Transcript Conjunctival pathology Conjunctival non-neoplastic and

THE CONJUNCTIVA
Case 1
History

75 year-old male.

Bilateral vascular, wedge shaped lesions,
encroaching on the medial cornea.

Lived in Australia for 30 years.
BIOPSY…….
Bluish curly
fibres of
degenerate
elastin in
substantia
propria
DIAGNOSIS ?
PTERYGIUM
WATCH FOR OCULAR SURFACE
SQUAMOUS NEOPLASIA.
Always send pterygia for histology
because of chance of squamous
neoplasia.
Response to chronic dryness and uv
exposure
Some association with HPV ??controversial…
Stocker’s line at preceding edge.
Pingeculum looks the same histologically
CASE 2
DIAGNOSIS ?
WHAT WOULD YOU EXPECT TO
FIND ON THE BIOPSY ?
Skin type tissue
Located on limbus
cartilage
Lacrimal gland tissue
Dermoids
Choristoma-congenital
overgrowth of normal tissue at
an abnormal location.
Associations: Goldenhaar,
Treacher-Collins and Naevus
Sebaceous Syndrome
Dermolipoma
Adult
Outer canthus
Mature adipose tissue and collagen.
CASE 3
HISTORY

25 year-old male

‘Growth’ on conjunctiva

Has had them before…………..
BIOPSY
DIAGNOSIS ?
Squamous papilloma
Fibrovascular cores making up finger like
projections
Covered in conjunctival type epithelium
(can be non goblet cell epithelium)
HPV 6 and 11 INFECTION
(THERFORE-SO CALLED INFECTIOUS
PAPILLOMAS)
CASE 4
BIOPSY
EPITHELIUM
?
Cystic benign naevus
Bland naevus cells in nests, arranged
around INCLUSION cysts
No mitoses IN NAEVUS COMPONENT.
Preservation of cysts means architecture
is being respected.
Can TRANSFORM TO MALIGNANT
MELANOMA.
BEWARE OF FORNICEAL OR TARSAL
CONJUNCTIVAL PIGMENTED LESIONSUSUALLY MALIGNANT.
CASE 5
Atypical melanosis / in-situ
melanoma (C-MIN)
Intraepithelial proliferation of atypical melanocytes .
Cytological Atypia =nucleus larger tha basal keratinocyte nucleus,
increase in cytoplasmic volume and nucleolus.
Architectural atypia=pagetoid, nested, nests, confluent nests…
MULTIFOCAL
PAM IS A CLINICAL DIAGNOSIS
MUST GIVE FULL INFORMATION ON HISTOLOGY FORM ie., age, how
long present for…..
IF LEFT 75-90% GIVE RISE TO INVASIVE MALIGNANT MELANOMA.
The pathologists role is to day whether melanocytic atypia present or not.
CASE 6
NODULE IN
SUBSTANTIA
PROPRIA
mitosis
Brown melanin pigment
DIAGNOSIS ?
Invasive malignant
melanoma
MACROSCOPIC PROGNOSTIC
FACTORS
a. Location
 Primary conjunctival melanoma located at unfavourable sites, such as the
fornix, palpebral conjunctiva, caruncle, plica seminlunaris and corneal
stroma is associated with a higher recurrence rate and a higher rate of
metastatic death, compared to favourable sites, such as the bulbar and
limbal conjunctiva
b. Size of melanoma
 Melanomas larger than 10 mm in greatest width6 and those that are
pathological stage pT3 and above have a greater local recurrence rate and
higher death rate from metastatic tumour.
c. Multifocality
 Multifocal primary conjunctival melanomas are associated with a higher rate
of recurrence and metastatic death, than unifocal tumours, principally at
favourable site locations.
MICROSCOPIC PROGNOSTIC
FEATURES
Thickness of invasive melanoma

The thickness of invasive melanoma has prognostic significance.
More than 0.8 mm thick-worse prognosis.
Cell types within the invasive melanoma

Tumours with an epithelioid cell component exhibit a higher recurrence rate and a higher tumourrelated mortality compared to those composed of pure spindle cells.
Lymphatic/blood vessel invasion

Tumours exhibiting lymphatic invasion, at favourable and unfavourable sites are associated with a
higher tumour metastatic death
Anatomical structures infiltrated
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The higher the TNM grade, the greater the cumulative probability of recurrence and the greater
the tumour related mortality from metastatic disease
Status of excision margins
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Excision margins involved by melanoma are correlated with local tumour recurrence, higher risk of
metastasis and greater magnitude of tumour related mortality.
CASE 7
SHARP CUT-OFF
ABNROMAL
NORMAL
DIAGNOSIS ?
Conjunctival squamous
epithelial dysplasia
(equates to in-situ SCC or
CIN3)
Sharp demarcation
from normal epithelium
Thickened epithelium
All the hallmarks of malignant cells but in-situ.
Dysplasia=disordered growth. Grade dysplasia according to
what extent the epithelium is taken over by tumour cells
(lower third, 2/3 rds, full thickness-CIN1,2 and 3)
Remember: actinic damage, HIV, Human papillomavirus,
xeroderma pigmentosum as predispositions to squamous
in-situ and invasive neoplasia.
In-situ can progress to invasive SCC
CONJUNCTIVAL INVASIVE
SQUAMOUS CELL CARCINOMA

