OCULAR PATHOLOGY

CHAPTER 18 OCULAR PATHOLOGY



Eyelid
Infections

Inflammation

Tumors

Lacrimal drainage system
Dacryocystitis

Canaliculitis

Lacrimal gland

Conjunctiva
Inflammation

Degenerative changes

Tumors

Cornea
Infections

Inflammation

Degenerative

Corneal dystrophies

Metabolic disease involving the cornea

Keratoconus

Corneal dermoids

Pseudophakic bullous keratopathy

Corneal graft rejection and failure

Developmental anomalies
Anterior segmental developmental anomalies

Persistent hyperplastic primary vitreous

Microphthalmia

Orbital pathology
Orbital pseudotumor

Optic nerve pathology
Optic nerve glioma

Meningioma

Intraocular tumors
Non-retinoblastoma intraocular ‘tumors’

Retinoblastoma

Miscellaneous ocular disorders
Epithelial down-growth

Endophthalmitis / panophthalmitis

Phthisis bulbi

Irido-corneal endothelial syndrome




INTRODUCTION



• Two broad groups of surgical pathology are specific to pediatric practice
image developmental anomalies

image tumors

• Most of the remaining pathology is either not specific to children or covered elsewhere in the book
image little detail is given here


EYELID



INFECTIONS




Bacterial



• External hordeolum/stye
image purulent infection of hair follicle of the eyelid

image spreads to adjacent follicles and develops an abscess

• Internal hordeolum
image purulent infection of Meibomian gland
– associated with bacterial infection and obstruction of duct

• Necrotizing fasciitis
image group A Streptococcus with Staphylococcus

image purulent exudate and necrosis

image bacteria

• Granulomatous
image rare in this site


Viral



• Warts

• Molluscum contagiosum
image well circumscribed nodule of epithelial cells

image viral inclusions


INFLAMMATION




Chalazion (Fig 18.1)



• Lipogranuloma

• Obstruction of the Meibomian gland duct

• Free fat surrounded by granulomatous inflammation

image

Fig 18.1 Photomicrograph of a chalazion showing a lipogranuloma consisting of dense active chronic inflammation and epithelioid histiocytes surrounding a lipid vacuole.



TUMORS




Cysts



• Sudoriferous cysts (Fig 18.2)
image translucent cysts

image double layered wall
– cuboidal inner cells

– external myoepithelial cells

• Epidermoid/dermoid

image

Fig 18.2 Photomicrograph of a sudiferous cyst. The cyst has a two-layer wall.



Xanthelasma



• Typically adult

• Foamy cells in dermis


Nevi



• Junctional

• Compound

• Intradermal


Hamartomas



• Cavernoma

• Lymphangioma

• Neurofibroma


Epithelial tumors



• Squamous cell papilloma
image warty lesion

image papillomatous

image squamous cells

• Other epithelial tumors common in adults are rare in childhood


Soft tissue tumors



• Rhabdomyosarcoma


LACRIMAL DRAINAGE SYSTEM



DACRYOCYSTITIS (Fig 18.3)



• Inflammation of the lacrimal sac
image associated with obstruction

image acute or chronic inflammation

• Mucocele

• Dacryolith

image

Fig 18.3 Photomicrograph from a chronic dacryocystitis. The wall of the lacrimal sac is infiltrated by dense chronic inflammation.



CANALICULITIS



• Epiphora

• Conjunctivitis

• Several organisms
image most common is Actinomyces


LACRIMAL GLAND



• Biopsy of lacrimal gland pathology is unusual in pediatric practice

• Inflammatory lesions
image dacryoadenitis

image sarcoidosis

• Tumors
image see orbital tumors

image pleomorphic adenoma may arise at this site but is predominantly a disease of adulthood


CONJUNCTIVA



INFLAMMATION




Non-granulomatous conjunctivitis



• Two patterns:
image Papillary
– subepithelial chronic inflammation forming papillae due to tethering of the epithelium by fibrous tissue
· lymphocytes

· plasma cells

· eosinophils

– central vessels

– causes
· bacteria

· allergy (vernal conjunctivitis)

· foreign body (contact lenses)

· chronic blepharitis

image Follicular (Fig 18.4)
– lymphoid follicles/aggregates

– surrounded by vessels

– causes
· viruses (Adenovirus, Molluscum, HSV)

· Chlamydia

· hypersensitivity

· topical medication

image

Fig 18.4 Photomicrograph showing follicular conjunctivitis.



Trachoma



• Chlamydia trachomatis infection

• Immunotypes A–K

• Diagnosis by scrapings

• Follicular conjunctivitis
image later papillary phase


Ophthalmia neonatorum



• Infection by Chlamydia acquired in the birth canal

• Papillary conjunctivitis


Keratoconjunctivitis sicca



• Inadequate tear film – ‘dry eyes’

• May occur in association with juvenile rheumatoid arthritis

• Conjunctiva may undergo squamous metaplasia


Ocular cicatricial pemphigoid



• Rare in childhood
image usually associated with age

• Irritation/burning sensation

• Scarring

• Dry eyes

• Biopsy
image diagnosis depends on staining for immunoglobulins (esp. IgG) on the epithelial basement membrane

image subepithelial bullae

image chronic inflammation in the stroma


Granulomatous conjunctivitis



• Sarcoid


DEGENERATIVE CHANGES




Pinguecula / pterygium



• Unusual in childhood
image but described occasionally

• Fibrovascular tissue showing elastosis

• Pinguecula
image nodule on the conjunctiva only

• Pterygium
image localized to limbus and extending across the cornea


Pseudopterygium



• Adhesion between conjunctiva and cornea following corneal damage

• Fibrovascular tissue lacking elastosis


TUMORS




Epithelial inclusion cysts (Fig 18.5)



• Benign epithelial cysts

• Lined by conjunctival epithelium

• May undergo squamous metaplasia

image

Fig 18.5 Photomicrograph showing an epithelial inclusion cyst taken from the eyelid.



