Eye

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The eye is rarely seen by pathologists. Typically, they go to neuropathologists, as the eye is really part of the brain. The article also covers lesions found around the eye. The lacrimal gland is covered in the lacrimal gland article.

Illustration of the eye. (Gray's Anatomy/WC)

An introduction to neuropathology is in the neuropathology article.

Procedures

  • Evisceration - eye muscles left intact.
  • Enucleation.
  • Exenteration - extensive resection.

Anatomy

Anterior to posterior

  1. Cornea.
  2. Iris.
  3. Lens.
  4. Conjunctiva - edge of cornea.
  5. Sclera.

Optic nerve

  • Surrounded by CSF.
  • Covered by dura.

Inside to outside

  1. Retina.
  2. Retinal pigment epithelium (RPE).
  3. Choroid.
  4. Sclera.

Anterior angle

  • Angle between cornea and iris.

Histology

Eye muscles

  • The muscles that move the eye have a high nerve:muscle ratio = ~1:4.[1]
    • Other muscles in the body ~1:250.

Conjunctiva

Features:[2]

  • Stratified squamous.
    • May be stratified columnar
  • Goblet cells.

Cornea

Layers:[3]

  1. Epithelium layer.
    • Squamoid cells.
  2. Bowman's layer.
    • Indistinct.
  3. Stroma.
    • Fibrous tissue.
    • No blood vessels.
  4. Descemet’s layer.
    • Indistinct.
    • PAS -ve.
  5. Endothelium.
    • Single layer.

Retina

Simplified structure - eosinophilic material separating:

  1. Intermediate size, round, pale-staining nuclei (ganglion cells).
  2. Two layers of small round nuclei (inner and outer nuclear layer).
  3. Eosinophilic ellipsoid structures - rods/cones (photoreceptors).
  4. Single layer of cuboidal cells (retinal pigment epithelium.

Detailed structure - in direction light travels:

  1. Inner limiting membrane.
  2. Nerve fibre layer.
  3. Ganglion layer.
  4. Inner plexiform layer.
  5. Inner nuclear layer.
  6. Outer plexiform layer.
  7. Outer nuclear layer.
  8. Layer of rods and cones.
  9. External limiting membrane.
  10. Retinal pigment epithelium.

Images

  • Retina - schematic. (WC/Gray's)

www:

Eye structures with melanocytes

Melanoma may arise from these sites:

  • Iris.
  • Conjunctiva.
  • Ciliary bodies.
  • Choroid.

Benign entities

Conjunctivitis

General

  • Benign.
  • Never biopsied.
    • It is an incidental finding in a biopsy for something else.

Gross

  • Red eye.

Microscopic

Features:

  • Conjunctival epithelium - stratified squamous epithelium with goblet cells.
  • Inflammatory cells.

Conjunctival cyst

Conjunctival cyst
External resources
EHVSC 10173

General

  • Rare.
  • May be due to surgery, trauma, or congenital (very rare).[4]

Microscopic

Features:

  • Conjunctival mucosa with atypia.
    • Stratified squamous epithelium with goblet cells.

DDx:

Image:

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CONJUNCTIVA, RIGHT SUPERIOR, BIOPSY:
- BENIGN CONJUNCTIVAL MUCOSA -- COMPATIBLE WITH CYST LINIG.

Pinguecula

  • Plural Pingueculae.

General

  • Raizada et al.[6] suggest it is an early pterygium; however, this is disputed.
  • Due to ultraviolet light exposure, e.g. sunlight.[7]
  • Tend to be older than individuals afflicted with a pterygium.

Gross

  • Yellow spot.

Microscopic

Features:

  • Similar to pterygium.[7]

Pterygium

  • AKA surfer eye.

General

  • Pronounced: "tuh-rij-ee-uhm".[8]
  • Conjunctiva lesion that covers part of the sclera.
    • Sclera = white part of the eye.[9]
  • Benign.
  • Due to ultraviolet light exposure, i.e. sunlight.[7]

Gross

  • Medial aspect of eye - covers sclera (white part) and part of the iris (coloured part).

Image:

Microscopic

Features:[7]

  • Hyaline material beneath epithelium.
  • Elastic fibres beneath the hyaline material.
  • +/-Inflammation.
  • Solar elastosis.[10]
    • Dense gray/light brown acellular material.
  • Dilated vessels.[10]

DDx:

Images

www:

  • Pterygium - intermed. mag. (WC/Nephron)

  • Pterygium - high mag. (WC/Nephron)

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Right eye

Right Eye, Conjunctiva (Submitted as "Pterygium"), Excision:
- Conjunctival mucosa with solar elastosis and dilated superficial blood vessels, compatible with pterygium.
- NEGATIVE for dysplasia.
Inflammation present
Right Eye, Conjunctiva (Submitted as "Left Pterygium"), Excision:
- Conjunctival mucosa with solar elastosis, mild inflammation and dilated superficial blood 
  vessels, compatible with pterygium.
- NEGATIVE for dysplasia.
Block letters
CONJUNCTIVA ("PTERYGIUM"), RIGHT, EXCISION:
- CONJUNCTIVAL MUCOSA WITH STROMAL ACTINIC CHANGES -- CONSISTENT WITH PTERYGIUM.

