<b><i>Aim:</i></b> This study aimed to characterize the clinical and pathologic presentation of ocular surface tumors (OSTs) and to more precisely differentiate the grades of ocular surface squamous neoplasia (OSSN) and benign lesions among Zambians. <b><i>Methods:</i></b> Two-hundred sixty-five Zambian patients presenting with ocular surface growths, suspicious for OSSN, were recruited between November 2017 and November 2019 to a cross-sectional study to investigate their lesions. Sociodemographic data were collected, HIV infection status and vision tests were performed, and lesions were measured and documented. Lesions &#x3e;2 mm in diameter were excised and sent for pathology analysis. In addition to the biopsies, tears, blood, and buccal swabs were collected. CD4+ T-cell counts were measured by flow cytometry. Lesions were classified according to the WHO guidelines. χ² and bivariate correlations were used to analyze variable associations and strengths with phi/Cramer’s V and correlation coefficients, respectively. Binary logistics was used to adjust for covariance. <b><i>Results:</i></b> In this study, 68.3% of the participants were found to be HIV positive. The most frequent diagnoses were invasive OSSN (45.3%), preinvasive OSSN (29.1%), and pterygium (22.6%). Invasive OSSN comprised keratinizing squamous cell carcinoma (SCC) (87.5%), basaloid SCC (3.3%), and spindle cell carcinoma (3.3%). Unusual carcinomas, not described previously, included hybrid SCC (5.0%) and acantholytic SCC (0.8%). Invasive OSSN had advanced tumor (T3/T4) staging (93.3%) at diagnosis. Lymphadenopathy was rare (2.3%), and metastasis was absent. Patients were mostly female (59.2%). Median age was 36 (interquartile ranges 33–41) years (ranges 18–81). Patients with invasive OSSN were more likely to present with pain (<i>p</i> = 0.007), redness (<i>p</i> = 0.034), excessive tearing (<i>p</i> = 0.0001), discharge (<i>p</i> = 0.011), bleeding (<i>p</i> = 0.007), reduced vision (<i>p</i> = 0.0001), fungating lesion (<i>p</i> = 0.001), and blindness (<i>p</i> = 0.005); location at temporal limbus (<i>p</i> = 0.0001), inferior limbus (<i>p</i> = 0.0001), or circumlimbal (<i>p</i> = 0.001); and extension to cornea (<i>p</i> = 0.006) and forniceal palpebral conjunctiva (<i>p</i> = 0.001). Invasive OSSN was associated with any smoking habit and alcohol consumption (<i>p</i> = 0.04 and 0.03, respectively). HIV positivity was strongly associated with OSSN (74.6% OSSN vs. 49.3% benign lesions; <i>p</i> = 0.0001; phi: 0.237 [<i>p</i> = 0.0001]). <b><i>Conclusion:</i></b> OSTs are very common in Zambia and are strongly associated with HIV coinfection. Patients with OSSN were more likely to be HIV positive than those with pterygia. Despite the commonality of OSTs in sub-Saharan Africa, these cancers have historically been poorly characterized.

BackgroundThe etiopathogenesis of ocular surface squamous neoplasia (OSSN) is not fully understood. We assessed the frequency of oncogenic viruses in OSSN by immunohistochemistry (IHC) and polymerase chain reaction (PCR) for human papillomavirus (HPV), Epstein–Barr virus (EBV), Merkel cell polyomavirus (MCPyV), Kaposi sarcoma virus, and adenovirus. Cases from Zambia were prospectively enrolled using a cross-sectional study design between November 2017 and March 2020.MethodsDemographic and clinical data [age, sex, HIV status, antiretroviral therapy (ART) history, CD4 count, plasma viral load] and tumor biopsies were collected from 243 consenting patients. Tumor samples were bisected, and half was used for DNA isolation, while the other half was formalin fixed and paraffin embedded (FFPE) for histopathology analysis. The expressions of latent EBV nuclear antigen 1 (EBNA1), CDKN2A/p16INK4A (p16), and MCPyV large T-antigen (LT) were tested by IHC. Multiplex PCR was used to detect 16 HPV genotypes and four other DNA tumor viruses [Kaposi’s sarcoma-associated herpesvirus (KSHV), EBV, MCPyV, and adenovirus]. Relationships between HIV status, viral DNA and protein expression, and tumor grades were determined by statistical analysis.ResultsOSSN tumors from patients were 29.6% preinvasive and 70.4% invasive. Patients presented with unilateral tumors that were 70.4% late stage (T3/T4). OSSN patients were HIV positive (72.8%). IHC on 243 FFPE biopsies resulted in the detection of EBNA1 (EBV), p16 high-risk HPV (HR-HPV), and MCPyV LT expression in 89.0%, 4.9%, and 0.0%, respectively. EBNA1 was expressed in all grades of preinvasive [cornea–conjunctiva intraepithelial neoplasia (CIN)1, 100%; CIN2, 85.7%; CIN3, 95.8%; and carcinoma in situ (CIS), 83.8%] and in invasive (89.2%) OSSN. PCR on 178 samples detected EBV, HR-HPV, and MCPyV in 80.3%, 9.0%, and 13.5% of tumors, respectively. EBV was detected in all grades of preinvasive and invasive OSSN. EBV detection was associated with high HIV viral loads (p = 0.022). HR-HPV was detected in 0.0% CIN1, 0.0% CIN2, 5.6% CIN3, 13.0% CIS, and 7.0% invasive OSSN.ConclusionsOur findings of EBV DNA and EBNA1 protein in all the grades of preinvasive and especially invasive OSSN are consistent with a potential causal role for EBV in OSSN. A role of HPV in OSSN was not clearly established in this study.

