—  SPECIALTY CONFERENCE HANDOUT  — Ophthalmic Pathology Wednesday, March 2, 2011, 7:30 PM CC 101 A/B Clinical histories are printed below. Click on the case numbers for text and references of each case. Click on each slide thumbnail image for an enlarged view Ophthalmic Pathology Classics Moderator: THOMAS J. CUMMINGS Duke University Medical Center Durham, NC Disclosure: In accordance with ACCME guidelines regarding disclosure, the USCAP policy requires that faculty members who have a significant financial or other relationship with a commercial company, entity, or service (which will be discussed in this Symposium) must disclose this to attendees. The Academy also requires that speakers disclose any products that are not labeled for the use under discussion. The speakers listed below have indicated they have nothing to disclose. Panelists: Patricia Chevez-Barrios, The Methodist Hospital, Houston, TX J. Douglas Cameron, Armed Forces Institute of Pathology, Washington, DC Diva R. Salomao, Mayo Clinic, Rochester, MN Codrin E. Iacob, The New York Medical College, New York, NY Sander R. Dubovy, Bascom Palmer Eye Institute, Miami, FL Clinical histories are displayed below. For the fastest viewing of virtual slides, click: under each thumbnail image below. You must have Aperio ImageScope installed on your PC. If you do not already have Aperio ImageScope, Windows users with administrator privileges may download and install a free version in order to view USCAP Virtual Slides. Click the icon on the right to get your free copy:   Or, click on slide thumbnail images to view each slide in a Web-based slide viewer, which is somewhat slower. If you have any difficulties viewing these slides, email or call George Clay at +1.724.449.1137. Case 1 - Click here for Text and References Submitted by: Patricia Chevez-Barrios - Clinical Summary: This is an 8-month-old male with history of leukocoria (white pupil) of the left eye noted by the mother 2 months prior to enucleation. Patient was seen by pediatrician and then by general ophthalmologist whom refer the patient to an ocular oncologist. The right eye was unremarkable. No treatment prior to enucleation was performed. Case 1 - Figure 1 Exophytic retinoblastoma occupying the subretinal space with chacky white calcifications Case 1 - Figure 2 Histologic section of the PO segment, geographic areas of necrosis contain multiple calcifications Case 1 - Figure 3 Sections of the two calottes in breadloaf fashion to examin more choroidal cut surfaces Case 1 - Figure 4 Retinoblastoma tumor (on top) associated with a fribroglial calcified tissue over an area of choroidal invasion Case 1 - Figure 5 Higher magnification of the invasive tumor in the choroid that replaces and spands the choroidal stroma Case 1 - Figure 6 The tumor contains Flexner-Wintersteiner (with holowed center) and Homer Wrigth rossettes (center filled by cytoplasmic proliferation) Case 1 - Figure 7 Tumor invades the prelaminar optic nerve region Case 1 - Figure 8 Freshly enucleated eye with a partial scleral window created to harvest fresh tissue Case 2 - Click here for Text and References Submitted by: J. Douglas Cameron - Clinical Summary: 78 year-old woman presenting with vitreous hemorrhage of the right eye. Subretinal hemorrhage was identified and thought to be due to subretinal neovascularization of age- related macular degeneration associated with a dense subretinal scar. The lesion increased in size. Ultrasound was not diagnostic, however, because of the risk of intraocular tumor the globe was enucleated. Pertinent Laboratory Data: Best corrected vision of the right eye was hand motions. The intraocular pressure was 21 mm Hg. Age-related macular degeneration was present in the left eye that had reduced her best corrected vision to 20/60. Case 2 - Figure 1 Striking spindle cell proliferation. Case 2 - Figure 2 Undulating growth of neoplastic cells, most of which have a spindle cell morphology. Case 2 - Figure 3 High-power view of prior illustrations showing focal vague tendency to form whorls. Case 2 - Figure 4 Uveal melanoma with typical overlying retinal detachment Case 2 - Figure 5 Densely cellular aggregates of spindle cells separated by a looser myxoid component. Case 2 - Figure 6 Whole-mount preparation of globe with uveal melanoma Case 3 - Click here for Text and References Submitted by: Diva R. Salomao - Clinical History: A previously healthy 47-year-old woman came to our institution for evaluation of a right orbital mass which was incidentally found during work-up for shortness of breath. A CTA to exclude pulmonary embolism incidentally revealed an orbital mass confirmed later by dedicated orbital imaging. Although at first, this