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Pathology of the Eyelids, Conjunctiva and Orbit

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Pathology of the Eyelids, Conjunctiva and Orbit Pathology of the Eyelids, Conjunctiva and Orbit Philippe Labelle, DVM, DACVP Antech Diagnostics 13th Biannual William Magrane Basic Science Course in Veterinary and Comparative Ophthalmology 1 Overview • Non‐neoplastic diseases of the eyelid skin • Non‐neoplastic diseases of the eyelid margin • Non‐neoplastic diseases of the conjunctiva 2 Eyelid/periocular skin 3 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) 4 Demodicosis • Demodex sp. • Juvenile and adult forms • Localized and generalized • Perivascular inflammation, periadnexal inflammation, folliculitis and furunculosis 5 Demodicosis 6 Demodicosis 7 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 8 Dermatophytosis Courtesy of Dr. Marlan Fender 9 Dermatophytosis Courtesy of Dr. Marlan Fender 10 Dermatophytosis Fungal hyphae invade the hair shaft. Spores surround the hair. Hamster 11 Habronemiasis • Draschia megastoma, Habronema microstoma/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 12 Habronemiasis Courtesy of Dr. Chris Reilly 13 Habronemiasis Courtesy of Dr. Chris Reilly 14 Eyelid Margin 15 Eyelid Margin 16 Chalazion • Meibomian adenitis • Lipogranulomatous inflammation • Secondary to leakage of meibomian secretions, most often from neoplasia • Macrophages and multinucleated giant cells • Acicular cytoplasmic clefts on HE, refractile/birefringent material 17 18 Chalazion 19 Chalazion 20 Chalazion Courtesy of Dr. Chris Reilly 21 Chalazion Courtesy of Dr. Chris Reilly 22 Idiopathic Marginal Blepharitis • Dogs • Sterile granuloma syndrome • Granulomatous to pyogranulomatous inflammation • Typically forms a mass effect, but can be poorly circumscribed or diffuse • Can be bilateral. • Unknown etiology • No microorganisms (HE or special stains) 23 Idiopathic Marginal Blepharitis 24 Idiopathic Marginal Blepharitis 25 Conjunctiva 26 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 27 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 28 Conjunctival Overgrowth 29 Conjunctival Overgrowth Courtesy of COPLOW 30 Ligneous Conjunctivitis • Doberman Pinscher, Yorkshire terrier, Golden Retriever, Scottish terrier • Conjunctivitis, hard consistency, pseudomembranous exudate • Subepithelial deposition of mostly acellular hyalinized eosinophilic 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 31 Ligneous Conjunctivitis Vet Ophthalmol. 2009 12(4):248‐5 32 Ligneous Conjunctivitis Courtesy of Dr. Chris Reilly 33 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 34 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 35 Solar Elastosis, Fibrosis and Vasculopathy 36 Solar Elastosis, Fibrosis and Vasculopathy 37 Solar Elastosis, Fibrosis and Vasculopathy 38 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 39 Lymphoplasmacytic Conjunctivitis 40 Lymphoplasmacytic Conjunctivitis 41 Lipogranulomatous Conjunctivitis • Cats • Nodular inflammation • Macrophages with lipid lakes, multinucleated giant cells may be present • Can be associated with neoplasia 42 Lipogranulomatous Conjunctivitis 43 Lipogranulomatous Conjunctivitis Courtesy of Dr. Chris Reilly 44 Lipogranulomatous Conjunctivitis Courtesy of Dr. Chris Reilly 45 Triamcinolone Granuloma • Macrophages and multinucleated giant cells • Rounded rectangular vacuoles • Rarely biopsied 46 Triamcinolone Granuloma 47 Triamcinolone Granuloma 48 Triamcinolone Granuloma 49 Triamcinolone Granuloma 50 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 51 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) 52 Nodular Granulomatous Episcleritis Courtesy of Dr. Chris Reilly 53 Nodular Granulomatous Episcleritis 54 Nodular Granulomatous Episcleritis 55 Nodular Granulomatous Episcleritis 56 Nodular Granulomatous Episcleritis 57 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) Herpesvirus infection in cats 58 Eosinophilic Conjunctivitis 59 Eosinophilic Conjunctivitis 60 Eosinophilic Conjunctivitis 61 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 62 Feline Herpes Keratoconjunctivitis Syncytial cell Inclusions Tongue from a shelter cat Courtesy of Dr. Chris Reilly 63 Feline Herpes Keratoconjunctivitis Skin from the face of a cat Inclusions 64 Feline Epitheliotropic Mastocytic Conjunctivitis • 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 65 Feline epitheliotropic mastocytic conjunctivitis 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 66 Feline epitheliotropic mastocytic conjunctivitis 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 67 Conjunctival Histoplasmosis • Histoplasma capsulatum • Cats • Subconjunctival nodules • Pyogranulomatous inflammation • Special stains (GMS) often needed to best visualize the organisms 68 Conjunctival Histoplasmosis 69 Conjunctival Histoplasmosis 70 Conjunctival Histoplasmosis 71 Conjunctival Histoplasmosis 72 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 73 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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