the pathologist’s approach to the vitreous...
TRANSCRIPT
![Page 1: The pathologist’s approach to the vitreous biopsycpo-media.net/ECP/2019/Congress-Presentations/1453/... · 2019-10-15 · The pathologist’s approach to the vitreous biopsy](https://reader033.vdocument.in/reader033/viewer/2022060302/5f088e557e708231d4229822/html5/thumbnails/1.jpg)
The pathologist’s approach to the vitreous biopsy
Sarah E CouplandGeorge Holt Chair in Pathology
Dept. of Molecular & Clinical Cancer MedicineInstitute of Translational Medicine, University of Liverpool, UK
![Page 2: The pathologist’s approach to the vitreous biopsycpo-media.net/ECP/2019/Congress-Presentations/1453/... · 2019-10-15 · The pathologist’s approach to the vitreous biopsy](https://reader033.vdocument.in/reader033/viewer/2022060302/5f088e557e708231d4229822/html5/thumbnails/2.jpg)
Normal Vitreous
•Composition: Hyaluronic acid, collagenous filaments
•Minimal cellular content: Hyalocytes, astrocytes and glial cells
![Page 3: The pathologist’s approach to the vitreous biopsycpo-media.net/ECP/2019/Congress-Presentations/1453/... · 2019-10-15 · The pathologist’s approach to the vitreous biopsy](https://reader033.vdocument.in/reader033/viewer/2022060302/5f088e557e708231d4229822/html5/thumbnails/3.jpg)
Vitreous opacities
Congenital
Acquired
Remnants of hyaloid vasculatur system (e.g. cysts)
Persistent hyperplastic primary vitreous
Endogenous: colloid coagula, crystalline deposits
Exogenous: protein coagula, amyloid, cells
Duke Elder
Chapter V, p322
![Page 4: The pathologist’s approach to the vitreous biopsycpo-media.net/ECP/2019/Congress-Presentations/1453/... · 2019-10-15 · The pathologist’s approach to the vitreous biopsy](https://reader033.vdocument.in/reader033/viewer/2022060302/5f088e557e708231d4229822/html5/thumbnails/4.jpg)
Vitreous opacities
Acquired
Inflammatory: Non-Infectious
Inflammatory: Infectious
Autoimmune
Degenerative
Traumatic
Neoplastic
Genetic
![Page 5: The pathologist’s approach to the vitreous biopsycpo-media.net/ECP/2019/Congress-Presentations/1453/... · 2019-10-15 · The pathologist’s approach to the vitreous biopsy](https://reader033.vdocument.in/reader033/viewer/2022060302/5f088e557e708231d4229822/html5/thumbnails/5.jpg)
Vitreous opacities
Acquired
Inflammatory: Non-Infectious
Inflammatory: Infectious
Autoimmune
Degenerative
Traumatic
Neoplastic
Pars planitis
Sarcoidosis
Behçets disease
Vogt-Koyanagi Harada
Juvenile xanthogranuloma
Genetic
![Page 6: The pathologist’s approach to the vitreous biopsycpo-media.net/ECP/2019/Congress-Presentations/1453/... · 2019-10-15 · The pathologist’s approach to the vitreous biopsy](https://reader033.vdocument.in/reader033/viewer/2022060302/5f088e557e708231d4229822/html5/thumbnails/6.jpg)
Vitreous opacities
Acquired
Inflammatory: Non-Infectious
Inflammatory: Infectious
Bacterial
Fungal
Viral
ParasiticAutoimmune
Degenerative
Traumatic
Neoplastic
Genetic
Spirochaetal
TBC
CMV
Fungal
Syphilis
Toxoplasmosis
