Exam 2: Eye - Clinical and Pathology (summarys and pictures from DSA)

Question 1

Name some conditions related to the following region of the eye:

Orbit

Answer 1

—Proptosis/Exophthalmos (Graves Disease)

inflammation

tumors

Question 2

Name some conditions related to the following region of the eye:

Eyelid

Answer 2

——Inflammations/Infections (Sty, Chalazion, Xanthelesma)

Tumors (Basal Cell Carcinoma, Sebaceous Carcinoma)

Question 3

Name some conditions related to the following region of the eye:

Conjunctiva

Answer 3

———Inflammations/Infections (e.g. Trachoma)

Degenerative (Pterygium, Pinnecula)

Neoplasms

Question 4

Name some conditions related to the following region of the eye:

Sclera

Answer 4

————Collagen Disorders

Question 5

Name some conditions related to the following region of the eye:

Cornea

Answer 5

—Inflammation/Infection (including HSV, Amebiasis)

Dystrophies (Fuchs)

Degenerations (Keratoconus)

Question 6

Name some conditions related to the following region of the eye:

Anterior Segment

Answer 6

—Glaucoma (Open-, Closed-angle)

Cataracts

Inflammation

Question 7

Name some conditions related to the following region of the eye:

Uvea

Answer 7

—Inflammation** (Uveitis – Sarcoidosis, Sympathetic Ophthalmia), **Neoplasms (Melanoma)

Question 8

Name some conditions related to the following region of the eye:

—Vitreous

Answer 8

Retinitis* (infections)

Retinoblastoma*

*vitreous as well as the retina

Question 9

Name some conditions related to the following region of the eye:

Retina

Answer 9

—Degenerations (Macular Degeneration)

Retinitis (Retinitis Pigmentosa)

Vascular (Hypertensive and Diabetic Retinopathy)

Neoplasms (Retinoblastoma, Melanoma)

Question 10

Name some conditions related to the following region of the eye:

Optic Nerve

Answer 10

• —Papilledema —(swelling of optic nerve/disc with increased intracranial pressure)
• Optic Neuritis (demyelination - MS)
• Tumors (Optic glioma – NF2)
• —Ischemia – Anterior Ischemic Optic Neuropathy (—Similar to stroke)
• —Glaucomatous nerve damage (See glaucoma) - cupping
• —Leber hereditary optic neuropathy (—Mitochondrial inheritance)

Question 11

Name some conditions related to the following region of the eye:

End-stage eye

Answer 11

—Phthis bulbi

Question 12

Name some conditions related to the following region of the eye:

——Systemic Diseases

Answer 12

• —MANY systemic diseases affect the eye
• —Can be a strong push towards diagnosis

—• Examples

—Sarcoidosis

—Sjögren Disease – lacrimal glands

—Infections

—Endocrine disorders

—Hypertension

—Diabetes

Question 13

Key facts and info for:

——Thyroid Ophthalmopathy (Graves disease)

Answer 13

• The accumulation of GAG (principally hyaluronic acid) causes a change in osmotic pressure, which in turn leads to a fluid accumulation, muscle swelling, and an increase in pressure within the orbit.
• These changes, together with retroorbital adipogenesis, displace the eyeball forward and can also interfere with the function of the extraocular muscles and the venous drainage of the orbits
• GAG secretion by fibroblasts is increased by thyroid-stimulating antibodies and activated T cell cytokines such as tumor necrosis factor (TNF) alpha and interferon gamma (implying that both B and T cell activation are important parts of this immunopathology)

Question 14

What condition would you consider with this image and buzz words:

• The accumulation of GAG (principally hyaluronic acid)
• increase in pressure within the orbit
• retroorbital adipogenesis
• displace the eyeball forward
• B and T cell activation

Answer 14

——Thyroid Ophthalmopathy (Graves disease)

• The accumulation of GAG (principally hyaluronic acid) causes a change in osmotic pressure, which in turn leads to a fluid accumulation, muscle swelling, and an increase in pressure within the orbit.
• These changes, together with retroorbital adipogenesis, displace the eyeball forward and can also interfere with the function of the extraocular muscles and the venous drainage of the orbits
• GAG secretion by fibroblasts is increased by thyroid-stimulating antibodies and activated T cell cytokines such as tumor necrosis factor (TNF) alpha and interferon gamma (implying that both B and T cell activation are important parts of this immunopathology)

Question 15

Key facts and info for:

Sty or Hordeolum

Answer 15

• In the eyelid region
• —acute inflammatory** involving **hair follicles or sebaceous/apocrine glands

