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Introduction to Gross Pathologic Handling of Eye Specimens Charleen T. Chu, M.D., Ph.D. Division of Neuropathology University of Pittsburgh

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Presentation on theme: "Introduction to Gross Pathologic Handling of Eye Specimens Charleen T. Chu, M.D., Ph.D. Division of Neuropathology University of Pittsburgh"— Presentation transcript:

1 Introduction to Gross Pathologic Handling of Eye Specimens Charleen T. Chu, M.D., Ph.D. Division of Neuropathology University of Pittsburgh

2 Eye Pathology Overview ð Grossing corneas ðPenetrating transplants ðDSEK, DSAEK, Descemet’s membrane ð Small eye specimens (< 4 mm) ð Eviscerations ð Eyelid or conjunctival lesions ðOrient biopsy using surgical diagram or anatomical knowledge ð Grossing an eyeball or exenteration

3 Penetrating or anterior lamellar keratoplasty l The classic “corneal button” l A concave disc l Measure, describe focal lesions –Bisect near, but not through focal lesion, so it will not be lost on faceoff, but can be stepped into l Use a slicing motion that draws sharp new blade lightly across cornea –Do NOT use chopping motion – if cornea flattens, the inside or back membrane which often has the diagnostic pathology will break and pop off! Front epithelial surface

4 For histotechs: l Embed both halves on the cut surface from bisecting l Green arrows show proper direction of cutting as step levels are generated. –We need sections through the central cornea, not tangential sampling of the edge l Cornea protocol –Embed on both halves on cut edge made from bisecting –3 H&E step levels –1 PAS

5 Descemet’s Membrane l Transparent basement membrane peeled from back surface of cornea l Synonyms: DSEK, DSAEK (Descemet’s stripping and endothelial keratoplasty) l A sloppy surgeon may throw the donor cadaver button in the same container. –If you see a button, go ahead and gross it, but keep looking for the patient’s membrane

6 DSEKs 1. Hold container up to light and examine lid to identify transparent tissue 2. If not visualized, add drop of erythrosine to jar and look again. 3. Bisect if flat; leave it wadded up if not. 4. Wrap in tea bag after final erythrosine staining. 5. Two H&E step levels and a PAS is sufficient Histotechs: hold specimen in mold for a bit per Chris so paraffin cools around it before capping to prevent fall over

7 Corneal Biopsies Smaller than 4 mm in maximal dimension l Do NOT order cornea protocol or step levels – even if it is labeled “cornea” l Instead, use “Eye Biopsy” protocol for small specimens

8 Small eye specimens!!!! l Any specimen whose maximal dimension is <0.4 cm (4 mm), or has one dimension so small it may not survive processing. –Erythrosin mark –Submit wrapped in tea bag l Please order according to “Eye biopsy protocol” as described on next slide (would be nice if someone that knows how can help set up this as a protocol in copath)

9 Eye Biopsy Protocol (<4 mm) l Instruct histology to minimize faceoff l H&E l PAS l 4 blanks l HHE in middle l 4 blanks l HHE at end

10 © CT Chu, 2012 ALWAYS call Dr. Chu or Kofler before handling an oriented biopsy for the Eye bench 1.Determine closest margin Generally will section perpendicular to this 2.BEFORE cutting, flip over and ink deep surgical margins so that limbal margin (most important) can be distinguished from other margins.

11 Flip back over to lesion side and section Preferred: line up pieces in order from superior to inferior on glass slide and fix with 1% agarose Superior Limbal Or, submit superior sections in different block as inferior sections © CT Chu, 2012

12 Perpendicular vs. Shave Margins l The CORNEAL or LIMBAL margin is the most important margin. l Try to get neatly inked PERPENDICULAR sections to sample the corneal/limbal margin. Do not shave this margin. l Use the diagram to figure out which margin is closest to the cornea. In this case, the lateral margin is the corneal/limbal margin. Ink this margin a different color!

13 Wedge resection of eyelid Ink surgical margins Section perpendicular to closest margin Arrange on glass slide and use agarose to keep in order, OR submit central sections and different tips (ink color coded) in different blocks. Skin side Mucosal side Use your anatomy knowledge to orient this right upper lid nasal These should all go to ENT bench, but just for fun… © CT Chu, 2012

14 Submit sections of cornea-scleral ellipse and sections sampling different areas of the uveal-retinal sac. Order 1 H&E and 1 PAS per block The pigmented uveal layer lies immediately underneath the sclera and completely surrounds the retina Evisceration specimen

15 Orbital exenteration and enucleation Do not attempt to gross without direct supervision with Dr. Chu or Kofler © CT Chu, 2012

16 Grossing an eyeball l Identify and orient l Measure ~Big eyes ~Little eyes l Describe lesions ~size, radial (clockface) and A-P locations l Transillumination l Selecting plane to open eye l Internal anatomy and description of lesions ~?margins

17 © 2002 CT Chu Which eye is this? Where is the lesion?

18 For more information on Melanotic Lesions, See Blackboard on-line lectures and quizzes. “ Ophthalmic Pathology ” in the Neuropath series © 2002 CT Chu

19 Measure

20 Clockface radial location. Dimensions. A-P location. Distance from/involvement of key structures. Describe Lesions

21 Transillumination – turn off lights! © CT Chu, 2012

22 Opening eye Draw blade in slicing motion rather than exerting pressure. Do NOT tilt towards optic nerve. Edge must remain same distance from optic nerve as from pupil.

23 Can you identify each subcompartment of the eye and describe the pathology? © CT Chu, 2012

24 How should you sample margins for suspected retinoblastoma? A. Posterior vortex vein B. Optic nerve - transverse in a separate cassette C. Ink entire eye and submit as usual D. Trabecular meshwork

25 All of these are prognostic factors for uveal melanoma that should be reported, except: A. Largest base dimension (along sclera) and elevation into eye B. Invasion into sclera C. Pagetoid spread D. Epithelioid cytology E. Location in uveal tract – does it involve anterior angle/ciliary body/iris? F. Extension to surface of eye Pagetoid spread is of prime importance to conjunctival melanomas

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