Journal of Cytology
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Year : 2007  |  Volume : 24  |  Issue : 1  |  Page : 11-15
Introduction to ophthalmic cytology - modalities and classification of neoplasms

Department of Pathology, Medical College, Kota, Rajasthan, India

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Keywords: Ophthalmic cytology, modalities, classification of neoplasms

How to cite this article:
Rai N N. Introduction to ophthalmic cytology - modalities and classification of neoplasms. J Cytol 2007;24:11-5

How to cite this URL:
Rai N N. Introduction to ophthalmic cytology - modalities and classification of neoplasms. J Cytol [serial online] 2007 [cited 2021 Sep 21];24:11-5. Available from:

   Introduction Top

Ophthalmic pathology is unique in many respect­as it encompasses wide range of tissues - epithelia, connective tissue and specialized tissue; it offers exposed surfaces and fluid filled chambers for diagnosis; it shows wide range of infections and Neoplasia-some are variants of similar tumours that present elsewhere and other are unique to eye; tumours show a well differentiated morphology to an undifferentiated primitive small cell feature. Many Neoplastic conditions masquerade as or mimic other less aggressive Neoplastic or non-Neoplastic inflammatory conditions and needs differentiation before definitive therapy is planned. A general surgical pathologist and cytopathologist might be un-familiar with the terminology and have limited experience in ocular tumours. Ophthalmic Cytology as a special procedure has been in use since many years. It is useful when clinical examination and non-invasive techniques fail to establish the diagnosis and early diagnosis needed when a potentially aggressive disease warrants a prompt surgical/therapeutic decision. Innovations in sampling techniques using small caliber needles guided by precise Imaging modalities have made Cytology a relatively simple, safe and accurate technique. Aim of this Symposium is to provide Pathologists a comprehensive account of application and utility of cytological techniques in eye.

   Surface Cytology Techniques Top

External surface of eye includes eyelid skin, lid margin, conjunctiva and cornea. They are readily accessible for simple cytological procedures within reach of any ophthalmologist or cytopathologist. Further sophistication of these techniques has expanded the scope of diagnosis and research.

   Scrape Cytology Top

Ulcerated skin of eye-lid can be scraped safely and it gives better results than fine needle aspiration cytology (FNAC) in ulcerated basal cell carcinoma. It is recommended to combine FNAC with scrape cytology for any ulcerated lesions of eyelid skin and conjunctiva. [1] Scraping of conjunctiva and cornea for surface lesions is, to be done under local anesthesia. Scrape is done with spatula or scalpel blade. However for conjunctival and corneal surface lesions, use of modified small endo-cervical brush with short, soft bristles (Cytobrush, S-brush) is recommended. [2] A new type of brush with a spherical tip (Acellon-M) was described by Fujihara et al [3] which has improved cell collection from conjunctival epithelium when the target cells are in a limited area. Combined with flow cytometry, the technique provides an additional diagnostic or research tool.

   Impression Cytology Top

Impression cytology refers to the application of a cellulose acetate filter to the ocular surface to remove the superficial layers of the ocular surface epithelium, generally removing 2-3 layers, but deeper cells can be accessed by repeat application over the same site. After local anesthesia, a cellulose acetate strip is placed on the surface of conjunctiva/cornea using gentle pressure, carefully peeled off, fixed in alcohol and stained with Papanicolaou stain, H and E or Periodic acid schiff's stain. Material can also be subjected to histo-pathology. Modifications in techniques like use of Biopore membranes or by transferring impressions from cellulose acetate filter to a gelatin coated glass slide; have extended its use in transmission electron microscopy, polymerase chain reaction (PCR), flow­cytometry and immuno-histochemistry. [4] Its application include diagnosing a wide range of ocular surface disorders including ocular surface squamous neoplasia (OSSN), documenting sequential changes in the conjunctival and corneal surface over time, staging conjunctival squamous metaplasia, and monitoring effect of treatment. [5]

   Fine Needle Aspiration Cytology Top

FNAC is an efficient, economical and relatively safe method of diagnosis when non-invasive techniques fail to confirm or rule out the suspicion of malignancy. [6] It is advisable that except eye-lid, use of ophthalmic FNAC be restricted to centers where close co­operation is possible between ophthalmologist, cytopathologist and ophthalmic pathologist. [7]

Indications of Ophthalmic FNAC: FNAC is indicated in ophthalmic lesions in following situations. [1],[8]