Question 16

Key facts and info for:

——Xanthelasma

Answer 16

• In the eyelid region
• ——yellow plaques

• ——nasal aspect often

• ——associated with hyperlipidemia (in young)

Question 17

Key facts and info for:

Chalazion

Answer 17

• In the eyelid region
• ———granulomatous
• around meibomian glands or glands of Zeis (sebaceous glands)

Question 18

Key facts and info for:

—Neoplasms

(In the eyelid region)

Answer 18

• In the eyelid region
• ————Basal cell carcinoma – Most common

—• ————Sebaceous carcinoma – Arise in sebaceous glands

—• ————Other - Kaposi sarcoma

Question 19

What condition would you consider with this image and buzz words:

• eyelid shows ectropion
• cornea shows neovascularization
• foamy cytoplasm
• clear cytoplasm

Answer 19

——Sebaceous Carcinoma

• (Left image) Pagetoid* spread of sebaceous carcinoma. Neoplastic cells with foamy cytoplasm are detected within the epidermis.
• Sebaceous cell carcinoma of the left lower eyelid. (Right Top image) The patient’s left lower eyelid shows ectropion**, and the cornea shows neovascularization.
• (Right Bottom) mild expansion of the conjunctival epithelium due to infiltration by single or small groups of malignant sebaceous cells with large, hyperchromatic nuclei and occasional mitoses. These display little clear cytoplasm reminiscent of sebaceous differentiation

* Pagetoid refers to this spread of neoplastic cells within the epidermis

** ectropion: a condition, typically a consequence of advanced age, in which the eyelid is turned outward away from the eyeball

Question 20

Key facts and info for:

Chlamydia** – **Trachoma

Answer 20

• In the Conjunctiva
• ————Caused by Chlamydia trachomatis infection that is transmitted through flies
• ————Epithelial cell inclusions
• ————Chronic inflammation results in follicles and scarring

Question 21

What condition would you consider with this image and buzz words:

• infection
• flies
• follicles and scarring

Answer 21

Conjunctiva - Trachoma

• Repeated infection with Chlamydia trachomatis ( transmitted through flies) causes chronic inflammation
• resulting in follicles (Panel A) and scarring (Panel B), in the form of white lines, bands, or sheets, in the tarsal conjunctiva of the upper eyelid and causing eyelashes to turn inward and abrade the cornea (Panel C).

Question 22

Key facts and info for:

Pinguecula

Answer 22

• In the Conjunctiva
• Degenerative (actinic* lesions)
• ————Does not invade cornea
• ————Yellowish area of thickening
• ————Elastosis

*actinic: refers to damage resulting from sun exposure. This part of the eye is on the outside and can be easily damaged by the sunlight.

Question 23

Key facts and info for:

Pterygium

Answer 23

• In the Conjunctiva
• Degenerative (actinic* lesions)
• Fibrovascular tissue migrates onto cornea
• White

*actinic: refers to damage resulting from sun exposure. This part of the eye is on the outside and can be easily damaged by the sunlight.

Question 24

Key facts and info for:

Inflammations

(In the cornea region)

Answer 24

• In the Cornea
• keratitis and ulcers (e.g. contact lens complications)
• Bacterial, Fungal, Viral (HSV, herpes zoster),
• Helminth (Onchocerciasis “Loa Loa”, River Blindness); Transmitted by blackflies. Fluffy opacities in cornea and conjunctiva (degenerating microfilariae.
• Protozoal – amoebic (contact lens)

Question 25

Key facts and info for:

Fuchs Endothelial Dystrophy

Answer 25

• In the Cornea

—• —Dystrophies** – Hereditary, _Non_inflammatory**

• —Loss of endothelial cells

—• —Stromal edema and bullous keratopathy

Question 26

Key facts and info for:

Keratoconus

Answer 26

• In the Cornea

—• —Degeneration** – **—Nonfamilial

• ——Thinning and fibrosis of cornea with breaks in Bowman layer.
• ——Leads to distortion of cornea and visual problems
• Thinning of cornea leads to astigmatism

• often hard to correct

Question 27

Key facts and info for:

Glaucoma (Open angle)

Answer 27

• In the Anterior Segment

—• —unimpeded flowofaqueous humor into anglewith increased resistancetooutflow**into**Canal of Schlemm

—• ——Primary

Some due to defects in gene coding for myocilin

—• —Secondary

Particles clog trabecular meshwork (tumors, RBC, lens fragments)

Increase in episclerial pressure secondary to surface ocular vascular malformations (Sturge Weber)

• Pathophysiology/Consequence

Glaucomatous retinopathy with cupping of optic nerve head and nasal displacement of retinal vessels

Optic atrophy – Loss of axons and ganglion cells

* Image: shows cupping of optic nerve head in glaucoma. This is secondary to axonal degeneration and subsequent loss of axons

Question 28

Key facts and info for:

Glaucoma (Closed angle)

Answer 28

• In the Anterior Segment

—• Blockage of angle prevent flow into angle and then through trabecular meshwork into Canal of Schlemm.