![Page 7: The pathologist’s approach to the vitreous biopsycpo-media.net/ECP/2019/Congress-Presentations/1453/... · 2019-10-15 · The pathologist’s approach to the vitreous biopsy](https://reader033.vdocument.in/reader033/viewer/2022060302/5f088e557e708231d4229822/html5/thumbnails/7.jpg)
Vitreous opacities
Acquired
Inflammatory: Non-Infectious
Inflammatory: Infectious
Crohn’s disease
Multiple sclerosis
Autoimmune
Degenerative
Traumatic
Neoplastic
Genetic
Behçet’s disease
![Page 8: The pathologist’s approach to the vitreous biopsycpo-media.net/ECP/2019/Congress-Presentations/1453/... · 2019-10-15 · The pathologist’s approach to the vitreous biopsy](https://reader033.vdocument.in/reader033/viewer/2022060302/5f088e557e708231d4229822/html5/thumbnails/8.jpg)
Vitreous opacities
Acquired
Inflammatory: Non-Infectious
Inflammatory: Infectious
Amyloid
Autosomal dominant VR disorderse.g. Wagner-Stickler syndrome
Familial exudative vitreoretinopathy
Snowflake degeneration
Autoimmune
Degenerative
Traumatic
Neoplastic
Genetic
![Page 9: The pathologist’s approach to the vitreous biopsycpo-media.net/ECP/2019/Congress-Presentations/1453/... · 2019-10-15 · The pathologist’s approach to the vitreous biopsy](https://reader033.vdocument.in/reader033/viewer/2022060302/5f088e557e708231d4229822/html5/thumbnails/9.jpg)
Vitreous opacities
Acquired
Inflammatory: Non-Infectious
Inflammatory: Infectious
Degenerative
Traumatic
Neoplastic
Asteroid hyalosis
Synchysis scintillans
Haemorrhage
Vitreous detachment
Autoimmune
Genetic
Syneresis
Pigment granula
![Page 10: The pathologist’s approach to the vitreous biopsycpo-media.net/ECP/2019/Congress-Presentations/1453/... · 2019-10-15 · The pathologist’s approach to the vitreous biopsy](https://reader033.vdocument.in/reader033/viewer/2022060302/5f088e557e708231d4229822/html5/thumbnails/10.jpg)
Vitreous opacities
Acquired
Inflammatory: Non-Infectious
Inflammatory: Infectious
Post-operativee.g. Irvine Gass
Cellophane retina
Haemorrhage
Vitreous detachment
Degenerative
Traumatic
Neoplastic
Autoimmune
Genetic
Pigment granula
![Page 11: The pathologist’s approach to the vitreous biopsycpo-media.net/ECP/2019/Congress-Presentations/1453/... · 2019-10-15 · The pathologist’s approach to the vitreous biopsy](https://reader033.vdocument.in/reader033/viewer/2022060302/5f088e557e708231d4229822/html5/thumbnails/11.jpg)
Vitreous opacities
Acquired
Inflammatory: Non-Infectious
Inflammatory: Infectious
Autoimmune
Degenerative
Traumatic
Idiopathic
Neoplastic
Primary
Secondary
Retinoblastoma
Vitreoretinal lymphoma
Metastatic
cutaneous melanoma
Acute myeloid leukaemia
![Page 12: The pathologist’s approach to the vitreous biopsycpo-media.net/ECP/2019/Congress-Presentations/1453/... · 2019-10-15 · The pathologist’s approach to the vitreous biopsy](https://reader033.vdocument.in/reader033/viewer/2022060302/5f088e557e708231d4229822/html5/thumbnails/12.jpg)
• To identify the nature of an infectious /inflammatory process in vitreous
• To establish the aetiological agent causing the vitritis
• To confirm or refute the clinical impression of an intraocular malignancy
• To classify, subtype and grade the intraocular neoplasm
Pathologist‘s role in vitreous samples
