteosarcoma in heritable form), Complications of treatment.
- SCC: Recurrence, Corneal scarring, Symblepharon (adhesions), Limbal stem cell deficiency, Invasive spread (orbital/intraocular - rare), Metastasis (very rare).
Prevention
- Retinoblastoma: Genetic counseling for affected families.
- SCC: UV protection (sunglasses, hats). HPV vaccination may have role. Management of HIV.
Patient education
- Explanation of the tumour type and seriousness.
- Treatment options, goals, potential side effects.
- Need for specialized care and long-term follow-up.
- Genetic implications for retinoblastoma.
- Importance of sun protection for SCC.
- Support resources for cancer patients/families.
Uganda-specific notes
Retinoblastoma presentation is often late, increasing need for enucleation. Access to chemotherapy, radiotherapy, and specialized surgery limited to UCI/RRH. SCC is strongly associated with HIV and sun exposure; common ocular surface tumour in adults.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 20, Section 20.4 (20.4.1 Retinoblastoma, 20.4.2 SCC)
- Uganda National Cancer Control Plan / Treatment Guidelines
(Refer for specific oncology protocols)