—• ——Primary

shallow anterior chamber (especially with pupil dilation)

—• —Secondary

can be due to development of membranes which contract and close angle – vessels (neovascularization), tumors, surgery

• Pathophysiology/Consequence

Glaucomatous retinopathy with cupping of optic nerve head and nasal displacement of retinal vessels

Optic atrophy – Loss of axons and ganglion cells

* Image: In angle-closure glaucoma, the aqueous humor is physically blocked from the canal of Schlemm. This can be due to a pupillary block or to a neovascular membrane.

Question 29

Key facts and info for:

Cataract

Answer 29

• In the Anterior Segment

—• Lens opacities interfere with vision

—• Systemic diseases can have increases in cataracts (i.e. association with cataract)

• Galactosemia, Diabetes, Wilson, Atopic dermatitis, Drugs (steroids), Radiation, Trachoma
• Age-related (senile)
• Debris from cataract may subsequently obstruct flow of aqueous humor
• When necessary, the affected lens can be replaced by a plastic lens

Question 30

Key facts and info for:

—Uveitis

Answer 30

• In the Uvea (choroid and stroma of ciliary body and iris; vascular layer)

—• —Infectious

e.g. pneumocystis, toxoplasmosis, MAI

——• —Noninfectious

—Sympathetic ophthalmia – often with penetrating injury which leads to protrusion of uveal tract followed by uveal tract inflammation in injured and opposite eye (via antibodies)

—Granulomatous (sarcoid)

Question 31

Key facts and info for:

—Neoplasms

(In the Uvea region)

Answer 31

• In the Uvea (choroid and stroma of ciliary body and iris; vascular layer)

—• —Nevi and Melanoma (Fig 29-15)

——• —Metastases (no lymphatics)

In pictures:

Uveal melanoma (Melanomas are often pigmented)

A, Fundus photograph from an individual with a relatively flat pigmented lesion of the choroid near the optic disc.

B, Fundus photograph of the same individual several years later; the tumor has grown and has ruptured through the Bruch membrane.

C, Gross photograph of a choroidal melanoma that has ruptured the Bruch membrane. The overlying retina is detached.

D, Epithelioid melanoma cells associated with an adverse outcome.

Question 32

Key facts and info for:

—Macular Degeneration

Answer 32

• In the Retina

—• —Center of macula is point of greatest visual acuity. Macular degeneration affects this region and visual acuity. Peripheral vision is often maintained.

——• —Most common cause of irreversible visual morbidity

——• —Many have genetic basis – mutations of CFH gene that codes for complement factor H or other mutations

—• ——Changes in underlying retinal pigment epithelium (including BM), and innermost layer of choroid vasculature (choriocapillaris) affect retinal health

——• —Types

—Dry – deposits of degraded material in Bruch’s membrane (drusen) and geographic atrophy of retinal pigment epithelium

—Wet** – **follows dry with angiogenesis leading to leakage and scars

Question 33

Key facts and info for:

Retinitis (infections)

Answer 33

• In the Retina/Vitreous

—• —Toxoplasmosis

Question 34

Key facts and info for:

Retinoblastoma

Answer 34

• In the Retina/Vitreous

—• Rb gene; inherited (often bilateral) vs. sporadic forms

• small blue-cell tumor
• Malignant

* Image: A, Gross photograph of retinoblastoma. B, Tumor cells appear viable when in proximity to blood vessels, but necrosis is seen as the distance from the vessel increases. Dystrophic calcification (dark arrow) is present in the zones of tumor necrosis. Flexner-Wintersteiner rosettes—arrangements of a single layer of tumor cells around an apparent “lumen”—are seen throughout the tumor, and one such rosette is indicated by the white arrow.

