EYE PATHOLOGY
OCULAR PATHOLOGY
ORBIT
NORMAL
- § Palpebral conjunctiva: nonkeratinizing squamous lining[1]
- § Conjunctiva at fornix: columnar rich in goblet cells with submucosal accessory lacrimal glands and prominent lymphoid aggregates[2]à fornix biopsy can be used for sarcoidosis with 50% sensitivity!!!
- § Bulbar conjunctiva: nonkeratinizing squamous lining
- § Limbus: junction between bulbar conjunctiva and cornea, contains epithelial stem cells
- § Corneal epithelium: same as bulbar conjunctiva but never goblet cells
- § ECM accumulation and fibrosis of rectus muscleà axial proptosis[3]
THYROID OPHTHALMOPATHY
IDIOPATHIC ORBITAL INFLAMMATION*** IOI
Clinical
- § Unilateral vs bilateral
- § All orbital tissue vs limited (lacrimal gland, extraocular muscles, Tenon’s capsule, fascial layer)
- § Sometimes with sclerosing inflammation elsewhere (RP, mediastinum, thyroid)
Micro
- § Chronic inflammation[4] with variable fibrosis
- § Vasculitis should raise possibility of Wegener
- § No1 tumors of orbit are vascular: capillary hemangioma, lymphangioma, cavernous hemangioma[5]
- § Periorbital ecchymosis: Wilms, neuroblastoma
- § Orbital chronic inflammation: metastatic prostatic carcinoma
- § Lacrimal gland tumors staged as SG tumors
TUMORS
EYELID
- § Accessory lacrimal glands in fornixè tear
- § Sebaceous glands (Zeis and Meibomian glands)à lipid to delay tear evaporationà chalazion[6] if lipid extravasates into tissue when tear drainage is blocked[7]
- § BCC[8] is no1, sebaceous carcinoma no2
TUMOR
SEBACEOUS CARCINOMA
How and where does sebaceous carcinoma spread
- § Pagetoid mimicking blepharitis or ocular pemphigoid
- § To parotid and submandibular LN
Micro
- § Cytoplasmic vacuolation
- § Chlamydia
- § Chemical
- § Pemphigoid
- § Surgery
- § Mostly at limbus
- § Squamous papilloma and CIS may be associated with HPV 16/18!
- § SCC indolent vs MEC aggressive
- § Conjunctival nevi benign[9]
- § Conjunctival melanoma: fair-complexioned persons, mid-aged, from primary acquired melanosis with atypia[10], spreads to parotid and submandibular LN[11]
- § Bacteria
- § Viruses (HSV[12])
- § Fungi
- § Protozoa (Acanthamoeba)
- § Band keratopathies: calcific[13] vs actinic[14]
- § Keratoconus: thin cornea with rupture of Bowman’s layer[15]
- § Fuchs endothelial dystrophy[16]
- § Stromal dystrophies
- § Systemic disease (DM, Wilson, atopic dermatitis)
- § Drugs (CTSD)
- § Radiation
- § Trauma
- § Age-related (nuclear sclerosis)
- § Posterior subcapsular cataract[17]
CONJUNCTIVA
CONJUNCTIVAL SCARRING
PINGUECULA
PTERYGIUM
TUMOR
SCLERA
CORNEA
KERATITIS AND ULCER
CORNEAL DEGENERATIONS
CORNEAL DYSTROPHIES
ANTERIOR SEGMENT
CATARACT
GLAUCOMA
ENDOPHTALMITIS/PANOPHTHALMITIS
UVEA
UVEITIS
UVEAL MELANOMA
Treatment
- § Radiation or enucleation
- § Rhegmatogenous
- § Non-rhegmatogenous
RETINA, VITROUS
RETINAL DETACHMENT
RETINAL VACULAR DISEASE
HTN
Changes
- § Atherosclerosis of retinal BV[18]à silver copper color[19] and artery compressing vein at crossing
- § Choroidal artery damage[20]à choroidal infarcts (Elschnig spots)
- § Exudate leakage from damaged BVà retinal detachment[21]
- § Retinal artery occlusionà retinal nerve infarct
DM
Changes
- § Microvascular injury and thick BMà edema, hemorrhage
- § Pericyte lossà microaneurysms
2 phases
- § Preproliferative: changes below internal limiting membrane
- § Proliferative: neovascularization breaching internal limiting membrane
- § O2à vasoconstriction of still immature BVà local ischemia
- § Sicklingà microvascular occlusion
RETINOPATHY OF PREMATURITY
SICKLE RETINOPATHY
RETINAL ARTERY/VEIN OCCLUSION
Differences
- § Atherosclerosisà artery occlusionà retinal infarct[22]
- § HTNà thickened arterioles compressing venulesà ischemia[23]
MACULAR DEGENERATION
Variants
- § Atrophic (dry)[24]
- § Exudative (wet)[25]
- § Inherited disorder
- § Loss of both rods and cones to apoptosis with perivascular pigment accumulation
- § No1 intraocular malignant in kids[26]
RETINITIS PIGMENTOSA
RETINOBLASTOMA
Prognosis
- § Extraocular extension by optic nerve or choroidal invasion
- § Trilateral (with pinealoblastoma)
Micro
- § Undifferentiated: SRBC
- § Differentiated[27]: Flexner-Wintersteiner rosettes, fleurettes
- § Extensive necrosis with residual viable tumor cells around BV
- § Dystrophic calcification characteristic
Spread: 2B
- § Brain
- § Bone
- § Not lung
Treatment
- § Shrink before excision
- § Systemic lymphoma: uvea[28]
- § Primary lymphoma: involves two retinal layers[29][30][31] derived from brain
RETINAL LYMPHOMA
OPTIC NERVE[32]
2 common tumors
- § Gliomas (pilocytic astrocytoma)
- § Meningiomas
- § Stroke of optic nerve
- § By temporal arteritis, embolism or thrombosis
- § Optic nerve head is swollen and hyperemic[34]
- § Unilateral if local compression
- § Bilateral if increased intracranial pressure
ANTERIOR ISCHEMIA OPTIC NEUROPATHY
PAPILLEDEMA[33]
GLAUCOMATOUS OPTIC NERVE DAMAGE
Micro
- § Atrophy
- § Optic nerve head cupping
- § Small atrophic, internally disorganized eye
PHTHISIS BULBI[35]
Etio
- § Trauma
- § Intraocular inflammation
- § Chronic retinal detachment
Micro
- § Ciliochoroidal effusion[36][37]
- § Cyclitic membrane[38]
- § Chronic retinal detachment
- § Optic nerve atrophy
- § Intraocular bone from osseous metaplasia of retinal pigment epithelium
- § Thickened sclera
- § Idiopathic orbital inflammation IOI
- § Wegener
- § Lymphoma
- § Metastatic prostatic carcinoma to orbit!