  1. Pre-treatment assessment of suspected lid tumours, where poor operative selection by non­ophthalmologic surgeons and dermatologists is the rule.
  2. Pre-operative assessment of ocular or conjunctival melanosis where conservative management is advisable.
  3. Pre-treatment selection of patients with visible, palpable or imaged orbital masses where open biopsy or excision is often consequently rendered un-necessary and undesirable.
  4. Pre-operative assessment of uveal melanoma, where enucleation is being considered. Small melanomas prior to irradiation or laser therapy.
  5. Pre-operative diagnosis of suspected lacrimal gland tumours (to avoid incomplete excision and orbital recurrence).
  6. Pre-treatment selection of patients with visible, palpable or imaged orbital masses.
  7. Suspected metastatic lesion.
  8. Any intra-orbital mass in which possible hemorrhagic complication would not seriously preclude clinical selection of local excision, laser ablation or irradiation and follow-up.

Sampling Techniques of FNAC

Close co-operation with ophthalmologist and radiologist and familiarity with intricate anatomy of eye is required for successful sampling.

Eye-lid Skin and Conjunctival Lesions: Routine FNAC using 23-24 G needle; combined with scrape cytology for ulcerated lesions.

Intra-Orbital Lesions: FNAC with long retro­bulbar needle or lumbar puncture needle aided with ultrasonography or computed tomography guidance. Local anesthesia is required.

Intra-Ocular Lesions (excluding aqueous and vitreous): FNAC of eye is quite complex and requires specialized technique and an incision of the cornea or sclera.

(a) FNAC of Posterior Uveal Tumours:

Trans-vitreous pars plana approach: Partial thickness scleral incision given at pars plana. A flexible tube is employed between the end of 25 G 0.5 mm bore needle and a syringe attached to an aspiration pistol, thereby isolating any otherwise transmitted shake. Under direct visual control of an operating microscope and a corneal lens, needle inserted into tumour through trans­vitreous trans-retinal route avoiding any vessels. Small bore of needle does not cause vitreous aspiration and resultant retinal detachment. [7]

Direct Trans-scleral FNAC: of underlying choroidal tumour using triangular lamellar scleral flap. [7]

USG guided Transocular approach: -probe placed on closed eyelid at a meridian opposite to that of lesion. Needle introduced from the side opposite to that of probe. [9]

(b) FNAC of Anterior Uveal Tumours: USG guided paraocular approach - probe placed on closed eyelid between orbital rim and globe. Needle passed from above or from side of probe. [9]

(c) FNAC in Aphakik Eye : Limbal approach. [8]

Washings of needle in tissue culture fluid can be subjected to cytospin for making additional smears for IHC, cell button for EM and many other ancillary studies. Studies have shown that FNAC can reduce the need of intra-ocular biopsy and enucleation substantially- to fewer than 3%. [10] Traumatic complications produced by fine needle are infrequent and almost never serious and the concerns about tumour seeding have largely been dispelled by recent studies.

Ocular Fluid Cytology

Two chambers divide the interior of eye. Anterior aqueous chamber is located between cornea and lens, and enclosing iris within a thin fluid. Posterior chamber is located between lens and retina and filled with transparent viscous vitreous fluid (vitreous body). Exfoliated cells in these fluids can help in diagnosing inflammatory/non-neoplastic lesions as well as tumours.

Vitreous Fluid Cytology: Vitreous sample is obtained by aspiration or vitrectomy. Sample can be processed in many different ways: direct smears, Millipore filtration and cyto-centrifugation. Sample can also be processed for histology by direct paraffin embedding (of centrifuged specimen), sandwich agar technique and celloidin bag/cytoblock. Cytospin smears and cell block can be subjected to IHC, EM and FCM. [11],[12],[13] Cytodiagnosis of infection, hemorrhage, amyloidosis, retinal detachment and malignant tumours like lymphoma and melanoma is possible by vitreous fluid cytology. [14],[15]

