Unit 8 Condensed Scribe Notes Lecture 141: Ophthalmic Pathology Orbit cone shaped, contains: - eyeball - optic nerve

- extraocular muscles - retrobulbar fat - lacrimal gland on supralateral aspect of orbit maxillary sinus pathology can push eyeball upwards optic nerve tumor canpush eyeball forwards lacrimal gland may push eyeball medially and inferiorly pathology can erode bone and travel intracranially sclera is white iris is pigmented cornea is transparent pupil is a hole

Three layers sclera (white), choroid (pink), and retina Cavity filled with vitreous fluid Optic disc has optic nerve and blood vessels Semilunar membrane on nasal side of eye = caruncle Iris appears in front of lens, continues as cilliary body, continues further as choroid together considered uveal tract Anterior chamber = space between cornea and iris Behind eyelids are thick collagen tarsal plates, which contain sebecous meibomian glands secrete sebum to keep tears viscous I. epidermis keratin layer on upper surface, and a basal layer toward basement membrane. As cells mature, they develop more cytoplasm and change orientation from [being perpendicular to the basement membrane] to [running parallel to the surface] called sequence of maturation

Squamous Papilloma - wart-like exophytic growths on the eyelids (papillomatosis)

finger-like projection of epithelium with fibrovascular cores. Epithelium shows acanthosis and hyperkeratosis Squamous papillomas are benign lesions, often seen in HPV 6 and 11

II eyelid Squamous cell carcinoma less common than basal cell carcinoma Basal cell carcinoma most common malignant tumor of eyelid (usually lower lid) Sebaceous carcinoma Melanoma of eyelid rare 1. Sebaceous Carcinoma - sebaceous glands are part of the pilosebaceous unit secrete sebum into hair shaft - older people usually affected - arise from sebaceous gland of eyelid (meibomian glands) - highly malignant eyelid tumor - manifestations nodule on eyelid may mimic chalazion (inflammation of gland) - diffuse eyelid thickening and loss of eyelashes - Histology: variable sebaceous differentiation with cytoplasmic vacuolation (intracytoplasmic lipid on fat stain) i.e. bubbly cytoplasm due to dissolving of the sebum during fixation - Mitoses may be numerous and squamous or basaloid differentiation often necrosis seen in center - Large polygonal cells with distinct cell border - Small and uniform nuclei 2. Stye (Hordeolum) - Infection of root of eyelash that manifests as a pimple-like swelling, redness, and pain on the eyelid - often staphylococcal infection - external hordeolums form on the skin. Internal hordeolums form on the conjunctiva - purulent exudate 3. Chalazion Hard, painless lump on eyelid caused by inflammation of the sebaceous gland that presents as a nodule, similar to sebaceous cell carcinoma - chalazions are painless, whereas styes are painful chronic granulomatous inflammation of the meibomian (sebaceous) gland where there is inflammation of the gland, sebum comes out and acts like foreign material. Granulomatous inflammation will occur in response. Multinucleated giant cells,

epitheloid cells, and lymphocytes seen. Clear circular area (dissolved fat) surrounded by epitheloid cells and multinucleated cells - stain with fat stain = fat appears pink or orange III Conjunctiva - Normal conjunctiva mucous membrane is composed of non-keratinizing squamous epithelium with goblet cells, sits on connective tissue substantia propria Three zones palpebral, forneceal, and bulbar (bulbar conjunctiva is the transparent layer over the sclera) 1. Conjunctivitis Acute or chronic inflammation of conjunctiva In acute cases, conjunctivitis stops at the limbus (border between cornea and sclera) Depending on infection, eye may be red, swollen, watery, or purulent Causes: bacteria (staph, strep, haemophilus, gonorrhea), viral (adenovirus), allergy In neonates gonococcal conjunctivitis (GC), chlamydia, or chemical (AgNO3 or silver nitrate is often administered to neonates to prevent infection. However silver nitrate itself can cause conjunctivitis)

2. Trachoma chlamydial (bacteria) infection of the conjunctiva and cornea sexually transmitted produce significant conjunctiva scarring C. trachomatis is a major cause of blindness in underdeveloped countries infections are common in areas of poor socioeconomic growth Histology inflammation causes formation of lymphoid follicles, which contain lymphocytes, germinal centers, and can cause papillary infolding of conjunctiva, giving a cobblestone look When follicles resolve, scarring occurs, leading to formation of pseudomembrane over conjunctiva When conjunctiva tissue is scraped, stained w/ geimsa stain, small cytoplasmic elementary bodies can be seen. This is diagnostic feature of trachoma

3. Pinguecula/Pterygium a transparent, triangular type of membranous overgrowth of the nasal side of the bulbar conjunctiva a pterygium is an overgrowth that grows over the cornea; a p ineguecula does not invade the cornea and stops at the limbus. Histologically, both look alike.

