Pathology of the Eye (Gianani)

Question 1

most common tumor of the eye?

Answer 1

metastasis (just like the brain)

Question 2

Retinal artery occlusion

Answer 2

(or one of its branches)…usually due to
A) atheromatous emboli from ipsilateral internal carotid stenosis;
B) stenosis from HT, diabetes;
C) vasculitis
- infarction of entire artery (or part of)

  TIA of  retinal artery (or branches of) = *** “Amaurosis fugax”… “browning  out” or “loss of vision” in one eye for about 10 minutes …usually  caused by ipsilateral internal 	carotid stenosis.

Question 3

Anterior ischemic optic neuropathy

Answer 3

neuropathy…short posterior ciliary arteries (branches of the ophthalmic artery)…supply anterior optic nerve.…occlusion results in sudden vision loss in one eye (common in patients over 50)…classic onset is upon wakening
-sometimes seen in temporal arteritis

Question 4

Stye (or hordeolum)

Answer 4

Acute inflammation involving gland of Zeis and/or orifice of meibomian gland….Staph…usually clears in 7 days

Question 5

layers of lubrication

Answer 5

lipid layer
aqueous layer
mucin layer

Meibomian gland creates the lipid layer

Question 6

Chalazion

Answer 6

Meibomian gland lipogranuloma

Lipogranulomatous inflammatory reaction to sebum in tissues (endogenous “foreign body” reaction)
Secondary to obstruction of gland
Subacute to chronic and painless nodule
Epithelioid cells and giant cells surround lipid vacuoles
Usually lasts weeks to months
May become secondarily infected
Surgical therapy, antibiotics if infected

Question 7

Xanthelasma Palpebratum

Answer 7

Soft, flat or slightly raised yellow papules and plaques
Usually more in inner canthus
Seen in hyperlipemic and normolipemic patients
Aggregates of foamy, lipid-laden histiocytes in dermis
Cosmetic surgery

Question 8

Nevi

Answer 8

Congenital or acquired (most)

Split nevus – a form of congenital nevus of the eyelids…rare

Nests of nevus cells

• Interface of the epidermis and dermis (junctional nevus)
• Dermis and epidermis (compound)
• Only in the dermis (dermal)

Question 9

Basal Cell Carcinoma

Answer 9

Most common eyelid malignancy

Lower lid>medial canthus>upper lid>outer canthus
Nodular, cystic, diffuse

Islands of basaloid cells with peripheral palisading, stromal desmoplasia, retraction artifact

Ulceration may or may not occur;
Pigmentation may occur, simulating a melanoma
Locally invasive, rarely metastasizes

Question 10

Squamous Cell Carcinoma

Answer 10

Elderly fair-skinned individuals

Lower lid most common

Typically shallow ulcer surrounded by a wide, elevated, and indurated border

• Potential for local or distant metastasis

Polygonal cells with pink eosinophilic cytoplasm, nuclear atypia, infiltrating cords into dermis, dyskeratotic cells, keratin pearls.

Question 11

Sebaceous Carcinoma

Answer 11

Elderly, more female, > Asians
Can mimic chalazion or chronic blepharoconjunctivitis
2/3rds in upper lid
Can arise from meibomian, Zeis (lash follicules) or caruncle glands
Malignant cells with foamy, lipid-laden cytoplasm, necrosis, pagetoid invasion of the skin
15% mortality, direct extension and distant metastasis (lung, liver, brain, skull)

Question 12

Pinguecula

Answer 12

Asymptomatic, small yellowish submucosal nodule at the limbus
Adults and older patients but younger if&raquo_space; sun exposure
Typical in tropical places
* Conjunctival equivalent of Solar Elastosis of skin
Does not extend to or invade the cornea as a pterygium
No therapy needed

Question 13

Pterygium

Answer 13

Submucosal growth of connective tissue that * migrates into cornea
Results from actinic (UV) damage, dust, wind
Removed for cosmetic and irritation of conjunctiva reasons
* Examine histologically to rule-out squamous neoplasia

