Keywords: Inflammation, non-neoplastic lesions, eye
|How to cite this article:|
Vemuganti G K. Inflammatory and non-neoplastic lesions of eyelids, eyeball and orbit. J Cytol 2007;24:26-30
| Introduction|| |
Cytologic diagnosis of lesions is one of the mainstays of diagnosis for lesions affecting various organs of the body. This speciality has made tremendous impact even in ophthalmic pathology, an upcoming subspecialty that has been referred by Fredrick Jokobiec as "queen of subspecialties of ophthalmology". The techniques of obtaining specimens of ocular cytology have undergone much refinement and with increasing reports of larger series of cases, the learning curve has been crossed by many experts. The specimens for ocular cytology are obtained from all the parts of the eye namely ocular surface, eyelid, eyeball and orbit. Based on the size of the lesion, location of the lesion, expertise available in the Institute (ophthalmologist, radiologist and the ophthalmic pathologist), the method of obtaining these samples would vary. In general, the techniques used for the lesions of various parts of the eye are as follows:
- Ocular surface lesions: Impression and scrape cytology, squash and imprint cytology of excised lesions.
- Eyelid lesions: Fine needle aspiration cytology (FNAC), scrape cytology, squash and imprint cytology.
- Intraocular lesions: Fine needle aspiration cytology of the specific lesions of choroid, iris, ciliary body, chorioretinal lesions. Vitreous biopsy for diagnosing lesions of vitreous, as well as of chorioretinal lesions as the lesional cells are expected to shed into vitreous and are of diagnostic value. Aqueous fluid is another sample, which could be subjected to cytology.
- Orbital lesions: Fine needle aspiration of palpable lesions or image guided FNAC, squash and imprint cytology of fresh tissue for rapid intraoperative diagnosis.
- Post-enucleation: Fine needle aspiration cytology, squash and imprint cytology to improve the cyto-histopathologic correlation.
This article outlines the inflammatory and nonneoplastic lesions of the eyelid, eyeball and orbit, the indications for doing the procedures, and cytology of the common lesions, and is inclusive of cytologic specimens obtained from different procedures.
| Cytology of Eye-Lid and Ocular Surface|| |
The lesions include those that present on the skin surface of the lid, the stroma as well as the conjunctival and subconjunctival aspect of the palpebral conjunctiva. The common lid lesions include the chalazion, inclusion cysts, retention cysts, parasitic cysts; however cytologic confirmation of these lesions is rarely required, except in cases of chalazion, which could mask the sebaceous cell carcinoma. The cytology specimens could be either from FNAC, scrape or squash and imprint smears.
| Lesions of Eyelid|| |
Chalazion: The smears show a polymorphic picture with neutrophils, plasma cells and macrophages. The granulomas are more of histiocytic cells with abundant vacuolated cytoplasm; the backround is generally dirty with nuclear debris and fat spaces. Dhaliwal et al  reported 16 patients with chalazia having an atypical clinical presentation that showed 2 broad patterns of granulomatous inflammation. One pattern had mixed-cell granulomas consisting of neutrophils, lymphocytes, plasma cells, macrophages, giant cells, and granulation tissue. Other cases were documented to have suppurating granulomas characterized by epithelioid cell granulomas with numerous neutrophils in a proteinaceous background. Fine needle aspiration cytology of chalazion could be considered for cases with atypical clinical presentation for reliable means of documenting the diagnosis and excluding malignancy.
Amyloidosis: Primary conjunctival amyloidosis is a rare entity and may mimic allergic or neoplastic etiology. It is a chronic disease commonly affecting the upper tarsal or forniceal conjunctiva. The clinical presentation may include lid swelling, ptosis, lagophthalmos, chronic discomfort, irritation, foreign body sensation and tear film abnormalities, papillary hyperplasia, flat raised mass and bleeding on touch, usually of prolonged onset. The clinical differential diagnosis includes: lymphoma, papilloma, viral conjunctivitis and allergic conditions. The squash of two of our conjunctival amyloidosis cases showed pink acellular matrix in the background surrounded by benign epithelial cells.  Histology confirmed the presence of abundant pink acellular masses of amyoid in conjunctiva and also within the vessel walls.
Xanthelasma: Scraping or FNAC from lesion show numerous foamy histiocytes with occasional multinucleated giant cells, neutrophils and cellular debris. Polarized microscopy may demonstrate birefringent cholesterol crystals. 
| Lesions of Conjunctiva and Cornea|| |
Viral Infections: Adenovirus and Herpes show intranuclear eosinophilic inclusions. Vaccinia virus show single eosinophilic cytoplasmic inclusion. 
