Plucking the plaque: Is it necessary?

An otherwise healthy 76-year-old male patient presented with a complaint of a gradually enlarging painless red lesion in his left eye over the past two months. He had previously consulted elsewhere, was diagnosed with ocular surface squamous neoplasia, and was referred for further management. On examination, a 2 × 2 mm smooth, fleshy, red, nodular lesion was noted in the nasal bulbar conjunctiva of the left eye, anterior to the area of medial rectus insertion, with a small bluish area superiorly, likely due to scleral thinning. A feeder vessel was observed nasally; there was no evidence of keratinization over the lesion [Fig. 1a]. The rest of his anterior and posterior segment examination was normal.Figure 1: Clinical and imaging findings of the patient with senile scleral plaque causing a full-thickness scleral defect. Clinical findings at presentation showing a fleshy bulbar conjunctival mass with feeder vessels (a). AS-OCT showing smooth epithelium with an ill-defined lesion with back shadowing (b). Intraoperative findings after removal of the scleral plaque showing scleral thinning with uveal show (c). Postoperative appearance at 1-month follow-up showing epithelialized scleral patch graft in situ (d)What is your next step? Observation Topical steroids Incision biopsy Review the systemic history and ocular imaging. Findings Anterior segment optical coherence tomography (OCT) revealed mild hyperreflectivity of the epithelium, without an abrupt transition, with well-defined internal areas of hyperreflectivity within the lesion, along with back shadowing [Fig. 1b]. On account of no systemic history suggestive of rheumatological disease, the patient was taken up for exploration and excision biopsy, which revealed the presence of a calcific plaque within the sclera, which was carefully removed. A full-thickness scleral defect was noted corresponding to the area of calcified plaque with uveal show [Fig. 1c], which was covered with a donor scleral patch graft. Histopathology did not reveal any cellular atypia within the calcified plaque. A provisional diagnosis of senile scleral plaque was made, and the patient did well on follow-up examinations, with the scleral graft being in situ and taken up well [Fig. 1d]. Diagnosis Senile scleral plaque. Correct Answer D. Discussion Senile scleral plaque, also known as Cogan’s scleral plaque, is a well-circumscribed, slate-gray, oblong area of scleral thinning usually found at the site of insertions of the horizontal rectus muscles in elderly patients. They are usually asymptomatic and detected as incidental findings on a computerized tomography scan.[1] Our patient had an atypical presentation, as a red nodular lesion along with a feeding vessel. The possibility of Ocular surface squamous neoplasia(OSSN) and nodular scleritis with scleral thinning was considered, although the anterior segment optical coherence tomography (AS-OCT) was not suggestive of OSSN and the systemic history was not suggestive of any autoimmune disorder. Exploration and histopathology of the excised lesion ruled out conjunctival granuloma or malignancy. Computed tomography (CT) scan can be a valuable investigation modality in such cases and can help in clinching the diagnosis in patients with atypical presentation like ours. The hyperdense episcleral calcific lesions at the site of the extraocular muscle insertions are characteristics findings on CT. Usually, the senile scleral plaques are asymptomatic and can be left untreated. However, in our case, a full-thickness scleral defect caused by the migration of plaque scleral degeneration required a scleral patch to prevent globe rupture. According to the literature, there have been cases of scleral plaques being misdiagnosed as orbital foreign body or being diagnosed as the preceding cause of globe rupture.[2,3] Awareness about this entity is crucial as it avoids unnecessary investigations. In our patient, systemic investigations, like serum parathyroid hormone and serum calcium levels, done to rule out a hypercalcemic state, were normal. In conclusion, this seemingly benign lesion can cause sight-threatening complications and needs prompt diagnosis and management with a scleral graft in patients with a full-thickness scleral defect caused by the calcific plaque. Financial support and sponsorship: Nil. Conflicts of interest: There are no conflicts of interest.