Anterior Chamber Paracentesis Cytology: Anterior chamber paracentesis is a valuable procedure in the management of uveitis, particularly in diagnosing infective causes. It is also indicated in ghost-cell glaucoma, phacolytic glaucoma, epithelial downgrowth after anterior segment surgery; and suspected neoplasm (lymphoma, melanoma and retinoblastoma). [16],[17],[18] Needle ranging from 25 G to 30 G is used. After instilling antibiotic drops in eye, patient is positioned at slit lamp, upper lid eyelashes are held out of way by an assistant. 27 G needle is fitted to insulin syringe or aqueous pipette having a 30 G needle mounted inside plastic tubing and having a polyethylene suction-infusion bulb. This is then inserted in paralimbal clear cornea in a plane above and parallel to iris. Sample is drawn by suction of syringe or bulb under direct vision. Antibiotic drops prescribed for 3 days. Patient is re-examined after 20 minutes and 1-2 week. [16] Sample is immediately sent to cytology laboratory for making cytospin smears. It can be an effective and minimally invasive cytodiagnostic alternative to vitrectomy.

Intraoperative Cytology

Need of rapid Intra-operative diagnosis arises when a definitive pre-operative diagnosis is not available or is discrepant with clinical impression. It is also used when unusual clinical presentation create a diagnostic dilemma. Intra-operative FNAC is also being used, [6] but as in CNS lesions, imprint and squash cytology is a better rapid intra-operative procedure for ophthalmic lesions too. [13],[19],[20]

Imprint Cytology: Imprint of fresh unfixed tissue or it's cut section to be preferred for large, firm or hard tissues. Smears prepared by simply touching the slides with freshly cut surface of tissue. Smears are wet fixed and stained with H and E / Papanicolaou stain or air-dried and stained with MGG/Diff-Quick.

Squash Cytology: Squash Smears are preferred for soft crushable tissue. Tiny bit of tissue (<0.1 cm), cut or teased from biopsy are placed between 2 clean slides, pressed lightly and drawn apart. Rapidity of preparation and simplicity of technique are advantages of squash techniques over frozen section. The squash technique preserves the architectural and cytological details without the intrinsic problems of frozen section artifact. [19]

   Tumours of Eye and Ocular Adnexa: Classification Top

1. Tumours of the Conjunctiva

Epithelial Neoplasms

  • Papilloma
  • Keratoacanthoma
  • Hereditary Benign Intraepithelial Dyskeratosis

Other Benign Epithelial Lesions: Inclusion Cysts, Leukoplakia, Pseudo-epitheliomatous Hyperplasia Conjunctival Intraepithelial Neoplasia

Squamous Cell Carcinoma and variants

Other Carcinomas: Basal Cell Carcinoma, Sebaceous Carcinoma,

Lymphoepithelioma-Like Carcinoma

Melanocytic Tumours: Nevi and variants, Melanoses, Melanoma

Soft tissue Tumours

  • Embryonal Rhabdomyosarcoma, Botryoid subtype

Kaposi's Sarcoma

Lymphoid Tumours


Metastatic Tumours

Tumour-Like Congenital lesions : Dermoid, Dermolipoma, Hamartomas, Choristomas.

2. Tumours of Caruncle : Oncocytoma, Sebaceous gland hyperplasia, Sebaceous Carcinoma, Melanoma.

3. Tumours of Cornea : Benign Hereditary Intraepithelial dyskeratosis.

Intra-epithelial Neoplasia

Squamous Cell Carcinoma


4. Tumours of the Uveal Tract

Melanocytic Tumours of Uvea: Nevi, Melanocytoma (Megnocellular Nevus), Malignant Melanoma, Diffuse Uveal

Melanocytic Proliferation.

Non-Melanocytic Tumours of Uvea

Reactive Lymphoid Hyperplasia

Primary Non-Hodgkin's B-Cell Lymphoma Other

Secondary and Metastatic Tumours: Leukemia, Lymphoma, Plasmacytoma, Metastatic Tumours

5. Tumours of the Retina



Glial Tumours and Tumour-Like conditions: Astrocytoma, Astrocytic Hamartoma, Massive Gliosis of the Retina

Vascular Tumours

Melanogenic Neuroectodermal Tumour of the Retina

Lymphoid Malignancies

Primary Intraocular Lymphoma Leukemia

Tumours of the Retinal Pigment Epithelium: Adenoma, Adenocarcinoma

Metastatic Neoplasms

Neuroepithelial Tumours: Congenital Tumours of the Ciliary Epithelium, Benign Acquired Tumours of the Ciliary Epithelium