Chlamydia trachomatis: results in Trachoma, involving conjunctiva and cornea; and is the most common cause of corneal opacification and blindness in developing world. In the United States, the Trachoma-Inclusion Conjunctivitis (TRIC) is the most common acute conjunctivitis in newborn, acquired during birth. Both show multiple small (0.5 cm) basophilic cytoplasmic inclusions with halo in infected conjunctival/corneal cells. Smears show many neutrophils, thick mucus and cellular debris. 
Allergic vernal conjunctivitis: Scrape/impression smears show eosinophils mixed with other inflammatory cells. Increase in goblet cells and presence of various foreign materials (of plant or mineral origin) has also been noticed. 
Acute Bacterial Conjunctivitis: shows abundant neutrophils with intracytoplasmic diplococci in Gonorrheal conjunctivitis, which is preventable in newborn with prophylactic antibiotics.
Mycotic infections like mucormycosis, candida and Aspergillus may infect cornea and cause loss of vision.
Parasites: Acanthamoeba keratitis is seen with increasing frequency, mainly in wearers of soft contact lenses. Early diagnosis and aggressive therapy is required to prevent blindness. Corneal scrapping smears show neutrophils, small spherical double walled cysts of parasite- may be seen in Papanicolaou stain, Gomori's methanamine silver method and by fluorescent technique.  Microsporidial keratitis, increasing in frequency because of HIV infection. Conjunctival scrape smear stained or seen under phase contrast, demonstrate intracellular protozoa. 
| Cytology of Intra-Ocular Lesions|| |
Unlike in other organs, intraocular cytology is done with extreme caution and apprehension. Intraocular cytology is not a routine procedure and is indicated only in atypical presentations where a clinical diagnosis could not be established. Intra-ocular FNAC is useful in selecting treatment for inconclusive intra-ocular disease by non-invasive techniques, where ultrasound findings are not completely consistent with the presumed diagnosis, in case of a large tumour in the only good eye and when requested by patient.  Though Augsburger et al  reported no complications or needle tract seeding in their series of intra-ocular FNAC, but Karcioglu  reported the histologic evidence of tumour cells in the needle track in 6 of 11 cases evaluated. Cytology specimens could also be obtained by squash/ imprint smears of eviscerated specimens. Transocular fine-needle aspiration biopsy is generally performed on selected patients in an institutional setup only.
| Vitreous Cytology|| |
Vitreous is the natural medium of the posterior segment. The common indications of vitreous biopsy include endoophthalmitis, uveitis, lymphoma, and masquerading syndromes. ,, The sample obtained from vitreous biopsy is generally very less, about 100150 microliters of fluid. The sample could be processed in milipore membrane filter, cytospin preparation, and if the sample could be spared, for cell block preparation.  Recent report describes the use of Herpes-glutamic acid buffer mediated organic solvent protection effect care (HOPE).  Care should be taken to send part of the specimens to microbiology diagnostic center since it is the mainstay of diagnosis of infectious diseases.
| Anterior Chamber Paracentesis and Aqueous Humour Cytology|| |
It has been found useful in the differential diagnosis of anterior chamber uveitis, phacoanaphylactic endoophthalmitis, chronic postoperative endoophthalmitis, phacolytic glaucoma, ghost cell glaucoma, post-traumatic lenticular abscess and specific iridocyclitis (tuberculous, rheumatoid). ,
Suppurative lesions/endophthalmitis: One of the important indications of intraocular biopsy / vitreous biopsy is to differentiate between opacities and space occupying lesions due to inflammatory and neoplastic lesions, which is not always possible using non-invasive techniques and imaging modalities. Whenever an infected etiology is suspected a sample of vitreous is always submitted to microbiology and for PCR studies
Fungal endophthalmitis: The FNAC or vitreous smears of suppurative inflammatory lesion show plenty of neutrophils with nuclear debris in the background. The Giemsa stained smears are usually very helpful and show fungal filaments. When in doubt, the same smears could be re-stained with Gomori's methalamine silver staining (GRO-PAP) technique to confirm the fungal filaments.
Chronic Granulomatous inflammation: Epithelioid cells seen singly or in clusters should raise the suspicion of granulomatous lesion. Special stains for AFB and GMS should be done to confirm or rule out myocabacterial and fungal etiology. Presence of eosinophils should raise the suspicion of parasitic lesions like toxocara, toxoplasmosis or cysticercosis.  Sometime a dead or live microfilaria can be seen in the vitreous aspirate. Presence of foreign body type of giant cells with phagocytosed material in cytoplasm is not uncommon. Giant cells with molded nuclei, and syncytial pattern should raise the suspicion of viral etiology. CMV inclusions could be seen in the vitreous cells, which could confirm the diagnosis.
Phacoanaphylactic endophthalmitis and Phacolytic glaucoma: Lens material, foamy histiocytes and neutrophils in vitreous or aqueous humour fluid confirms the diagnosis. The lens material is PAS positive and can be seen within the cytoplasm of histiocytes.