Question 14

Ulcerative Keratitis

Answer 14

Viral: Herpes simplex - most common cause of central corneal ulcer (dendritic ulcer); herpes zoster

Bacterial: Pseudomonas aeruginosa and Staphylococcus aureus - especially associated with cosmetics or contact lenses

Mycotic: Aspergillosis, Candida, and Fusarium represent over 80% of all fungal keratitis

Parasitic: microsporidia

Question 15

Amebic Keratitis

Answer 15

Hot tubs, contact lenses and fresh water exposure (ponds)

Acanthamoeba often presents as an irregular dendritiform epithelial keratitis, often mis-diagnosed as herpes simplex

Later progresses to a ring ulcer or less commonly as radial keratitis

Calcoflour white staining can give rapid diagnosis, confirmed by culture in special medium

Question 16

• Keratoconus

Answer 16

Degenerative deformation of the corneal curvature

Irregular myopic astigmatism; progressive myopic astigmatism

Conical deformation of the cornea

.
Usually bilateral

Progressive visual distortion (multiple images), light sensitivity

treat: Corrective lenses, asymmetric keratotomy, or corneal transplant

Question 17

is the major refractive surface of the eye.

Answer 17

The cornea—not the lens—is the major refractive surface of the eye. Keratoconus is an example of a condition that distorts the contour of the cornea and alters this refractive surface, producing an irregular form of astigmatism.

Question 18

Munson’s sign

Answer 18

In Keratoconus: When patient looks down, the cones in each eye causes the lower lids to bulge

Question 19

Age-related Macular degeneration

Answer 19

(>75 yrs. Of age)
Loss of central vision

Dry form (absence of neoangiogenesis) 10x more common
Wet form (presence of neoangiogenesis)

Dry: deposits in Brush membrane and atrophy of retinal pigmented epithelium…no treatment

Wet…Tx with injection of VEGF antagonists into the vitreous of affected eye

Question 20

Retinoblastoma*

Answer 20

Most common intraocular tumor of childhood (90% dx before age 3)

30-40% are bilateral…associated with germ line mutations.

Sporadic cases are associated with somatic mutations.

Signs/symptoms
Leukocoria, strabismus, red, 
painful eye, poor vision
* Retinoblastoma gene  Chr 13 
           (tumor suppressor)

Question 21

microscopic look of retinoblastoma

Answer 21

Blue with rosettes

Flexner-Wintersteiner rosettes

Question 22

Retinoblastoma Treatment & Prognosis

Answer 22

Treatment
Enucleation, Photocoagulative Ablation and Hyperthermia, Cryotherapy, Chemoreduction Therapy, External-beam Radiation, Plaque Radiotherapy (Brachytherapy)

Prognosis
Overall survival rates of 95%
Most important risk factor is extraocular extension of tumor through ON or sclera

Question 23

Uveal Melanoma

Answer 23

Clinical risk factors for mortality
- Larger tumor size, anterior eye location, extraocular extension

Metastasis usually 2-4 years from time of diagnosis

Patients who develop metastasis (usually to the liver) generally survive less than 6 months

Question 24

Sympathetic opthalmia

Answer 24

Non-infectious granulomatous inflammation of uvea of both eyes

Can result from trauma to one eye…retinal antigens become visible to immune system…delayed hypersensitivity reaction in the other eye (and the damaged eye)…2 weeks to many years after the injury

Question 25

Treatment of uveal melanoma

Answer 25

Globe-conserving

• Brachytherapy (iodine 125, ruthenium 106, palladium 103)
• Charge-particle therapy

Enucleation

• Large tumor
• Orbital or optic nerve involvement

Question 26

open-angle glaucoma

Answer 26

the aqueous humor has complete physical access to the trabecular meshwork, and the elevation in intraocular pressure results from an increased resistance to aqueous outflow in the open angle.

In primary open-angle glaucoma, the most common form of glaucoma, the angle is open, and few changes are apparent structurally.

Question 27

angle-closure glaucoma

Answer 27

the peripheral zone of the iris adheres to the trabecular meshwork and physically impedes the egress of aqueous humor from the eye.