![Page 13: The pathologist’s approach to the vitreous biopsycpo-media.net/ECP/2019/Congress-Presentations/1453/... · 2019-10-15 · The pathologist’s approach to the vitreous biopsy](https://reader033.vdocument.in/reader033/viewer/2022060302/5f088e557e708231d4229822/html5/thumbnails/13.jpg)
Vitreous/aqueous tap
Diagnostic vitrectomy
Chorioretinal biopsy
Subretinal aspirates
Ocular fluid sample types
![Page 14: The pathologist’s approach to the vitreous biopsycpo-media.net/ECP/2019/Congress-Presentations/1453/... · 2019-10-15 · The pathologist’s approach to the vitreous biopsy](https://reader033.vdocument.in/reader033/viewer/2022060302/5f088e557e708231d4229822/html5/thumbnails/14.jpg)
Glutaraldehyde
EM
CD20
Cytolyt, PreserveCyt, HOPE (fluid samples)
•Conventional stains
•Immunohistochemistry
•FISH(Fluorescence in situ hybridisation)
•PCR(Polymerase chain reaction)
•MLPA(Multiplex ligation probe-dependent
amplification) • MSA
(Microsatellite analysis)•CGH array
(Comparative genomic hybridisation array)
•SNP array(Single nucleotide polymorphism array)
Formalin (tissue Bx)
IgH-PCR
GeneScan
FISH
Fresh
•Microbiological analysis• Biochemical analysis•Gene expression profiling
Immunofluorescence
ELISA
GEP
Intraocular biopsies
![Page 15: The pathologist’s approach to the vitreous biopsycpo-media.net/ECP/2019/Congress-Presentations/1453/... · 2019-10-15 · The pathologist’s approach to the vitreous biopsy](https://reader033.vdocument.in/reader033/viewer/2022060302/5f088e557e708231d4229822/html5/thumbnails/15.jpg)
Pathologist‘s approach to vitreous samples
Inadequate sample
Adequate sample
Cytomorphology
Non-Cellular
Cellular
![Page 16: The pathologist’s approach to the vitreous biopsycpo-media.net/ECP/2019/Congress-Presentations/1453/... · 2019-10-15 · The pathologist’s approach to the vitreous biopsy](https://reader033.vdocument.in/reader033/viewer/2022060302/5f088e557e708231d4229822/html5/thumbnails/16.jpg)
Acellular Vitreous Samples
Conjunctival squames Vitreous condensed fibrils
Retained lens material Asteroid hyalosis
![Page 17: The pathologist’s approach to the vitreous biopsycpo-media.net/ECP/2019/Congress-Presentations/1453/... · 2019-10-15 · The pathologist’s approach to the vitreous biopsy](https://reader033.vdocument.in/reader033/viewer/2022060302/5f088e557e708231d4229822/html5/thumbnails/17.jpg)
![Page 18: The pathologist’s approach to the vitreous biopsycpo-media.net/ECP/2019/Congress-Presentations/1453/... · 2019-10-15 · The pathologist’s approach to the vitreous biopsy](https://reader033.vdocument.in/reader033/viewer/2022060302/5f088e557e708231d4229822/html5/thumbnails/18.jpg)
Synchisis scintillans
Cholesterol Crystals
![Page 19: The pathologist’s approach to the vitreous biopsycpo-media.net/ECP/2019/Congress-Presentations/1453/... · 2019-10-15 · The pathologist’s approach to the vitreous biopsy](https://reader033.vdocument.in/reader033/viewer/2022060302/5f088e557e708231d4229822/html5/thumbnails/19.jpg)
Cellular Vitreous Sample: Haemorrhage
Perl’s
