Pathology of the Eyelids, Conjunctiva and Orbit · 6/5/2018 · Nodular Granulomatous Episcleritis...
Transcript of Pathology of the Eyelids, Conjunctiva and Orbit · 6/5/2018 · Nodular Granulomatous Episcleritis...
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Pathology of the Eyelids, Conjunctiva and Orbit
Philippe Labelle, DVM, DACVPAntech Diagnostics
13th Biannual William Magrane Basic Science Course in Veterinary and Comparative Ophthalmology
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Overview
• Non‐neoplastic diseases of the eyelid skin
• Non‐neoplastic diseases of the eyelid margin
• Non‐neoplastic diseases of the conjunctiva
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Eyelid/periocular skin
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General Considerations
• Any skin disease can affect the eyelid skin (allergic/hypersensitivity disease, zinc‐responsive dermatosis, pemphigus foliaceus, demodicosis, dermatophytosis, habronemiasis, etc)
• Eyelid skin reacts similarly to skin elsewhere
• Eyelids may be the first or the most severely affected site
• Veterinary Ocular Pathology (Dubielzig et al.), Veterinary Dermatopathology (Gross, Ihrke, Walder)
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Demodicosis
• Demodex sp.
• Juvenile and adult forms
• Localized and generalized
• Perivascular inflammation, periadnexalinflammation, folliculitis and furunculosis
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Demodicosis
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Demodicosis
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Dermatophytosis
• Microsporum sp., Trichophyton sp.
• Fungal hyphae and spores colonize hairs
• Folliculitis and furunculosis
• Lesions may be more subtle in cats and pustular disease may predominate
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Dermatophytosis
Courtesy of Dr. Marlan Fender
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Dermatophytosis
Courtesy of Dr. Marlan Fender
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Dermatophytosis
Fungal hyphae invade the hair shaft. Spores surround the hair. Hamster
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Habronemiasis
• Draschia megastoma, Habronemamicrostoma/majus, Habronema muscae
• Eosinophilic and granulomatous inflammation
• Larvae may be few in numbers
• May be diagnosed as “Equine eosinophilic granuloma” if no larvae are present
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Habronemiasis
Courtesy of Dr. Chris Reilly
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Habronemiasis
Courtesy of Dr. Chris Reilly
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Eyelid Margin
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Eyelid Margin
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Chalazion
• Meibomian adenitis
• Lipogranulomatous inflammation
• Secondary to leakage of meibomiansecretions, most often from neoplasia
• Macrophages and multinucleated giant cells
• Acicular cytoplasmic clefts on HE, refractile/birefringent material
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Chalazion
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Chalazion
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Chalazion
Courtesy of Dr. Chris Reilly
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Chalazion
Courtesy of Dr. Chris Reilly
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Idiopathic Marginal Blepharitis
• Dogs
• Sterile granuloma syndrome
• Granulomatous to pyogranulomatousinflammation
• Typically forms a mass effect, but can be poorly circumscribed or diffuse
• Can be bilateral.
• Unknown etiology
• No microorganisms (HE or special stains)
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Idiopathic Marginal Blepharitis
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Idiopathic Marginal Blepharitis
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Conjunctiva
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General Considerations
• The conjunctiva has limited ways in which it responds to injury
• Conjunctival biopsies rarely identify a specific cause for the conjunctivitis
• Only a few specific entities
• Biopsies are taken late in the disease process, often after treatment
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Conjunctival Overgrowth
• Rabbits• Pseudopterigium• Unknown cause• Hyperplastic conjunctival tissue• Normal tissue organization• Extends to cover the cornea• Does not invade and is not adhered to the cornea
• Note: true pterygium should have solar/actinic changes (ie solar elastosis +/‐ actinic keratosis) and will invade the cornea following dissolution of Bowman’s membrane
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Conjunctival Overgrowth
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Conjunctival Overgrowth
Courtesy of COPLOW
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Ligneous Conjunctivitis
• Doberman Pinscher, Yorkshire terrier, Golden Retriever, Scottish terrier
• Conjunctivitis, hard consistency, pseudomembranous exudate
• Subepithelial deposition of mostly acellular hyalinizedeosinophilic matrix
• PTAH positive, Congo red negative• Fibrin deposition in the conjunctiva, oral cavity,
esophagus and +/‐ glomeruli and other sites• Plasminogen deficiency in humans and some dogs
– Plasmin is fibrinolytic– PTAH positive (compatible with fibrin)
• Mason et al, JSAP, 2016; Mason et al, JSAP, 2012; Torres et al, VO 2009; McLean et al JAVMA, 2008; Ramsey et al, JAAHA , 1996
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Vet Ophthalmol. 2009 12(4):248‐5
Ligneous Conjunctivitis
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Ligneous Conjunctivitis
Courtesy of Dr. Chris Reilly
