Transcript impression cytologic analysis of superior limbic keratoconjunctivitis

IMPRESSION CYTOLOGIC ANALYSIS OF
SUPERIOR LIMBIC KERATOCONJUNCTIVITIS:
NEW DIAGNOSTIC AID
Jayangshu Sengupta
Cornea Services, Priyamvada Birla Aravind Eye Hospital Kolkata, India
Nibaran Gangopadhyay
Head-Eye Care, Sanjiban Hospital, Howrah, India
Merle Fernandez
Director & Cornea Consultant, Vizag-LVPEI,AP, India
The authors have no financial interest in the subject matter of the poster
IMPRESSION CYTOLOGIC ANALYSIS OF
SUPERIOR LIMBIC KERATOCONJUNCTIVITIS:
NEW DIAGNOSTIC AID
Conjunctival impression cytology
 Simple, noninvasive technique
 Sample the superficial layers of epithelium for analysis.
 Gold standard procedure for analysis of squamous
metaplasia and goblet cell loss.
 Light microscopy- remains most commonly used in
clinical practice.
Superior Limbic Keratoconjunctivitis
 Disorder of unknown etiology
 Role of impression cytology as a diagnostic modality
remains largely unknown.
IMPRESSION CYTOLOGIC ANALYSIS OF
SUPERIOR LIMBIC KERATOCONJUNCTIVITIS:
NEW DIAGNOSTIC AID
To demonstrate the morphological changes induced in the
conjunctival epithelium in presence of SLK using the process of
impression cytology.
Prospective, non-comparative, observational case series
50 eyes(26 patients) were analyzed
2 eyes with inadequate samples were not analyzed
January 2008 – December 2008
IMPRESSION CYTOLOGIC ANALYSIS OF
SUPERIOR LIMBIC KERATOCONJUNCTIVITIS:
NEW DIAGNOSTIC AID
Diagnostic criteria
Localized superior bulbar congestion
with conjunctivochalasis +/- filament
Localized punctuate Rose Bengal
staining
Papillary changes over upper tarsal
conjunctiva
Bilateral involvement.
Evaluation
Detailed history
Slit lamp examination
Schirmer test
Tear film break up time
Rose Bengal staining
Fluorescein stain score
Systemic examination
Exclusion criteria
Use of contact lens
Schirmers II value<5mm
Prior steroid therapytopical/systemic
(within previous 3 months)
IMPRESSION CYTOLOGIC ANALYSIS OF
SUPERIOR LIMBIC KERATOCONJUNCTIVITIS:
NEW DIAGNOSTIC AID
Standard technique of impression cytology
Haematoxylin- PAS staining
Grossly labeled as normal/abnormal
 epithelial cell morphology
 cohesion of cells
 keratinization
 nuclear characteristics
 goblet cell density.
Abnormal specimens graded
 Tsengs classification system
Goblet cells
Normal epithelial pattern
(Scheffer C.G.Tseng Ophthalmology 92:728-733,1985)
Abnormal Impression
IMPRESSION CYTOLOGIC ANALYSIS OF
SUPERIOR LIMBIC KERATOCONJUNCTIVITIS:
NEW DIAGNOSTIC AID
Age Range was found to be 36 to 55 yrs
M:F ratio of 1:12
Co morbidity factors were found in 4 patients
Hypothyroid
Rheumatoid Arthritis
1 patient each
Post Lasik
High Prolactin level
All samples from superior bulbar portion of conjunctiva
demonstrated Grade V squamous metaplasia
IMPRESSION CYTOLOGIC ANALYSIS OF
SUPERIOR LIMBIC KERATOCONJUNCTIVITIS:
NEW DIAGNOSTIC AID
Increase in cell size
Lack of cohesiveness
with increased intercellular
spaces and folded edges
Keratinisation
Complete absence of goblet
cells
Pyknotic nucleus
IMPRESSION CYTOLOGIC ANALYSIS OF
SUPERIOR LIMBIC KERATOCONJUNCTIVITIS:
NEW DIAGNOSTIC AID
Snake chromatin
100%
Snake like chromatin
Due to alteration in the
nuclear and
cytoplasmic skeleton
Knop E, Reale E Fine structure and significance of snake like chromatin in conjunctival epithelial cells. Invest. Ophthalmol. Visual Sci 35:711, 1994
Margarita Calonge, Yolanda Diebold, Victoria Saez et al Impression cytology of the ocular surface: a review Experimental Eye Research78:457, 2004
IMPRESSION CYTOLOGIC ANALYSIS OF
SUPERIOR LIMBIC KERATOCONJUNCTIVITIS:
NEW DIAGNOSTIC AID
Multinucleation
(100 perent)
Balloon degeneration
Multinucleation
Balloon degeneration
(96%)
IMPRESSION CYTOLOGIC ANALYSIS OF
SUPERIOR LIMBIC KERATOCONJUNCTIVITIS:
NEW DIAGNOSTIC AID
Multilobulated nuclei
(70%),
Multilobulation
Spindle Configuration
Spindle configuration
(68%)
Dumb-bell configuration
(60%).
Dumb- bell
Dumb- bell
IMPRESSION CYTOLOGIC ANALYSIS OF
SUPERIOR LIMBIC KERATOCONJUNCTIVITIS:
NEW DIAGNOSTIC AID
Hallmark of squamous metaplasia from histopathological
specimens
 Extensive nuclear pyknosis
 Condensation of masses of chromatin
 The shrinkage of the nuclear envelope from its surrounding cytoplasm
Though electron microscopy of histological samples in patients
with SLK better demonstrates such nuclear changes, conjunctival
impression cytology in SLK conclusively demonstrates
 Localized squamous metaplasia of high grade
 Complete lack of goblet cells
 Characteristic nuclear changes like balloon degeneration, condensed chromatin,
snake like chromatin, multi lobulated and strangulated nuclei
Formation of snake like chromatin is characteristic
 Probably an indicator of mechanical stress on the ocular surface like blink related
micro-trauma.
Barry Collin, Peter C. Donshik, S. Arthur Boruchoff, et al. The fine structure of nuclear changes in superior limbic keratoconjunctivitis.
Invest. Ophthalmol. Visual Sci 17(1):79, 1978
IMPRESSION CYTOLOGIC ANALYSIS OF
SUPERIOR LIMBIC KERATOCONJUNCTIVITIS:
NEW DIAGNOSTIC AID
To conclude, impression cytology is a simple, noninvasive
method of demonstrating the underlying pathological changes
and thereby becomes an important tool in diagnosing SLK.