CONJUNCTIVA ("PTERYGIUM"), RIGHT, EXCISION:
- CONJUNCTIVAL MUCOSA WITH STROMAL ACTINIC CHANGES -- CONSISTENT WITH PTERYGIUM.
- NEGATIVE FOR DYSPLASIA.

CONJUNCTIVA ("PTERYGIUM"), RIGHT EYE, EXCISION:
- CONJUNCTIVAL MUCOSA WITH SOLAR ELASTOSIS AND DILATED SUPERFICIAL BLOOD VESSELS -- CONSISTENT WITH PTERYGIUM.
- NEGATIVE FOR DYSPLASIA.

Left eye

CONJUNCTIVA ("PTERYGIUM"), LEFT EYE, EXCISION:
- CONJUNCTIVAL MUCOSA WITH SOLAR ELASTOSIS AND DILATED SUPERFICIAL BLOOD VESSELS -- CONSISTENT WITH PTERYGIUM.
- NEGATIVE FOR DYSPLASIA.

Eccrine hidrocystoma

  • Occasionally spelled eccrine hydrocystoma.[12]

General

  • Benign.
  • Eyelid lesion.

Clinical DDx:[12]

Microsopic

Features:[13][14]

  • Cyst lined by a bland bilayer.
    • Inner lining cells have:
      • Small, round nuclei - usu. basal.
      • Moderate pale/greyish cytoplasm.
      • No apocrine snouts - flat surface.
    • Outer lining cells - spindled.
      • May be difficult to see.

Note:

DDx:

  • Apocrine hidrocystoma - have apocrine snouts; surface is not flat.
  • Cystadenoma - has epithelial proliferation.

Image

  • Apocrine hidrocystoma (AH). AH looks similar to eccrine hidrocystoma. (WC)

www:

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SKIN LESION, ADJACENT TO RIGHT EYELID, EXCISION:
- ECCRINE HIDROCYSTOMA.

Micro

The sections show hair bearing skin with a cyst lined by a bland bilayered epithelium. The predominant lining cell has moderate pale grey cytoplasm and a small round nucleus.

The lesion is excised in the plane of section.

Chalazion

General

  • Benign eye thingy that arises from the special sebaceous gland associated with the eyelid (Meibomian gland).
  • Usually diagnosed based on clinical appearance - accuracy ~94% in one series.[15]

Gross

  • Focal eyelid swelling - typically upper eyelid.

DDx (clinical):[15]

Images

  • Chalazion (WC)

www:

Microscopic

Features:

Images

  • Chalazion. (WC/euthman)

www:

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EYELID LESION, RIGHT UPPER, BIOPSY:
- LIPOGRANULOMAS.
- LYMPHOPLASMACYTIC RICH INFLAMMATORY INFILTRATE.
- GRANULATION TISSUE.
- REACTIVE SQUAMOUS MUCOSA.

COMMENT:
The findings are consistent with a chalazion.

Special stains (ZN, PASD, GMS) did not demonstrate microorganisms.

Alternate

SKIN LESION, LEFT LOWER EYELID, PUNCH BIOPSY:
- LIPOGRANULOMAS WITH GIANT CELLS AND A LYMPHOPLASMACYTIC RICH INFLAMMATORY
  INFILTRATE -- CONSISTENT WITH CHALAZION.
- GRANULATION TISSUE.
- NEGATIVE FOR MALIGNANCY.

Micro

The sections show a reactive squamous mucosa with palisading granulomas that surround clear spaces (lipid). This is accompanied by a lymphoplasmacytic rich inflammatory infiltrate. Granulation tissue is present. Rare multinucleated giant cells are identified. Neutrophils are numerous and seen in association with the histiocytes.

No significant nuclear atypia is apparent.

Retinal hemorrhage

See Traumatic brain injury in infants.

Image:

Glaucoma

General

  • Leading cause of irreversible blindness.

Classification:

  • Open angle - more common.
  • Closed angle.

Microscopic

Features (closed angle):

  • Cornea and iris opposed to one another.

Retinal detachment

General

  • Blindness.

Causes:

  • Trauma (classic) - pathologist doesn't usually see.
  • Tumours - common in pathology specimens.

Microscopic

Features:

  • Retina separated from retinal pigment epithelium.
  • Eosinophilic exudate containing macrophages.