- § Spindle vs epithelioid
LYMPHOCYTES IN ORBIT***
OCULAR MELANOMA CLASSIFICATION AND PROGNOSIS***
Prognosis
- § Location (indolent if limited to iris vs more aggressive in ciliary body and choroid)
- § Epithelioid more aggressive than spindle cell
- § Lateral growth bad[39]
- § Mitoses
- § Heavy intratumoral lymphocytic infiltrate bad
- § Extraocular extension
- § Looping patterns rich in laminin (vasculogenic mimicry) bad
PINGUECULA AND PTERYGIUM
| Pinguecula | Pterygium |
| Actinic injury | Actinic injury |
| Raised white-yellow spots on limbus | Grows from limbus to cornea |
| -Does not invade Bowman’s
-Solar elastosis+/-granulomas |
-Submucosal FV tissue proliferation that migrates into cornea
-Dissects Bowman’s layer[40] |
| Focal dehydration causing depression (dellen) | No vision problem |
| Benign but rarely SCC and melanoma |
NORMAL LAYERS OF CORNEA
- § Nonkeratinizing squamous epithelium
- § BM
- § Bowman’s layer (acellular)[41]
- § Stroma[42]
- § Descemet membrane[43]=BM (PAS+)
- § Endothelium[44]
- § Inflammation
- § High intraocular pressure (staphyloma)
- § OI
- § Congenital nevus
BLUE SCLERA
[1] Can form papillae when inflamed
[2] Very large in viral conjunctivitis and favorite site for lymphoma
[3] Independent of thyroid function in Graves
[4] Lymphocytes, plasma cells, eosinophils
[5] First 2 are non-encapsulated and in kids whereas cavernous hemangioma is encapsulated and in adult
[6] Provoking granulomas
[7] By blepharitis or tumor
[8] Distinct ppredilection for lower eyelid and medial canthus
[9] May become really inflamed at late childhood or adolescence with tons of lymphocytes, plasma cells and eosinophilsà inflamed juvenile nevus
[10] Equivalent to melanoma in situ
[11] Similarly to sebaceous carcinoma of eyelids
[12] Chronic HSV can cause granulomatous reaction to Descemet’s membrane!!!
[13] Calcium in Bowman’s layer. Complicate chronic uveitis
[14] Solar elastosis in superficial layer of corneal stroma
[15] Non-inflammatory, non-vascular. Treated with corneal transplantation
[16] Causes stromal edema and bullous keratopathy
[17] Migration of lens epithelium posterior to lens equator
[18] Most vascular
[19] Instead of red
[20] In malignant HTN
[21] Exudate accumulation dissects between neurosensory and pigmented layers of retina
[22] Sudden, no prolonged infarction, no neovascularization
[23] Neovascularization
[24] Geographic atrophy of retinal pigment epithelium
[25] Due to leaky choroidal neovascular membranes
[26] Intraocular melanoma is no1 malignancy in adults
[27] No prognostic value
[28] ICC=iris, ciliary body, choroid
[29] Neurosensory retina and retinal pigment epithelium
[30] Outer-lying choroid is not infiltrated by malignant lymphocytes
[31] Diagnosis by FNA of vitreous fluid
[32] Considered part of CNS (not PNS)
[33] Optic nerve edema
[34] Because it’s due to venous compression by CSF. In contrast, optic nerve stroke is swollen and pale due to arterial blockage
[35] End-stage eye
[36] Blood or fluid between ciliary body-choroid and sclera
[37] Leading to hypotony (low intraocular pressure)
[38] Bridging membrane from ciliary body to the other across eye
[39] Different from cutaneous melanoma where radial growth has not clinical value
[40] Just underneath BM
[41] Efficient barrier against penetration by malignancy
[42] No BV, no lymphatics
[43] Thickens with age and also site of copper deposition (Kayser-Fleischer ring)
[44] Malfunction of endotheliumà stromal edemaà bullous keratopathy