We read with interest Meel and Dhiman’s recent proposal for a new classification for ocular surface squamous neoplasia (OSSN) [1]. The authors offer a modified criteria for conjunctival neoplasia that takes into account invasion (on ultrasound biomicrosopy (UBM)) and provides a rough guide for treatment. They suggest that OSSN of Grade III (with intraocular involvement present) should be managed with enucleation.

The potential of advanced ocular surface squamous lesions to invade through the sclera or cornea is well recognised with enucleation being the traditional management [2]. However, many studies over the past decade have shown success with globe-sparing therapy for these advanced lesions—and it is certainly our experience that invasive squamous lesions can be managed in this way [3]. Shields et al. showed that plaque brachytherapy is a safe and reliable alternative to globe removal for eyes with conjunctival squamous cell carcinoma (SCC) showing scleral invasion and/or intraocular involvement [2]. Further, Graue et al. demonstrated local tumour control in 75% of recalcitrant conjunctival SCCs treated with electron beam radiotherapy [4].

The relevance of the American Joint Committee on Cancer (AJCC) staging of conjunctival SCC in guiding initial management was challenged in a recent work by Belleverie et al. [5]. They also suggest reclassification of the T3 category (diffuse vs deep invading) to better guide initial treatment. However, similar to previous reports, these authors also advocate the use of surface brachytherapy for scleral invasion of SCC [5].

The AJCC publications are recognised as authoritative guides for cancer staging and communicating information about cancer. Evidence-based staging is important to guide therapy and define prognosis, and the AJCC aims to help doctors design a treatment plan for individual patients. Meel and Dhiman's proposal include treatment in their modified staging system, and, although these management options are perhaps not available in their centre, we feel it would be useful to include staged options of therapy for advanced lesions as alternative to enucleation [1]. There appears to be an error in the classification table, listing Grade II lesions incorrectly as having no invasion into ocular coats on imaging, which contradicts the imaging findings and manuscript definitions of this grade.

We support the current classification system published by the AJCC, but agree with recent studies suggesting reclassification of the T3 category [5].