SEE EYELID SECTION-VERY SIMILAR
MORPHOLOGY.
Case 8
Upper respiratory tract
infection….
Reactive lymphoid follicles in
substantia propria.
Paler, reactive
germinal centre
Follicular conjunctivitis
Reaction pattern, not a diagnosis.
CASE 9
Sea of blue nodules in
substantia propria
Each nodule composed
of back to back
lymphocytes
Regular, round, ovoid cells
with little
cytoplasm, packed closely
Nearly all lymphocytes positive
for CD20-a B cell
lymphocyte cell surface marker
Note membranous pattern
DIAGNOSIS ?
B-cell Non-Hodgkin’s
lymphoma
Commonest subtype OF B-CELL NON HODGKIN’S
LYMPHOMA IS EXTRANODAL MARGINAL ZONE
LYMPHOMA OF MALT TYPE (MALTOMA) at this site and in
the orbit.
Arises form reactive lymphoid hyperplasia background.
Polyclonal-oligoclonal-monoclonal lymphocyte progression
with evolution to lymphoma.
What is the antigenic drive?-New evidence suggests it is
chlamydia psittaci
CASE 10
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65 year old woman presents with bilateral cicatrizing
conjunctivitis
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You send off conjunctival tissue for direct
immunofluorescence studies…..

The pathology report comes back as:
‘Liner IgG and Complement along the epithelial basement
membrane’.

The histology is non-specific.
THIS IS THE IMMUNOFLUORSCENCE IMAGE OF THE
CONJUNCTIVA, SHOWING
LINEAR IgG ALONG THE
EPITHELIAL BASEMENT
MEMBRANE.
Questions….
1.
2.
3.
4.
5.
Why is it a good idea to call the Histopathology
Dept prior to performing the conjunctival
biopsy in this case? 2 marks
How would you send the biopsy to the
Histopathology Dept? 1 mark
What is the diagnosis in this case? 1mark
Give 3 differential diagnoses for a cicatrising
conjunctivitis? 3marks
Give 2 clinical complications of a cicatrising
conjunctivitis? 2 marks
Answers….
1. Prior warning of frozen sections to allow planning. Ask which medium
to send biopsy in.
2. Fresh in Mitchell’s medium.
3. Ocular cicatricial pemphigoid or mucous membrane pemphigoid.
4. Infection: trachoma, adenovirus, corynebacterium diphtheriae,
streptococcus.
Systemic disorders: sarcoidosis, systemic sclerosis, Sjogren’s, SLE.
Topical drugs: adrenaline, pilocarpine, idoxyuridine, ecothiopate.
Ocular trauma- chemical , thermal and surgery.
Skin and mucous membrane disorders: practolol induced eruption,
Steven-Johnson, Toxic epidermal necrolysis, atopic skin diseases,
rosacea blepharoconjunctivitis, Porphyria cutanea tarda, lichen
planus
5. Papillary conjunctivitis, pseudo-membranes. Subconjunctival fibrosis,
symblepharon and ankyloblepharon. Dry eye. Tear deficiency.
Corneal exposure, opacification, vascularisation. Secondary
bacterial keratitis, trichiasis.
OCP / MMP
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Autoimmune disease-deposition of Ig and
complement in the basement membrane.

Type 2 hypersensitivity reaction caused tissue
damage
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Female bias 6th-7th decade
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Any mucous membrane in body
How to send ? OCP biopsies
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Send the biopsy fresh (without fixative) or
in Michel’s medium (aqueous medium).
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Michel’s medium preserves the
immunoglobulins in the tissue.
Case 11
Bilateral conjunctival
problem in kid.
Biopsy
surface
Hyalinised centre covered
by inflammatory tissue…
Diagnosis ?
Ligneous conjunctivitis.
Some facts….
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Autosomal recessive inherited disease caused
by mutations in the PLASMINOGEN type-1
GENE (PLG).
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Show low levels of plasmatic plasminogen
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Show low plasminogen functional activity.
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Gene located at 6q26.
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Recurrent, bilateral lesions on many mucous
membranes of body.
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Recurrent pseudomembranous conjunctivitisevolve to wood like consistency.
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Tarsal conjunctiva
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Histology usually shows eroded, inflamed
epithelium and granulation tissue over clotted
fibrin (hyalin-like material). The histology reflects
arrested wound healing at granulation tissue and
fibrin clot stage. The fibrin clot reflects a lack of
plasmin-mediated extracellular fibrinolysis.