6. Tumours of the Optic Nerve and Optic Nerve Head


Juvenile Pilocytic Astrocytoma, Malignant



Melanocytoma, Primary Malignant Melanoma

Secondary and Metastatic Tumours


7. Tumours of the Eyelids

Benign Epithelial Tumours: Squamous Cell Papilloma, Seborrheic Keratosis, Inverted Follicular keratosis, Benign Lichenoid Keratosis, Large Cell Acanthoma, Pseudocarcinomatous Hyperplasia, Keratoacanthoma

Precancerous Epithelial Lesions: Actinic Keratosis, Bowen's Disease, Radiation Dermatosis, Xeroderma Pigmentosum

Malignant Epithelial Tumours:

Basal Cell Carcinoma, and variant

Squamous Cell Carcinoma, and variant

Melanocytic Tumours

Nevi, and variant

Malignant Melanoma, and variant

Benign Sebaceous Gland Tumours: Adenoma Adenoma of Krause's Accessory lacrimal gland

Sebaceous gland Carcinoma

Tumours of Eccrine and Apocrine Glands of the Eyelids: Syringoma, pleomorphic adenoma, Eccrine Acrospiroma, Primary Cutaneous Adenoid Cystic Carcinoma, Adenoma and Adenocarcinoma of Glands of Moll.

Tumours of the Pilar Structures of the Eyelid: trichoepithelioma, trichofolliculoma, trichilemmoma, Pilomatrixoma.

Adnexal Carcinoma

Vascular Tumours

Xanthomatous Lesions: Xanthelasma, Fibrous Histiocytoma and other Lipoid Proteinosis

Cysts: Dermoid, Epidermal Inclusion, Sudoriferous (apocrine and Eccrine hydrocystoma)

Miscellaneous Lesions: Mycosis Fungoides, Granular Cell Tumour, Merkel Cell Tumour, Metastatic Tumours, and other.

8. Tumours of the Lacrimal Gland

Benign Epithelial Tumours: Pleomorphic Adenoma, Oncocytoma, Warthin's Tumour, Myoepithelioma

Malignant Epithelial Tumours: Adenoid Cystic Carcinoma, Malignant mixed Tumour, Primary Adenocarcinoma, Mucoepidermoid Carcinoma, Primary ductal Adenocarcinoma, Acinic Cell Carcinoma, Sebaceous Carcinoma.

Lymphoid Tumours

Mesenchymal Tumours

Secondary and Metastatic Tumours

Tumour-Like Lesions: Chronic Dacryoadenitis, Benign Lympho-epithelial Lesions, Lacrimal Gland Cysts.

9. Tumours of the Lacrimal Drainage System

Epithelial Tumours (Papillomas and Carcinomas of Lacrimal Sac)

Non-Epithelial Tumours

10. Tumours of the Orbit

Fibrous Tumours

Lipomatous Tumours

Myogenic Tumours, including Rhabdomyo-


Vascular Tumours

Peripheral Nerve Sheath Tumours

Bone Tumours

Lymphoid Tumours

Reactive Lymphoid Hyperplasia Lymphoma

Orbital Plasmacytoma

Leukemic Disorders

Granulocytic Sarcoma

Histiocytosis: Langerhans Cell Histiocytosis Histiocytic Disorders of Mononuclear Phagocytes

Miscellaneous Orbital Tumours: Germ Cell Tumours, Choristoma, Melanoma, Carcinoid, Ewing's Sarcoma and P.N.E.T., Alveolar Soft Part Sarcoma

Secondary Tumours

Metastatic Tumours[22]