![Page 20: The pathologist’s approach to the vitreous biopsycpo-media.net/ECP/2019/Congress-Presentations/1453/... · 2019-10-15 · The pathologist’s approach to the vitreous biopsy](https://reader033.vdocument.in/reader033/viewer/2022060302/5f088e557e708231d4229822/html5/thumbnails/20.jpg)
Inflammatory non-infectious, macrophage-poor vitritis
CD3
PAS
Immunocytology
Cultures
(IgH-PCR)
Chronic non-specific vitritis
![Page 21: The pathologist’s approach to the vitreous biopsycpo-media.net/ECP/2019/Congress-Presentations/1453/... · 2019-10-15 · The pathologist’s approach to the vitreous biopsy](https://reader033.vdocument.in/reader033/viewer/2022060302/5f088e557e708231d4229822/html5/thumbnails/21.jpg)
Inflammatory non-infectious, macrophage-rich vitritis
PAS stain - important to exclude cytoplasmic inclusions
DD: Whipple’s disease, Histoplasma capsulatum
CD68PAS
Giemsa
![Page 22: The pathologist’s approach to the vitreous biopsycpo-media.net/ECP/2019/Congress-Presentations/1453/... · 2019-10-15 · The pathologist’s approach to the vitreous biopsy](https://reader033.vdocument.in/reader033/viewer/2022060302/5f088e557e708231d4229822/html5/thumbnails/22.jpg)
Inflammatory non-infectious, granulomatous vitritis
ZNPASWSGrocott
Juvenile XanthogranulomatosisSarcoidosis
Chorioretinal
biopsy
Vitreous
CulturesPCR
![Page 23: The pathologist’s approach to the vitreous biopsycpo-media.net/ECP/2019/Congress-Presentations/1453/... · 2019-10-15 · The pathologist’s approach to the vitreous biopsy](https://reader033.vdocument.in/reader033/viewer/2022060302/5f088e557e708231d4229822/html5/thumbnails/23.jpg)
Inflammatory infectious, neutrophil-rich vitritis
Bacterial
HE HE
Grocott Gram
E. coliStaphylococcu aureusStreptococcus sp.Neisseria sp.P. acnes
e.g. Behçets disease
DD: Non-Bacterial
![Page 24: The pathologist’s approach to the vitreous biopsycpo-media.net/ECP/2019/Congress-Presentations/1453/... · 2019-10-15 · The pathologist’s approach to the vitreous biopsy](https://reader033.vdocument.in/reader033/viewer/2022060302/5f088e557e708231d4229822/html5/thumbnails/24.jpg)
Inflammatory infectious, eosinophil-rich vitritis
HEPapanicolou
DD:
Parasitic-induced endophthalmitis
Toxocara canis
Birdshot chorioretinopathy
(Chronic myeloid eosinophilic leukaemia)Borrelia burgdorferi.
HE
Levaditi
![Page 25: The pathologist’s approach to the vitreous biopsycpo-media.net/ECP/2019/Congress-Presentations/1453/... · 2019-10-15 · The pathologist’s approach to the vitreous biopsy](https://reader033.vdocument.in/reader033/viewer/2022060302/5f088e557e708231d4229822/html5/thumbnails/25.jpg)
Inflammatory infectious, granulomatous vitritis
Mycobacteria
Ziehl-Neelsen
Ziehl-Neelsen
Acid fast bacilli often found within macrophages and RPE
![Page 26: The pathologist’s approach to the vitreous biopsycpo-media.net/ECP/2019/Congress-Presentations/1453/... · 2019-10-15 · The pathologist’s approach to the vitreous biopsy](https://reader033.vdocument.in/reader033/viewer/2022060302/5f088e557e708231d4229822/html5/thumbnails/26.jpg)
Inflammatory infectious, (non)granulomatous vitritis
Candida sp.
Candida sp.
PAS PAS
Aspergillus sp.