Blepharochalasis

General

  • Rare, benign eyelid disorder.[20]
  • Upper eyelids +/-lower eyelids (severe cases).[20]

Clinical:

  • Swelling of eyelids - recurrent.[21]
  • Onset in childhood.
  • Leads to ptosis.

Clinical DDx:[20]

  • Recurrent angioedema.
  • Hereditary angioedema.
  • Contact dermatitis.
  • Melkersson-Rosenthal syndrome.
  • Dermatochalasis.
  • Floppy-eyelid syndrome.
  • Lax eyelid syndrome.
  • Cutis laxa.

Note:

  • The term may be abused; it may be used when an eyelid tuck is done for other reasons.[citation needed]

Microscopic

Features:[20]

  • Edema.

DDx:

Stains

  • Elastin stain - shows loss of elastin.[23]

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EYELID, LEFT UPPER, PTOSIS REPAIR:
- SQUAMOUS EPITHELIUM WITHIN NORMAL LIMITS.
- SUBEPITHELIAL TISSUE WITH MILD EDEMA.
- SOLAR ELASTOSIS.
- NEGATIVE FOR MALIGNANCY.

Lower eyelids in an older individual labelled blepharochalasis

A. EYELID, LEFT LOWER, BLEPHAROPLASTY:
- BENIGN SKIN WITH MILD SOLAR ELASTOSIS.
- BENIGN SKELETAL MUSCLE AND ADIPOSE TISSUE.
- NEGATIVE FOR MALIGNANCY.

B. EYELID, RIGHT LOWER, BLEPHAROPLASTY:
- BENIGN SKIN WITH MILD SOLAR ELASTOSIS.
- BENIGN SKELETAL MUSCLE AND ADIPOSE TISSUE.
- NEGATIVE FOR MALIGNANCY.

Papilloma of the caruncle

  • AKA caruncle papilloma.

General

  • Benign.
  • Second most common caruncle tumour ~ 15% of caruncle tumours.[24]
    • Most common is nevus ~ 50% of caruncle tumours.

Gross

  • Frond-like lesion.

Image:

Microscopic

Features:[24]

  • Fibrovascular fronds in a cauliflower-like arrangement.
  • No nuclear atypia.

Image:

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LESION, RIGHT CARUNCLE, EXCISION:
- PAPILLOMA.
- NEGATIVE FOR MALIGNANCY.

Micro

The sections show benign conjunctival mucosa and a lesion consisting of fibrovascular cores covered by a conjunctival epithelium with a cauliflower-like appearance at low power. Parakeratosis is present. No significant nuclear atypia is identified. No koilocytic change is seen. No mitotic activity is appreciated.

External links

Malignant entities

Retinoblastoma

General

  • Rare.
  • Malignant.
  • May be familial.[25]

Gross

  • White, solid.
  • Patterns:
    • Endophytic - grow into the vitreous cavity.
    • Exophytic - grow toward choroid.
    • Mixed - components of endophytic and exophytic.

Image:

Note:

  • Tumour is extremely friable.

Microscopic

Features:

  • Small round cell tumour:
    • Scant cytoplasm.
  • Flexner-Wintersteiner rosette - key feature.
    • Rosette with empty centre (donut hole).[26]
  • +/-Homer-Wright rosette.[27]
    • Circular rosette with neuropil at the centre.[26]
  • Mitoses - common.
  • +/-Necrosis.
  • +/-Calcification.

DDx:

  • Retinocytoma (retinoma) - benign counterpart of retinoblastoma.

Notes:

  • DDx of Flexner-Wintersteiner rosette includes:
    • Pineoblastoma.
    • Medulloepithelioma.

Image:

Malignant melanoma

Main article: Malignant melanoma

Common malignancy in the eye in adults.