Degenerative changes (elastic degeneration) in the subepithelial connective tissue - just as in actinic keratosis, UV light damage to subepithelial stroma connective tissue causes elastic degredation, which is bluish-grey in appearance instead of normal pink tissue Histologically almost identical to actinic elastosis of skin

4. Conjunctival Papilloma - Papillary conjunctival growth growth appear as tiny red dots that grow towards the epithelium because every papillae has blood vessels - Sessile or pedunculated - Papillae covered by squamous epithelium with goblet cells - papillae covered by squamous epithelium with goblet cells - surface keratinization may be present if there is chronic irritation (ex rubbing) - secondary to HPV 6 and 11 infection these lesions are benign lesions that can be excised 5. Pyogenic Granuloma - presents as a cherry red, papillary/nodular lesion on conjunctiva - usually develops in response to trauma capillaries grow and form a bulgy nodule - occur on the conjunctiva or eyelid - radiating capillaries embedded in cellular stroma and inflammatory cells edema and fibroblasts also seen on histology - in most cases, secondary to trauma, surgery, or infection - this granuloma will eventually shrink and epithelialize again this is the normal healing process 6. Sarcoidosis - nodular lesions that may appear in many ocular tissues, including lacrimal glands - non-caseating granulomatous inflammation (epitheloid cells, lymphocytes, multinucleated giant cells) 7. Conjunctival nevus pigmented lesion of the conjunctiva usually found close to the limbus typically present at birth benign, near the limbus cystic epithelium can invade and form glandular structure that secretes mucus. Mucus gets collected and appear as a cyst on the nevus surface Brown in color and move with conjunctival manipulation nevi can be moved and manipulated, whereas melanomas are fixed to underlying structure

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Occasionally can be difficult to differentiate from melanoma biopsy in this case Primary acquired melanosis without atypical (PAM) minimal melanocytic hyperplasia can be seen, but is completely benign confined to basal layer, does not migrate towards surface insignificant risk of progression

9. Primary acquired melanosis (PAM) with atypia (PAM) - also known as conjunctival melanocytic intraepithelial neoplasia (C-MIN) or melanoma in situ - a pigmented lesion similar to PAM without atypia, but melanocytes have traveled up towards the surface. They have not invaded through the basement membrane and have non-uniform nuclei. - Confluent basilar nests - Intraepithelial pagetoid spread - Cells with epithelioid feature, enlarged and pleomorphic nuclei, significant cases progress to melanoma. 10. Conjunctiva squamous cell carcinoma - presents as a nodule, sometimes ulcerated, with irregular borders and neovascularization - etiology solar UV radiation - HPV 16 and 18 - Immunosuppression (HIV positive or renal transplant) - Marked by accelerated growth, ulceration, induration, or fixation - Lesion may extend into the cornea - It is important to remember that when excising an eye lesion, you want to save as much conjunctiva as possible avoid dryness to prevent corneal ulcers - Histology hyperplastic and dysplastic conjunctival epithelium; malignant squamous cells invade underlying stroma basement membrane is gone, tumor invades stroma large polygonal cells, abundant eosinophilic cytoplasm, intercellular bridges, and keratin pearls intercellular bridges are tractlike structures that develop between cells. It is a key feature of squamous cell carcinoma IV Cornea - major refractive surface if cornea is opaque, refractory issues will occur. - Epithelium rests on bowmans membrane, which rests on corneal stroma cells - Stroma lacks blood vessels and lymphatics - Endothelium is derived from neural crest and rests on descemets membrane - Decrease or malfunctioning of endothelium bulbous keratopathy - Cornea is avascular

1. Bulbous Keratopathy - decrease or malfunctioning of endotheliu normally the endothelial cells keep the cornea hydrated, but in bulous keratopathy, the endothelial cells are gone. - Endothelial damage due to increased intraocular pressure, trauma, inflammation, and degenerative conditions - Edema of corneal stroma and epithelium with bullae between epithelium and bowmans layer the stroma looks fuzzy due to the edema - If the fluid goes all the way to the epithelium, it causes the cell junction to be lost between the epithelium and bullous membrane, forming a bullae in the cornea Later subepithelial scar after the bullae resolves, a subepithelial scar forms near the bulbous membrane