PAS
![Page 27: The pathologist’s approach to the vitreous biopsycpo-media.net/ECP/2019/Congress-Presentations/1453/... · 2019-10-15 · The pathologist’s approach to the vitreous biopsy](https://reader033.vdocument.in/reader033/viewer/2022060302/5f088e557e708231d4229822/html5/thumbnails/27.jpg)
Inflammatory infectious viral vitritis/ chorioretinitis
Herpes simplex
virus
Immunofluorescence
Cytomegalovirus
CMV Ab
![Page 28: The pathologist’s approach to the vitreous biopsycpo-media.net/ECP/2019/Congress-Presentations/1453/... · 2019-10-15 · The pathologist’s approach to the vitreous biopsy](https://reader033.vdocument.in/reader033/viewer/2022060302/5f088e557e708231d4229822/html5/thumbnails/28.jpg)
Inflammatory infectious parasitic vitritis
Toxoplasmosis
MGG
![Page 29: The pathologist’s approach to the vitreous biopsycpo-media.net/ECP/2019/Congress-Presentations/1453/... · 2019-10-15 · The pathologist’s approach to the vitreous biopsy](https://reader033.vdocument.in/reader033/viewer/2022060302/5f088e557e708231d4229822/html5/thumbnails/29.jpg)
CD20 Ki-67MGG H&E
Barry RJ, et al. Br J Ophthalmol 2018
Vitreoretinal lymphoma
![Page 30: The pathologist’s approach to the vitreous biopsycpo-media.net/ECP/2019/Congress-Presentations/1453/... · 2019-10-15 · The pathologist’s approach to the vitreous biopsy](https://reader033.vdocument.in/reader033/viewer/2022060302/5f088e557e708231d4229822/html5/thumbnails/30.jpg)
• Flow cytometry
• ELISA
• IgH-PCR
• MYD88 mutational analysis
IgH-PCR GeneScan
Bonzheim et al., Blood 2015
IL10:IL6
+/- IFN-Gamma
Vitreoretinal lymphoma: adjunctive diagnostics
![Page 31: The pathologist’s approach to the vitreous biopsycpo-media.net/ECP/2019/Congress-Presentations/1453/... · 2019-10-15 · The pathologist’s approach to the vitreous biopsy](https://reader033.vdocument.in/reader033/viewer/2022060302/5f088e557e708231d4229822/html5/thumbnails/31.jpg)
• Flow cytometry
• ELISA
• IgH-PCR
• MYD88 mutational analysis
IgH-PCR GeneScan
Bonzheim et al., Blood 2015
IL10:IL6
+/- IFN-Gamma
JAMA Ophthalmol. 2018;136(10):1098-1104
Vitreoretinal lymphoma: adjunctive diagnostics
![Page 32: The pathologist’s approach to the vitreous biopsycpo-media.net/ECP/2019/Congress-Presentations/1453/... · 2019-10-15 · The pathologist’s approach to the vitreous biopsy](https://reader033.vdocument.in/reader033/viewer/2022060302/5f088e557e708231d4229822/html5/thumbnails/32.jpg)
• Flow cytometry
• ELISA
• IgH-PCR
• NGS panelse.g. MYD88, CDKN2A and AKT1
IL10:IL6
+/- IFN-Gamma
IgH-PCR GeneScan
Cani AK et al., Oncotarget, 2016
Bonzheim I, Fend F, Coupland SE et al: European Association Haematopathology Meeting 2018
MYD88, CD79B, PIM1, TBL1XR1, CARD11, IRF4, BTG1/2, PRDM1, CREBBP, IGLL5, ETV6
Vitreoretinal lymphoma: adjunctive diagnostics
![Page 33: The pathologist’s approach to the vitreous biopsycpo-media.net/ECP/2019/Congress-Presentations/1453/... · 2019-10-15 · The pathologist’s approach to the vitreous biopsy](https://reader033.vdocument.in/reader033/viewer/2022060302/5f088e557e708231d4229822/html5/thumbnails/33.jpg)
IL10:IL6
+/- IFN-g
IgH-PCR GeneScan
• Flow cytometry
• ELISA
• IgH-PCR
• MYD88 mutational analysis
• miRNAs
(miRs 19, 22, 92 and 155) Kakkassery V et al., 2016
Vitreoretinal lymphoma: adjunctive diagnostics
![Page 34: The pathologist’s approach to the vitreous biopsycpo-media.net/ECP/2019/Congress-Presentations/1453/... · 2019-10-15 · The pathologist’s approach to the vitreous biopsy](https://reader033.vdocument.in/reader033/viewer/2022060302/5f088e557e708231d4229822/html5/thumbnails/34.jpg)