See also

References

  1. ↑ Bilbao. 24 November 2010.
  2. ↑ URL: http://www.lab.anhb.uwa.edu.au/mb140/corepages/eye/eye.htm. Accessed on: 20 October 2011.
  3. ↑ URL: http://www.ophthobook.com/questions/question-name-the-layers-of-the-cornea-and-their-function. Accessed on: 26 January 2012.
  4. ↑ Robb, RM.; Elliott, AT.; Robson, CD. (Apr 2012). "Developmental conjunctival cyst of the eyelid in a child.". J AAPOS 16 (2): 196-8. doi:10.1016/j.jaapos.2012.02.001. PMID 22525180.
  5. ↑ Elshazly, LH. (Jan 2011). "A clinicopathologic study of excised conjunctival lesions.". Middle East Afr J Ophthalmol 18 (1): 48-54. doi:10.4103/0974-9233.75886. PMID 21572734.
  6. ↑ Raizada, IN.; Bhatnagar, NK. (Jul 1976). "Pinguecula and pterygium (a histopathological study).". Indian J Ophthalmol 24 (2): 16-8. PMID 1031388.
  7. ↑ 7.0 7.1 7.2 7.3 Hill, JC.; Maske, R. (1989). "Pathogenesis of pterygium.". Eye (Lond) 3 ( Pt 2): 218-26. doi:10.1038/eye.1989.31. PMID 2695353.
  8. ↑ URL: http://dictionary.reference.com/browse/pterygium. Accessed on: 20 October 2011
  9. ↑ URL: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002006/. Accessed on: 20 October 2011.
  10. ↑ 10.0 10.1 URL: http://www.uic.edu/depts/mcpt/eyepath/specco4.htm. Accessed on: 25 October 2011.
  11. ↑ Clear, AS.; Chirambo, MC.; Hutt, MS. (Feb 1979). "Solar keratosis, pterygium, and squamous cell carcinoma of the conjunctiva in Malawi.". Br J Ophthalmol 63 (2): 102-9. PMC 1043407. PMID 427069. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1043407/.
  12. ↑ 12.0 12.1 12.2 Adams, SP. (Feb 1999). "Dermacase. Eccrine hydrocystoma.". Can Fam Physician 45: 297, 306. PMC 2328272. PMID 10065300. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2328272/.
  13. ↑ Singh, AD.; McCloskey, L.; Parsons, MA.; Slater, DN. (Jan 2005). "Eccrine hidrocystoma of the eyelid.". Eye (Lond) 19 (1): 77-9. doi:10.1038/sj.eye.6701404. PMID 15205675.
  14. ↑ Busam, Klaus J. (2009). Dermatopathology: A Volume in the Foundations in Diagnostic Pathology Series (1st ed.). Saunders. pp. 314. ISBN 978-0443066542.
  15. ↑ 15.0 15.1 15.2 15.3 Ozdal, PC.; Codère, F.; Callejo, S.; Caissie, AL.; Burnier, MN. (Feb 2004). "Accuracy of the clinical diagnosis of chalazion.". Eye (Lond) 18 (2): 135-8. doi:10.1038/sj.eye.6700603. PMID 14762403. http://www.nature.com/eye/journal/v18/n2/full/6700603a.html.
  16. ↑ D'hermies, F.; Fayet, B.; Meyer, A.; Morel, X.; Halhal, M.; Elmaleh, C.; Azan, F.; Behar-Cohen, F. et al. (Feb 2004). "[Chalazion mimicking an eyelid tumor].". J Fr Ophtalmol 27 (2): 202-5. PMID 15029054.
  17. ↑ URL: http://emedicine.medscape.com/article/1212709-workup. Accessed on: 9 February 2012.
  18. ↑ URL: http://www.surgical-pathology.com/chalazion.htm. Accessed on: 24 January 2012.
  19. ↑ URL: http://library.med.utah.edu/WebPath/EXAM/IMGQUIZ/fofrm.html. Accessed on: 6 December 2010.
  20. ↑ 20.0 20.1 20.2 20.3 Koursh, DM.; Modjtahedi, SP.; Selva, D.; Leibovitch, I.. "The blepharochalasis syndrome.". Surv Ophthalmol 54 (2): 235-44. doi:10.1016/j.survophthal.2008.12.005. PMID 19298902.
  21. ↑ Bergin, DJ.; McCord, CD.; Berger, T.; Friedberg, H.; Waterhouse, W. (Nov 1988). "Blepharochalasis.". Br J Ophthalmol 72 (11): 863-7. PMID 3207663.
  22. ↑ Wang, G.; Li, C.; Gao, T. (Apr 2009). "Blepharochalasis: a rare condition misdiagnosed as recurrent angioedema.". Arch Dermatol 145 (4): 498-9. doi:10.1001/archdermatol.2009.19. PMID 19380685.
  23. ↑ Kaneoya, K.; Momota, Y.; Hatamochi, A.; Matsumoto, F.; Arima, Y.; Miyachi, Y.; Shinkai, H.; Utani, A. (Jan 2005). "Elastin gene expression in blepharochalasis.". J Dermatol 32 (1): 26-9. PMID 15841657.
  24. ↑ 24.0 24.1 Kaeser, PF.; Uffer, S.; Zografos, L.; Hamédani, M. (Sep 2006). "Tumors of the caruncle: a clinicopathologic correlation.". Am J Ophthalmol 142 (3): 448-55. doi:10.1016/j.ajo.2006.04.035. PMID 16935590.
  25. ↑ Lohmann D (2010). "Retinoblastoma". Adv. Exp. Med. Biol. 685: 220–7. PMID 20687510.
  26. ↑ 26.0 26.1 Wippold FJ, Perry A (March 2006). "Neuropathology for the neuroradiologist: rosettes and pseudorosettes". AJNR Am J Neuroradiol 27 (3): 488–92. PMID 16551982.
  27. ↑ WH. 14 March 2011.
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