Kim and Abramson the conjunctiva and adequate wound healing. In this case series, follow-up was 14 months in one case, 22 months in another case, and not mentioned in the 3rd case. The authors reported that chemoreduction was effective in reducing the tumor base a mean of 57% using an average of 4 cycles of topical MMC. Postoperative MMC has also been used by several authors as adjunctive therapy to reduce recurrence rates. Chen and colleagues (2004) reported the clinical outcomes of topical MMC used as adjunctive treatment following primary excision of OSSN (Chen et al 2004). In this study, 27 primary OSSN lesions in 26 patients were treated with surgical excision, followed by topical MMC. All cases were treated with one week courses of MMC 0.04% four times a day, after complete epithelial healing. Nineteen patients received three courses and eight cases received two courses due to ocular toxicity. It was not men- tioned whether the surgical margins were positive in these cases. With a mean follow-up of 27 months, there were no tumor recurrences reported in this group, and the authors concluded that MMC treatment following surgical excision was well-tolerated and decreased the recurrence rates of OSSN (Chen et al 2004). Other authors have reported similar outcomes with postoperative MMC following excision of OSSN lesions, albeit with smaller numbers of cases (Akpek et al 1999; Frucht-Pery et al 2002). Table 2 summarizes the clinical reports on the use of topical MMC for OSSN. For the purposes of our review, treatment failure was deﬁned as persistent disease despite repeated courses of topical treatment necessitating surgical excision, or clinical evidence of recurrence or regrowth after the last course of topical treatment. When used for superﬁcial disease (ie, dysplasia, carcinoma in situ, recurrent disease), the success rate for topical agents compares favorably to other modalities; overall recurrence rate among 38 patients treated was 24%, with variable lengths of follow-up between the 5 studies with CIN patients. Interestingly, both 0.02% and 0.04% concentrations have been used successfully for CIN, although in general, shorter courses were required with the stronger concentration to obtain an adequate clinical response. For invasive SCC, the recurrence rate was only 5%, although there were only 19 patients identiﬁed in this review among 5 authors. The case series reported by Frucht-Pery and colleagues (2002) consisted of 5 patients with conjunctival SCC that were referred after incomplete surgical excision. In this series, all 5 patients were shown to have negative conjunctival biopsies after being treated with topical MMC. Table 2 Summary of clinical studies of topical agents used as primary therapy for OSSN Author Agent-DX No. cases Treatment Surgery failure Heigle et al 1997 MMC/SCC 2 0 0 MMC/CIN 1 0 0 Wilson et al 1997 MMC/CIN 7 1 1 Frucht-Pery et al 1997 MMC/CIN 16 5 0 MMC/SCC 1 1 1 Rozenman et al 2000 MMC/CIN 8 2 1 Shields et al 2002 MMC/SCC 10 0 0 Frucht-Pery et al 2002 MMC/SCC 5 0 0 Prabhasawat et al 2005 MMC/CIN 6 1 0 SCC 1 0 0 Totals 57 10 3 de Keizer et al 1986 5-FU/CIN 2 0 0 Yeatts et al 1995 5-FU/CIN 3 0 0 5-FU/SCC 2 2 2 Yeatts et al 2000 5-FU/CIN 7 3 0 Midena et al 2000 5-FU/SCC 8 1 0 Totals 22 6 2 Maskin 1994 IF/CIN 1 0 0 Vann and Karp 1999 IF/CIN 6 0 0 Karp et al 2001 IF/CIN 5 1 0 Schechter et al 2002 IF/CIN 1 0 0 Boehm and Huang 2004 IF/CIN 7 2 0 Totals 20 3 0 Follow-up (months) 7–9 6 2–16 3–23 6 24–44 6–50 18–37 2–52 33 10–18 15–36 7–36 13–53 9 7.2 7–28 19 8–17 Dose 0.04% 0.04% 0.04% 0.02%–4% 0.02% 0.02% 0.04% 0.02%–0.04% 0.02% 0.02% 1% 1% 1% 1% 1% 1 m/ml 1 m/ml 1 m/ml 1 m/ml 1 m/ml Regimen (QID/weeks) 3 3 1–3 1–4 4 2–4 1–4 4–6 2–14 5 5–6 6–7 QID/4–24 d 4 8 8–20 16 20 12 Abbreviations: DX,clinical diagnosis;CIN,conjunctival intraepithelial neoplasia;SCC,squamous cell carcinoma;MMC,mitomycin-C;OSSN,ocular surface squamous neoplasia; 5-FU, 5-ﬂuorouracil; IF, interferon; d, days; m/ml, million units per ml; QID, 4x per day. 510 Clinical Ophthalmology 2008:2(3)