Ghost-cell glaucoma: show ghost erythrocytes in aqueous cytology.
Hemoglobulin spherulosis: hemorrhagic vitreous can be seen in traumatic conditions, bleeding disorders, metastatic disease or any other conditions. Old hemorrhage could pose diagnostic dilemma. In such cases, the vitreous aspirate show rounded acellular brown spherules, classical of hemglobulin spherulosis. 
Asteroid hyalosis: It is a condition in which minute white spherical particles, composed of calcium soap (asteroid bodies) are suspended in the vitreous, usually in the dependent part of the vitreous and cause vitreous opacification. Spherical bodies measure 3080 micrometers in diameter and show central birefringent crystalline particles. ,, These particles seldom cause serious visual symptoms; however, their presence can be a source of irritation. It has been suggested, but not confirmed, that asteroid hyalosis may be associated with systemic diseases such as diabetes, hyperlipidemia, or hypertension. Studies indicate that these particles are composed of lipid material and calcium; however, the specific composition and structure of asteroid bodies remains unknown.
Iris nodule with Hyphema: This is one of the common diagnostic dilemmas in children. Hyphema with an iris nodule could be seen in juvenile xanthogranuloma, metastatic lesions of leukemia, lymphoma, retinoblastoma seedlings, or in bleeding diathesis. Retinoblastoma would show clusters of tumour cells with nuclear molding. Iris granuloma would show clusters of epithelioid cells with occasional giant cells. The diagnosis is facilitated with the cellblock preparation. Leukemic deposits can well be identified in smear preparations specially stained by Giemsa or other Romanowsky stains.
Coat's Disease: Sediment from ocular aspirate contains numerous "pigmented bodies" of unknown derivation and cholesterol crystals. 
Retinal detachment: Fragments of Retina seen in vitreous aspirates.
| Cytology of orbit|| |
As already mentioned earlier the inflammatory lesions of eyelid and orbit share many characteristics of lesions seen elsewhere in the soft tissue compartments. Fine needle cytology of all infective lesions appears similar.
Orbitopalpabral cysts : Congenital orbitopalpabral cysts are seen as congenital cysts in the orbit associated with many other deformities of orbit and eye.  One of the modalities of treatment is aspiration of cyst and injecting a sclerosing agent so as to induce fibrosis and prevent recurrences. The fluid from such cysts shows cyst macrophages and nonspecific changes. Some of the cysts that are in communication with the intra-cranial structures may show cerebro-spinal fluid within the cysts. When suspected such fluid should be sent for chemical analysis. Presence of epithelial cells should raise a suspicion of inclusion cysts. Keratinised cells, anucleated squames and Cholesterol crystals are seen in dermoid or epidermal inclusion cysts.
Fungal granuloma: It is one of the common sinoorbital lesions mimicking a neoplastic lesion.  It is also one of the common indications of FNAC and squash imprint cytology of orbital lesions. The smears show large number of foreign body giant cells, usually disproportionate to the epithelioid granulomas. The background shows mixed inflammatory cells consisting of neutrophils, eosinophils, lymphocytes and plasma cells. Giant cells with prominent eosinophils should raise the suspicion of fungal granuloma in orbit.
Granulomatous Inflammations: Epithelioid granuloma with necrosis should raise a suspicion of mycobacterial infection and warrants AFB staining and PCR studies to confirm the diagnosis. Differential diagnosis includes sarcoidosis, parasitic cysts, eosinophilic granuloma, and inflammatory psuedotumour. Orbital lesions of temporal lesions, in and around the lacrimal gland regions invariably tend to involve the gland, specially the inflammatory pseudotumour, fungal granuloma, sarcoidosis, and Wegener's granulomatosis. Hence it is not unusual to find benign acinar cells or lacrimal gland origin in aspirates of orbital lesions. Histopathology is required for final confirmation in many of the lesions. Another important role of FNAC of lesions of uncertain etiology is regarding the decision to start steroids in the post-operative period. It is important to rule out fungal lesions and lymphoma so that the patients can be started on steroids to reduce the postoperative edema, pain and compression symptoms.
Parasitic Cysts: We saw 2 cases of hydatid cysts, which were confirmed by cytologic aspiration of cyst fluid, which shows the characteristic scolices. 
In summary, it is important for the general pathologists and cytologists to be aware of the lesions that occur in the eye and orbit, which could be similar to those, found in other systems, or is specific to eye and orbit
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G K Vemuganti
Ophthalmic Pathology Service, L V Prasad Eye Institute, LV Prasad Marg, Banjara Hills, Hyderabad - 500 003.
Source of Support: None, Conflict of Interest: None