Question 35

What condition would you consider with this image and buzz words:

• bilateral
• small blue-cell tumor
• Malignant
• Dystrophic calcification
• Flexner-Wintersteiner rosettes

Answer 35

Retinoblastoma

—• Rb gene; inherited (often bilateral) vs. sporadic forms

• small blue-cell tumor
• Malignant

* Image: A, Gross photograph of retinoblastoma. B, Tumor cells appear viable when in proximity to blood vessels, but necrosis is seen as the distance from the vessel increases. Dystrophic calcification (dark arrow) is present in the zones of tumor necrosis. Flexner-Wintersteiner rosettes—arrangements of a single layer of tumor cells around an apparent “lumen”—are seen throughout the tumor, and one such rosette is indicated by the white arrow.

Question 36

Key facts and info for:

Hypertensive Retinopathy

Answer 36

• In the Retina

—• —HTN leads to arteriosclerosis

—Arteriolar wall is thickened with narrowed lumen

—Compression of vein at crossing points

—Changes in appearance of vessel (—Copper-wire, —Silver-wire)

—• ——Malignant hypertension leads to vascular damage

—Hemorrhage, Exudates

—Cotton wool spots (—Infarcts of choroid and retina; —Axonal damage and accumulation of mitochondria in swollen axons)

—Damage to retinal pigment epithelium – detachment

Question 37

What condition would you consider with this image and buzz words:

• Copper-wire
• —Silver-wire
• —Hemorrhage, Exudates
• Cotton wool spots

Answer 37

Hypertensive Retinopathy

• In the Retina

—• —HTN leads to arteriosclerosis

—Arteriolar wall is thickened with narrowed lumen

—Compression of vein at crossing points

—Changes in appearance of vessel (—Copper-wire, —Silver-wire)

—• ——Malignant hypertension leads to vascular damage

—Hemorrhage, Exudates

—Cotton wool spots (—Infarcts of choroid and retina; —Axonal damage and accumulation of mitochondria in swollen axons)

—Damage to retinal pigment epithelium – detachment

Question 38

Key facts and info for:

Diabetes

Answer 38

• —Cataracts

—• —basement membrane thickening in ciliary body

—• —Retinal vasculopathy

* image: The ciliary body in chronic diabetes mellitus, PAS stain. Note the massive thickening of the basement membrane of the ciliary body epithelia, reminiscent of changes in the mesangium of the renal glomerulus.

Question 39

Key facts and info for:

Diabetic Retinopathy

Answer 39

——Retinal vasculopathy

1) ——Background (preproliferative)

—Thickening of basement membrane; can be seen in the ciliary body

—Loss of pericytes and then capillary endothelial cells (apoptosis)

—Microaneurysms and dot intraretinal hemorrhages

—Leakage: —Macular edema** (breakdown of blood-retinal barrier) and **hard exudates; —Hemorrhagic exudates; —Cotton – wool spots

2) ———Proliferative (VEGF)

—Neovascularization of retina: —Hemorrhages (posterior vitreous detachment); —Traction retinal detachment

—Neovascularization of iris: —Glaucoma

—Newly formed blood vessels are the target of laser therapy

Question 40

What condition would you consider with this image and buzz words:

• Thickening of basement membrane
• Microaneurysms

—• Cotton – wool spots

—• Neovascularization —of retina or iris

Answer 40

Scene viewed by a person with diabetic retinopathy (vs. normal).

The areas with loss of vision are secondary to the diabetic vascular changes.

Question 41

Name some conditions related to the following region of the eye:

Optic Nerve

Answer 41

• —Papilledema —(swelling of optic nerve/disc with increased intracranial pressure)
• Optic Neuritis (demyelination - MS)
• Tumors (Optic glioma – NF2)
• —Ischemia – Anterior Ischemic Optic Neuropathy (—Similar to stroke)
• —Glaucomatous nerve damage (See glaucoma) - cupping
• —Leber hereditary optic neuropathy (—Mitochondrial inheritance)

Question 42

Name some conditions related to the following region of the eye:

Optic Glioma

Answer 42

• ——Seen in childhood

—• ——Association with NF1

—• ——Mostly low-grade astrocytomas

* image: Optic nerve glioma. B, Optic nerve glioma seen on axial computed tomography (CT) scan. Although the tumor is clearly seen on the CT scan, magnetic resonance imaging is preferred to monitor for extension of tumor into brain. C, Histopathologic appearance of a low-grade astrocytoma of the optic nerve.

Question 43

Name some conditions related to the following region of the eye:

End-Stage - Phthisis Bulbi

Answer 43

• ———Severe damage to eye can result in end-stage eye (phthisis bulbi)

—• ———Can be result of different insults and conditions (e.g. trauma, inflammation, chronic detachments, etc.).

—• ———End-stage eye is shrunken and internally disorganized.