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Solar Elastosis, Fibrosis and Vasculopathy
• Conjunctiva, not cornea
• “Solar conjunctivitis”
• Overlaps with solar induced neoplasia
• Solar elastosis– Altered fibers within the superficial substantia propria
– New production +/‐ degradation of collagen and elastin
• Can form plaques in horses
• Often seen with conjunctival squamous cell carcinoma, hemangioma or hemangiosarcoma
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Solar Elastosis, Fibrosis and Vasculopathy
• Solar “fibrosis”
– Altered collagen, pale, hypocellular (sclerotic)
– Forms a band underlying the epithelium
– Not true fibrosis
• Solar vasculopathy
– Rare, more common in skin
– Thickened hyalin vessel walls
– May be endothelial swelling
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Solar Elastosis, Fibrosis and Vasculopathy
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Solar Elastosis, Fibrosis and Vasculopathy
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Solar Elastosis, Fibrosis and Vasculopathy
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Lymphoplasmacytic conjunctivitis
• Most common inflammatory response
• Does not suggest a specific etiology
• Infectious and non‐infectious causes
• Perivascular to diffuse
• Non‐ulcerative
• Can be severe enough to warrant concern for neoplasia
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Lymphoplasmacytic Conjunctivitis
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Lymphoplasmacytic Conjunctivitis
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Lipogranulomatous Conjunctivitis
• Cats
• Nodular inflammation
• Macrophages with lipid lakes, multinucleated giant cells may be present
• Can be associated with neoplasia
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Lipogranulomatous Conjunctivitis
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Lipogranulomatous Conjunctivitis
Courtesy of Dr. Chris Reilly
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Lipogranulomatous Conjunctivitis
Courtesy of Dr. Chris Reilly
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Triamcinolone Granuloma
• Macrophages and multinucleated giant cells
• Rounded rectangular vacuoles
• Rarely biopsied
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Triamcinolone Granuloma
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Triamcinolone Granuloma
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Triamcinolone Granuloma
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Triamcinolone Granuloma
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Nodular Granulomatous Episcleritis
• Episclerokeratitis, episcleritis, NGE
• Smooth nodules to diffuse thickening
• Most often in the limbal conjunctiva
• Also occurs in other conjunctival sites, orbit
• Unknown cause
• Epithelioid and spindle macrophages admixed with lymphocytes and plasma cells
• Some spindle cells are myofibroblasts
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Nodular Granulomatous Episcleritis
• The relative proportion of inflammatory cell types is highly variable
• The macrophages do not form distinct granulomas• Some cases may include multinucleated giant cells or
eosinophils• Cases with a predominance of spindle cells have been
called nodular fasciitis• Special stains for infectious organisms are always negative
(and must be) • The proportion of T‐cells and B‐cells has been said to be
predictive of response to treatment (B‐cell predominant were more refractory).
• Breaux et al. VO, 2007 (T vs B); Barnes et al, VO 2010 (orbit)
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Nodular Granulomatous Episcleritis
Courtesy of Dr. Chris Reilly
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Nodular Granulomatous Episcleritis
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Nodular Granulomatous Episcleritis
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Nodular Granulomatous Episcleritis
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Nodular Granulomatous Episcleritis
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Eosinophilic conjunctivitis
• Eosinophils are a component of the inflammation
• Eosinophils may not be the predominant cell type (lymphoplasmacytic)
• Perivascular to diffuse
• Allergic/ hypersensitivity disease
• Cannot exclude (or confirm) Herpesvirusinfection in cats
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Eosinophilic Conjunctivitis
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Eosinophilic Conjunctivitis
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Eosinophilic Conjunctivitis
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Herpes Keratoconjunctivitis
• Cats, primarily kittens
• Unlikely to be biopsied
• Window for inclusions is narrow
• May include eosinophils
• Role of Herpervirus in adult cats is controversial
• Clinical lesions suspected to be, diagnosed as, and treated for herpesviral infection lack any histologic evidence to specifically support a viral cause
• The presence of eosinophils is not a helpful feature as many hypersensitivity disease has eosinophils as a hallmark of the lesion
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Feline Herpes Keratoconjunctivitis
Courtesy of Dr. Chris ReillyTongue from a shelter cat
Inclusions
Syncytial cell
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Feline Herpes Keratoconjunctivitis
Skin from the face of a cat
Inclusions
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Feline Epitheliotropic MastocyticConjunctivitis
• Mast cells are numerous
• Mast cells infiltrate the surface epithelium
• Edema and papillary epithelial hyperplasia
• May be allergic
• Association with eosinophilic conjunctivitis?