   References Top

1.Deery ARS : Eye and its adnexae. In: Fine needle aspiration cytopathology. Young JA, editor. London: Blackwell Scientific Publication; 1993. p. 282-91.  Back to cited text no. 1    
2.Tsubota K, Kajiwara K, Ugajin S, Hasegawa T. Conjunctival brush cytology. Acta Cytol 1990; 34: 233-5.  Back to cited text no. 2  [PUBMED]  
3.Fujihara T, Takeuchi T, Saito K, Kitajimi Y, Kobayashi TK, Tsubota K. Evaluation of human conjunctival epithelium by a combination of brush cytology and flow cytometry: An approach to the quantitative technique. Diagn Cytopathol 1997; 17:456-60.  Back to cited text no. 3    
4.Dart J. Impression cytology of the ocular surface-research tool or routine clinical investigation? Br J Ophthalmol 1997; 81: 930.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]
5.Singh R, Joseph A, Umapathy T, Tint NL and Dua HS. Impression cytology of the ocular surface. Br J of Ophthalmol 2005; 89:1655­9.  Back to cited text no. 5    
6.Midena E, Segato T, Piermarcchi S, Boccato P. Fine needle aspiration biopsy in ophthalmology. Surv Ophthalmol 1985; 29:410-22.  Back to cited text no. 6    
7.Augsburger JJ. Fine needle aspiration biopsy of suspected metastatic cancers of the posterior uvea. Trans Am Ophthalmol Soc 1988; 86: 499-560.  Back to cited text no. 7  [PUBMED]  [FULLTEXT]
8.Davey CC, Deery ARS. Through the eye of a needle: intra­ocular fine needle aspiration biopsy. Trans Am Ophthalmol Soc UK 1986; 105: 78-83.  Back to cited text no. 8    
9.Gupta S, Sood B, Gulati M, et al. Orbital mass lesions: US­guided fine needle aspiration biopsy-experience in 37 patients. Radiology 1999, 213:568-72.  Back to cited text no. 9  [PUBMED]  [FULLTEXT]
10.Robertson DM, Cambell RJ. Errors in diagnosis of malignant melanoma of the choroid. Am J Ophthalmol 1979; 87:269-275  Back to cited text no. 10    
11.Engel H., de la Cruz ZC, Jimenez-Abalahin LD, Green WR, Michels RG. Cytopreparatory techniques for eye fluid specimens obtained by vitrectomy. Acta Cytol 1982; 26: 551-60.  Back to cited text no. 11    
12.Martin F, Shepherd JC, Saornil MA, Aragon J, et al. Comparison of different techniques for cytologic analysis of vitreous specimens. Arch Soc Esp oftalmol 2001; 76:723-30.  Back to cited text no. 12    
13.Vemuganti GK, Murthy SI. A review of ophthalmic pathology techniques. Noida J Ophthalmol 2005; 2: 5-15.  Back to cited text no. 13    
14.Caya JG, Clowry LJ, Wollenberg NJ, Aaberg TM and Tieu TM. The clinicopathological significance of vitreous fluid cytology examinations in a series of 38 patients. Diagn Cytopathol 1985; 1: 267-71.  Back to cited text no. 14    
15.Farkas T, Harbour JW, Davila RM. Cytologic diagnosis of intraocular lymphoma in vitreous aspirates. Acta Cytol 2004; 48: 487-91.  Back to cited text no. 15    
16.Cheung CMG, Durrani OM and Murray PI. The safety of anterior chamber paracentesis in patients with uveitis. Brit J Ophthalmol 2004; 88:582-3.  Back to cited text no. 16    
17.Das DK, Das J, Chachra KL and Natrajan R. Diagnosis of retinoblastoma by fine needle aspiration and aqueous cytology. Diagn Cytopathol 1989; 5: 203-6.  Back to cited text no. 17    
18.Finger PT, Papp C, Latkany P, Kurli M and Iacob CE. Anterior chamber paracentesis cytology (cytospin technique) for the diagnosis of intraocular lymphoma. Brit J Ophthalmol 2006; 90:690-2.  Back to cited text no. 18    
19.Font RL, Lauciricia R and Ramzy I. Cytological evaluation of tumours of the orbit and ocular adnexa: an analysis of 84 cases studied by the "squash technique". Diagn Cytopathol 1994; 10: 135-42.  Back to cited text no. 19    
20.Vemuganti GK, Naik MN, Honavar SG, Chandra Shekhar G. Rapid intraoperative diagnosis of tumours of the eye and orbit by squash and imprint cytology. Ophthalmology 2004; 111: 1009-15.  Back to cited text no. 20    
21.Klintworth GK, Eagle Jr. RC. Eye and ocular adnexa. In: Damajanov I, Linder J, editors. Anderson's pathology vol.2.10th ed. St. Louis: Mosby; 1996. p. 2841-4.  Back to cited text no. 21    
22.Font RL, Croxatto JO, Rao NA,editors. Tumours of eye and ocular adnexa- AFIP atlas of tumour pathology. Series 4, no. 5. Washington: American Registry of Pathology: 2006.  Back to cited text no. 22    

Correspondence Address:
N N Rai
II/5, Medical College Campus, Rangbari Road. Kota, Rajasthan 324009
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0970-9371.42083

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