Intraocular LymphomasPrimary
Secondary
Choroidal
Low grade B-cell ‘MALT’ Ly
Iridal
CD20High grade B-cell Ly
Choroidal infiltration: B-CLL
Retinal
Vitreoretinal
VitrealHigh grade B-cell Ly
![Page 35: The pathologist’s approach to the vitreous biopsycpo-media.net/ECP/2019/Congress-Presentations/1453/... · 2019-10-15 · The pathologist’s approach to the vitreous biopsy](https://reader033.vdocument.in/reader033/viewer/2022060302/5f088e557e708231d4229822/html5/thumbnails/35.jpg)
Vitreous Infiltrates: Neoplastic other
Primary
Retinoblastoma
Secondary
Met. cutaneous melanoma
Acute myeloidleukaemia
![Page 36: The pathologist’s approach to the vitreous biopsycpo-media.net/ECP/2019/Congress-Presentations/1453/... · 2019-10-15 · The pathologist’s approach to the vitreous biopsy](https://reader033.vdocument.in/reader033/viewer/2022060302/5f088e557e708231d4229822/html5/thumbnails/36.jpg)
Pathologist‘s findings in vitreous samples
Non-diagnostic !
Diagnostic
Cytomorphology
Non-Cellular
Cellular
![Page 37: The pathologist’s approach to the vitreous biopsycpo-media.net/ECP/2019/Congress-Presentations/1453/... · 2019-10-15 · The pathologist’s approach to the vitreous biopsy](https://reader033.vdocument.in/reader033/viewer/2022060302/5f088e557e708231d4229822/html5/thumbnails/37.jpg)
Cytomorphology
Immunocytology
Fresh
Fixed (Cytolyt; HOPE fixation medium)
Culture medium
CytospinsAgar cell blockFilter techniques
Vitreous Sample: insufficient for diagnosis!
Possible Causes
•Normal vitreous•Sampling error•Small sample and/or scanty cells•Prior steroid therapy •Loss of material in transport•Loss of material in processing•Insufficient material for all tests•Transport delays (Fri -> Mon)•Wrong fixative
![Page 38: The pathologist’s approach to the vitreous biopsycpo-media.net/ECP/2019/Congress-Presentations/1453/... · 2019-10-15 · The pathologist’s approach to the vitreous biopsy](https://reader033.vdocument.in/reader033/viewer/2022060302/5f088e557e708231d4229822/html5/thumbnails/38.jpg)
• Extensive DDx -> Essential = detailed history on request form
• Delicate specimens require proper and careful handling
• Close collaboration between clinicians, pathologists and microbiologists
• Experienced technical staff with up-to-date techniques
• Specialist expertise in assessing vitreous samples
Conclusions
“It used to be said that syphilis - particularly syphilitic chorioretinitis - was the mostcommon cause of exogenous opacities but, while they are numerous andpronounced in this disease, it by no means holds a monopoly”
(Duke Elder, page 360, Vol. XI)
![Page 39: The pathologist’s approach to the vitreous biopsycpo-media.net/ECP/2019/Congress-Presentations/1453/... · 2019-10-15 · The pathologist’s approach to the vitreous biopsy](https://reader033.vdocument.in/reader033/viewer/2022060302/5f088e557e708231d4229822/html5/thumbnails/39.jpg)
Some photographs courtesy of:Heinrich HeimannBertil DamatoNikolaos BechrakisMatthias BeckerNarsing RaoPaty Chevez-Barios
AcknowledgmentsSome scanned photographs from:“Diseases of the Ocular Fundus” Kanski, Milewski, Damato, Tanner“Retina and Vitreous” Federman, Gouras, Schubert, Slusher & Vrabec“Clinical Ophthalmology”, Kanski“Ocular Pathology” Yanoff and Fine“Atlas of Clinical Ophthalmology”, Spalton, Hitchings and Hunter