orbital mass seemed to be asymptomatic, on further questioning the patient reported intermittent short lived blurry vision and episodic discomfort near the right temple for the past year. She denied any discrete ocular pain, diplopia, limitation of ocular movements or noticed proptosis. On clinical examination, a 4 mm proptosis was present and there was tenderness to palpation over the superior temporal aspect of the right orbit which appeared full but was not discolored. The clinical differential diagnosis based on the infiltrative appearance of the mass on MRI included lymphoma, favored due to the lack of symptoms, but also idiopathic orbital inflammation and sarcoidosis, given the history of cough. Case 3 - Figure 1 HE 100 X – Marked collagenized fibrosis with aggregates of small lymphocytes. The vessels in the middle of the field are not involved by the inflammation. Case 3 - Figure 2 HE 100 X – The process involves lacrimal gland tissue in addition to orbital soft tissues Case 3 - Figure 3 HE 200 X – Lacrimal gland involvement by marked fibrosis and chronic inflammation predominantly by lymphocytes Case 3 - Figure 4 HE 200 X – The process is causing acinar atrophy and replacement of the lacrimal gland tissue by fibrosis and inflammation Case 3 - Figure 5 CD 3 – The lymphocytic infiltrate is represented by a number of CD3+ T-cells Case 3 - Figure 6 CD 20 – The lymphocytic infiltrated shows numerous CD20+ B-cells that were polyclonal for Kappa and Lambda immunoglobulin light chain Case 4 - Click here for Text and References Submitted by: Codrin E. Iacob - Clinical Summary: A 53 year old African American male presented with a right medial canthus mass evolving over the past few months. Best corrected visual acuity was 20/20 in both eyes; visual field, pupillary exam, and ocular motility were within normal limits bilaterally. Imaging studies revealed a right anterior orbital pre-septal mass without sinus extension; SUV of 4.2 was noted in the lesion on PET-CT scan. The patient underwent excision of the mass followed by cryotherapy of the surgical bed and conjunctivoplasty using amniotic membrane grafting. Postoperatively, 60 Gy external beam radiotherapy was applied. Clinical and microscopic images of the lesion are presented. Case 4 - Figure 1 Thickened conjunctiva of caruncle due to proliferation of markedly atypical sebaceous cells which also involve underlying sebaceous glands of the caruncle. Also note subjacent lacrimal canaliculus with skeletal muscle rimming. Case 4 - Figure 2 Thickened conjunctiva of caruncle due to proliferation of markedly atypical sebaceous cells which also involve underlying sebaceous glands of the caruncle. Also note subjacent lacrimal canaliculus with skeletal muscle rimming. Case 4 - Figure 3 Thickened conjunctiva of caruncle due to proliferation of markedly atypical sebaceous cells which also involve underlying sebaceous glands of the caruncle. Also note subjacent lacrimal canaliculus with skeletal muscle rimming. Case 4 - Figure 4 Pagetoid intraepithelial spreading of atypical cells with marked nuclear pleomorphism and fair amount of clear cytoplasm. Case 4 - Figure 5 Pagetoid intraepithelial spreading of atypical cells with marked nuclear pleomorphism and fair amount of clear cytoplasm. Case 4 - Figure 6 High power view of the malignant neoplasm including brisk mitotic activity and areas of relatively well preserved intercellular bridging. Case 4 - Figure 7 Clinical images of the right canthal neoplasm. Case 4 - Figure 8 Clinical images of the right canthal neoplasm. Case 4 - Figure 9 Clinical images of the right canthal neoplasm. Case 5 - Click here for Text and References Submitted by: Sander R. Dubovy - Clinical Summary: This 84 year old male with a history of endophthalmitis in May, 2007 underwent pars plana vitrectomy and progressed to no light perception vision OD. The patient was lost to follow-up until the patient presented to BPEI on 9/14/07 with on week of decreased visual acuity, pain, and photophobia OS. Upon examination, the patient had a perforated corneal ulcer OD and multifocal exudative retinal detachments and disc edema OS. The patient's visual acuity was NLP OD and 20/200 OS. The patient now undergoes enucleation OD to rule out sympathetic ophthalmia. Case 5 - Figure 1 Case 5 - Figure 2 Case 5 - Figure 3 Case 5 - Figure 4 Case 5 - Figure 5 Case 5 - Figure 6 Case 5 - Figure 7 Case 5 - Figure 8 Case 5 - Figure 9 Case 5 - Figure 10 Case 5 - Figure 11 Case 5 - Figure 12 Handouts for all Specialty Conferences will be accessible via the "Educational Materials" section on the homepage the morning after each respective conference. Printed copies of the handout will not be available at the meeting.