Pyogenic granuloma



• Relatively common surgical specimen from this site

• Histological features as seen elsewhere


Hamartoma



• Lymphatic cyst / lymphangiectasia

• Capillary hemangioma

• Dermoids (Fig 18.6)
image solid
– mixtures of mesenchymal elements

image cystic
– epidermal and adnexal structures

image

Fig 18.6 Photomicrograph showing a conjunctival dermoid. There is extensive adipose tissue and fibrous tissue together with a few small glands.



Amyloid



• Conjunctival nodules

• Associated with systemic amyloid or local inflammation


Melanocytic tumors (Figs 18.7, 18.8)



• Conjunctival nevi
image junctional

image compound

image intra-stromal

image often associated with secondary epithelial cysts

• Melanoma and primary acquired melanosis are predominantly diseases of adulthood

• Melanosis may be seen as a congenital phenomenon
image oculodermal melanocytosis (nevus of Ota)
– associated dermal nevus

image malignant transformation is rare

image

Fig 18.7 Photomicrograph showing a conjunctival junctional nevus. There are multiple nests of melanocytes.


image

Fig 18.8 Photomicrograph showing an epithelial cyst within a conjunctival nevus.



Epithelial tumors



• Papilloma
image two patterns
– placode/sessile

– pedunculated/papillary

• Premalignant/malignant tumors rare in children


Lymphoma



• Predominantly a disease of adulthood but childhood cases described

• Mostly MALT type


CORNEA



INFECTIONS




Bacterial keratitis



• Neutrophils in the cornea

• Outcomes
image healing

image descemetocele
– epithelial down growth on to the remaining Descemet’s membrane
· more frequent in viral infections

image perforation
– endophthalmitis


Crystalline keratopathy



• Bacterial infection in the context of topical steroids

• Clumps of bacteria

• Lacks a significant vascular or inflammatory response


Fungal keratitis



• Immunocompromise

• Purulent inflammation

• Fungal elements


Acanthameba



• Associated with contact lens use with contaminated disinfection procedures

• Atrophic epithelium

• Reduction in visible keratocytes in the stroma

• Parasitic cysts in stroma


Virus



• HSV
image early stages
– epithelial inclusions

image later stages
– inflammation

– necrosis

– neovascularization

– lipid keratopathy
· granulomatous reaction

· cholesterol clefts

· not specific

• VZV
image similar to HSV


Syphilis



• Interstitial keratitis
image stroma chronic inflammation

• Ghost vessels
image neovascularization of the stroma lacking circulation


INFLAMMATION



• Wegener’s granulomatosis and rheumatoid arthritis can cause corneal ulceration


DEGENERATIVE




Band keratopathy (Fig 18.9)



• Spotty deposition of calcium in Bowman’s membrane

• Causes include
image uveitis

image sarcoid

image topical medication

image hyperparathyroidism/hypercalcemia

image

Fig 18.9 Photomicrograph showing a band keratopathy with fine speckled calcification of Bowman’s membrane.



Spheroidal degeneration



• Deposits of spheroidal structures in superficial stroma
image contain keratin

• As a primary disease in excess UV exposure

• As a secondary phenomenon in inflammatory disease


Amyloid



• May occur in scarred cornea

• See also ‘Lattice dystrophy’ below


Lipid keratopathies



• May occur as secondary phenomena to neovascularization in inflammatory disease

• Crystalline stromal dystrophy (Schneider’s dystrophy)
image see below


Blood staining



• Following bleeding into the anterior chamber (hyphema)

• Blood products seep into the corneal stroma


CORNEAL DYSTROPHIES



• A range of bilateral, hereditary, progressive disorders in most cases limited to the eyes (Klintworth 2009, Poulaki & Colby 2007)

• Variable corneal opacity

• Classified according to the major anatomical layer affected

• Clinical features important in the diagnosis in many cases

• Fuchs’ dystrophy commonest in adults
image does not affect children

• Important considerations in pediatric histopathological practice
image lattice dystrophy

image macular dystrophy

image granular dystrophy

image posterior polymorphous corneal dystrophy

image congenital hereditary endothelial corneal dystrophy (CHED)


Epithelial and superficial dystrophies



Corneal epithelial membrane dystrophy (map dot corneal dystrophy, MDCD)



• Often asymptomatic

• Presentation typically in adults

• Recurrent corneal erosion

• Redundant basement membrane

• Intraepithelial cysts

• Usually not genetic

• Mutations in βig-H3 gene (transforming growth factor inducing gene/TGFBI) described


Meesmann’s epithelial corneal dystrophy



• Onset in early childhood

Related posts:

  1. METABOLIC DISEASE PATHOLOGY
  2. BONE PATHOLOGY
  3. RENAL PATHOLOGY
  4. TUMORS AND TUMOR-LIKE LESIONS

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Jun 18, 2016 | Posted by in PEDIATRICS | Comments Off on OCULAR PATHOLOGY

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