• FHV‐1 is not a likely cause/factor
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Published in: B. Beckwith-Cohen; R. R. Dubielzig; D. J. Maggs; L. B. C. Teixeira; Vet Pathol 54, 141-146.DOI: 10.1177/0300985816653793 Copyright © 2016 American College of Veterinary Pathologists
Feline epitheliotropic mastocyticconjunctivitis
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Published in: B. Beckwith-Cohen; R. R. Dubielzig; D. J. Maggs; L. B. C. Teixeira; Vet Pathol 54, 141-146.DOI: 10.1177/0300985816653793Copyright © 2016 American College of Veterinary Pathologists
Feline epitheliotropic mastocyticconjunctivitis
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Conjunctival Histoplasmosis
• Histoplasma capsulatum
• Cats
• Subconjunctival nodules
• Pyogranulomatous inflammation
• Special stains (GMS) often needed to best visualize the organisms
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Conjunctival Histoplasmosis
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Conjunctival Histoplasmosis
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Conjunctival Histoplasmosis
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Conjunctival Histoplasmosis
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Conjunctival/Orbital Onchocerciasis
• Onchocerca lupi• Dogs and cats• Europe, Tunisia, Turkey, Iran, USA, Canada (USA)
• Subconjunctival or periscleral/orbital nodules• Granulomatous inflammation• Eosinophils may be present in large numbers, there may be fibrosis
• Parasites may not elicit severe inflammation
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Conjunctival/Orbital Onchocerciasis
• Must be differentiated from other nematodes with microfilariae
• Annular/circumferential ridges distinguish from Dirofilaria immitis
• Association with onchocerciasis and glaucoma in humans, unclear in dogs and cats
• Endosymbiotic bacteria Wolbachia• Larval development in blackflies• One report of aberrant location (larynx)
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Conjunctival/Orbital Onchocerciasis
• Canine• Hodzic A et al. Transbound Emerg Dis
2018• Colella V et al. PLoS Negl trop Dis 2018• McLean NJ et al. VO 2017• Verocai GG et al. Emerg Infect Dis 2016• Alho AM et al. Parasitol Int 2016• Miro G et al. Parasit Vectors 2016• Tudor et et al Parasitol Res 2016• Otranto D et al. Emerg Infect Dis 2015• Otranto D et al Parasit Vectors 2015• Otranto D et al. Emerg Infect Dis 2013• Labelle AL et al. Vet Parasitol, 2013
• Intraocular k9• Komnenou AT et al. VO 2016
• Feline• Labelle AL et al. VO 2011
• Review• Gracio AJ et al. Parasitol Res 2015
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Conjunctival/Orbital Onchocerciasis
Modified from : Am J Trop Med Hyg. 2013 Mar;88(3):601‐5
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Conjunctival/Orbital Onchocerciasis
Modified from : Parasit Vectors 2015
Feline cases
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Conjunctival/Orbital Onchocerciasis
Vet Ophthalmol.
2002 5(4):119‐26
Vet Ophthalmol. 2016 May;19(3):245‐249Emerg Infect Dis. 2015 21(5):868‐871
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Conjunctival/Orbital Onchocerciasis
Courtesy of COPLOW
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Conjunctival/Orbital Onchocerciasis
Courtesy of Dr. Chris Reilly
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Conjunctival/Orbital Onchocerciasis
Courtesy of COPLOW
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Conjunctival/Orbital Onchocerciasis
Feline
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Conjunctival/Orbital Onchocerciasis
Feline
Annular ridges
Striae
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Parasitic Conjunctivitis
• Histolopathologic findings are non‐specific• Unlikely to be biopsied
• Thelaziosis (Thelazia callipaeda)– Dogs, cats, rare (Europe)– Subclinical to severe, also keratitis– Papadopoulos E et al. Transbound Emerg Dis 2018– Seixas F et al. Vet Parasitol 2018
• Dirofilariasis (Dirofilaria repens)– Dogs, rare (Europe, UK)– Agapito D et a. J Small Anim Pract 2018– Graham‐Brown J et al. Vet Rec 2016
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Conjunctival thelaziosis
Papadopoulos E et al. Transbound EmergDis 2018.
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ORBIT
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Orbital extraocular polymyositis
• Affects all the extraocular muscles except the retractor bulbi muscle
• Rare disease, typically young dogs• Bilateral and variably symmetric exophthalmos,
retraction of the upper eyelid, and mild chemosis• Chronic: enophthalmos and strabismus• CD3+ predominant lymphocytic myositis with
myonecrosis• Attempts at regeneration with muscle atrophy and
fibrosis• Immune‐mediated attack directed specifically against
the extraocular muscles is suspected• Unlikely to be biopsied
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Orbital extraocular polymyositis
Courtesy of COPLOW
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Orbital lesions
• Abscesses
• Cysts
• Extension of disease at other sites
• Unlikely to be biopsied
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Orbital lesions
Goblet cells