Yes-associated protein-1 (YAP-1) is a Hippo system transcription factor, which serves as an oncogene in squamous cell carcinoma, and several solid tumors when the Hippo pathway is dysregulated. Yet, the activity of YAP-1 in ocular surface squamous neoplasia (OSSN) has not been determined. Here, we investigate the relationship between YAP-1 overexpression and OSSN. Using a cross-sectional study design, we recruited 227 OSSN patients from the University Teaching Hospitals in Lusaka, Zambia. Immunohistochemistry was used to assess YAP-1 protein overexpression in tumor tissue relative to surrounding benign squamous epithelium. OSSN patient samples (preinvasive, n = 62, 27% and invasive, n = 165, 73%) were studied. One hundred forty-nine invasive tumors contained adjacent preinvasive tissue, bringing the total number of preinvasive lesions examined to 211 (62 + 149). There was adjacent benign squamous epithelium in 50.2% (114/227) of OSSN samples. Nuclear YAP- 1 was significantly overexpressed in preinvasive (Fisher’s (F): p &lt;.0001, Monte Carlo (MC): p &lt;.0001) and invasive (F: p &lt;.0001, MC: p &lt;.0001) OSSN in comparison to adjacent benign squamous epithelium when analyzed for basal keratinocyte positive count, staining intensity, expression pattern, and Immunostaining intensity-distribution index. YAP-1 expression did not differ between preinvasive and invasive OSSN (p &gt;.05), keratinizing and non- keratinizing cancer (p &gt;.05), or between T1/T2 and T3/T4 stages in invasive tumors (p &gt;.05). However, grade 2 and 3 tumors had significantly stronger nucleus YAP-1 overexpression intensity than grade 1 tumors (F: p = .0078, MC: p = .0489). By immunohistochemistry, we identified significant overexpression (upregulation of YAP-1 protein expression) in preinvasive and invasive OSSN lesions compared to neighboring benign squamous epithelium. YAP-1 expression was significantly higher in poorly and moderately differentiated invasive squamous cancer than in well-differentiated carcinomas. Overexpression of YAP-1 within the margin of preinvasive and invasive OSSN, but not in the neighboring normal epithelium, indicates that it plays a role in the development and progression of OSSN.

Objective: Kabwe District is largely an urban town in the Central Province of Zambia. We aimed to determine the prevalence of refractive errors and visual impairment in primary and secondary school learners in this District. Method: A cross-sectional survey of 41 primary and secondary schools in Kabwe District. The examination included visual acuity (VA) testing, cycloplegic retinoscopy with subjective refinement if indicated, ocular motility testing and anterior segment and fundus examinations in visually impaired children. Results: There was an estimated total of 32,971 learners who were eligible to participate of which 23,915 (72.5%) were enrolled into the survey. Of the 2,424 learners examined by the mobile ophthalmic team, 418 were refracted representing 17.2 %. Of the 418 learners refracted, 359 were diagnosed with refractive errors and prescribed spectacles. The mean spherical equivalent in the right eyes was 0.57 diopter (D) (95% confidence interval [CI], 0.49 - 0.75), and the mean spherical equivalent in the left eyes was 0.59 (95% CI, 0.50 - 0.71). The prevalence of hyperopia was 0.9% (95% CI, 0.4 - 1.3; 207 subjects), and the prevalence of myopia was 0.5% (95% CI, 0.1-1.0; 119 subjects). The majority of learners (98.3%; 95% CI, 97.0 -99.0) had normal unaided binocular VA (at least 6/9 in their better eye). The overall prevalence of any visual impairment (presenting VA 6/9 in the better eye) was 1.7% (95% CI, 1.0 -2.5; 418 subjects) and the overall refractive error prevalence was 1.5% (95% CI, 1.0 -2.3; 359 subjects). In multivariate logistic regression analysis, age (P 0.001) was a significant predictor and female gender (P 0.06) was a borderline significant predictor of the presence of any visual impairment. Conclusions: Visual impairment is not a public health concern in this school-aged population in Kabwe District. The prevalence of uncorrected significant refractive errors among learners is not too high to justify a regular school eye screening programme in schools in Kabwe District.