Ocular Pathology Case Reviews - Azari, Amir (SRG) PDF

Ocular Pathology
Case Reviews
Executive Content Strategist: Russell Gabbedy
Senior Content Development Specialist: Sharon Nash
Senior Project Manager: Beula Christopher
Design: Miles Hitchen
Marketing Manager(s) (UK/USA): Gaynor Jones/Kathleen Reid
Ocular Pathology
Case Reviews
Amir A. Azari, MD
Clinical Assistant Professor
Wills Eye Institute
Jefferson Medical College of Thomas Jefferson University
Philadelphia, PA, USA
Daniel M. Albert, MD, MS

F.A. Davis Professor, Department of Ophthalmology and Visual Sciences, University of
Wisconsin School of Medicine and Public Health
Founding Director, University of Wisconsin McPherson Eye Research Institute
Madison, WI, USA
London,â•‡ New York,â•‡ Oxford,â•‡ Philadelphia,â•‡ St Louis,â•‡ Sydney,â•‡ Torontoâ•‡ 2015

© 2015, Elsevier Inc. All rights reserved.
No part of this publication may be reproduced or transmitted in any form or by any

means, electronic or mechanical, including photocopying, recording, or any
information storage and retrieval system, without permission in writing from the
publisher. Details on how to seek permission, further information about the
Publisher’s permissions policies and our arrangements with organizations such as the
Copyright Clearance Center and the Copyright Licensing Agency, can be found at our
website: www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under
copyright by the Publisher (other than as may be noted herein).
Notices
Knowledge and best practice in this field are constantly changing. As new research and
experience broaden our understanding, changes in research methods, professional
practices, or medical treatment may become necessary.
Practitioners and researchers must always rely on their own experience and
knowledge in evaluating and using any information, methods, compounds, or
experiments described herein. In using such information or methods they should be
mindful of their own safety and the safety of others, including parties for whom they
have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised
to check the most current information provided (i) on procedures featured or (ii) by
the manufacturer of each product to be administered, to verify the recommended dose
or formula, the method and duration of administration, and contraindications. It is
the responsibility of practitioners, relying on their own experience and knowledge of
their patients, to make diagnoses, to determine dosages and the best treatment for
each individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors,
or editors, assume any liability for any injury and/or damage to persons or property as
a matter of products liability, negligence or otherwise, or from any use or operation of
any methods, products, instructions, or ideas contained in the material herein.
Proudly sourced and uploaded by [StormRG]
ISBN: 978-0-323-28795-1 Kickass Torrents | TPB | ET | h33t
e-book ISBN: 978-0-323-28796-8

Printed in China
Last digit is the print number:â•‡ 9â•… 8â•… 7â•… 6â•… 5â•… 4â•… 3â•… 2â•… 1
The
publisher’s
policy is to use
paper manufactured
from sustainable forests
Contents
Preface vii
Acknowledgments ix
Dedication xi
CHAPTER 1: EYELID 1
CHAPTER 2: ORBIT AND OPTIC NERVE 83
CHAPTER 3: CORNEA AND CONJUNCTIVA 135
CHAPTER 4: UVEAL TRACT TUMORS 277
CHAPTER 5: RETINA AND VITREOUS 313
CHAPTER 6: GLAUCOMA AND OTHER DISORDERS 359
Index of Cases 401

Index 403
v
This page intentionally left blank
Preface
The goal of this book is to provide clinicians with the ability to look at images of the
important lesions of the eye and adnexa so they can more quickly and accurately make
the diagnosis. This facility is achieved by providing case studies with representative clin-
ical pictures, accompanied by the histopathological appearance of that lesion. As resi-
dents and fellows, we gain experience in “sight recognition” of lesions as viewed directly
on the lids and external surface of the eye or by slit-lamp, ophthalmoscope or an
imaging study. Some lesions are sufficiently distinctive to be diagnosed based on “sight
recognition” without analysis. Often, however, they suggest more than one possibility,
i.e., a differential diagnosis. Analysis of both the clinical evidence and histopathology is
necessary to make a final correct diagnosis.
This book highlights 200 frequently encountered or challenging examples of ocular
and adnexal disorders, together with their associated pathologic appearance. It attempts
to simulate what the clinician experiences when examining the patient in a clinical
setting, by presenting each case initially as an “unknown”, without specifically pointing
out to the reader the diagnostic, clinical, and pathologic features that characterize the
diagnosis. The reader must then analyze, on his or her own, the clinical or differential
diagnosis, and then the confirming pathologic diagnosis. Supporting pages for each
case present the same images accompanied by concise labels indicating the key points
to be noted in order to make the correct diagnosis. This enables the reader to determine
if his or her interpretation and diagnosis is accurate.
In this manner, utilizing self-instruction, Ocular Pathology Case Reviews enables oph-
thalmologists to recognize those features necessary to make correct diagnoses. With
repetition, his or her ability to analyze, interpret, and make that diagnosis is reinforced,
and the clinical appearance and histological features become correlated in a manner
closely approximating that of clinical experience.
Clinicians who have a firm grasp of the clinical–pathologic correlation are better able
to meet the challenges of everyday clinical practice, allowing for a high quality and more
enjoyable experience that ultimately benefits patients. Whether used as an initial learn-
ing tool, or as a method of review, the authors believe Ocular Pathology Case Reviews will
be an effective and enjoyable support to you in your practice of ophthalmology.
Amir A. Azari, MD
Daniel M. Albert, MD, MS
vii
Acknowledgments
The authors express their gratitude to Drs Mozghan Rezai Kanavi and Heather Potter for
their assistance and encouragement in compiling this book. Drs Neal Barney, Sarah
Nehls, Jason Sokol, and Justin Gottlieb generously helped in providing clinical
photographs. Laura Cruz and Patty Rasmussen provided valuable assistance in its
preparation. Vicky Rogness has meticulously prepared the high quality slides that are
used in this book. Russell Gabbedy, Executive Content Strategist, and Sharon Nash,
Senior Content Development Specialist, of Elsevier guided this book through the
editorial and publishing process with expertise, insight, and graciousness.
ix
Dedication
This book is dedicated to

our wives for their love, patience, and support
xi
Chapter 1â•…Eyelid CASE 1 â•…
A 67-year-old woman presented with a left lower eyelid lesion. Excisional biopsy of the lesion
demonstrates the histological findings shown below.
1
ANSWER â•… Case 1
Diagnosis:â•‡ Basal cell carcinoma.
Clinical description:â•‡ A raised telangiectatic lesion with associated madarosis is present in the left lower
eyelid.
Histological description:â•‡ Histopathology demonstrates tissue covered with keratinized stratified squamous
epithelium. The dermis contains cords, and islands of basaloid cells, which exhibit peripheral palisading of
their nuclei. A retraction artifact is seen.
Islands of basaloid cells
Peripheral
palisading of nuclei
Retraction
artifact
2
A 68-year-old woman presented with a red, itchy left lower eyelid lesion present for the past 3
months.
3
Diagnosis:â•‡ Actinic keratosis.
Clinical description:â•‡ A red, minimally elevated, scaly lesion at the margin of the left lower lid is
demonstrated.
Histological description:â•‡ Variable amounts of hyperkeratosis (increased thickness of the keratin layer),
parakeratosis (presence of nuclei in the keratin layer), and acanthosis (thickening of the prickle cell layer) is
seen. There is some atypia in the basal layer. Mild nongranulomatous inflammation is seen within the dermis.
Hyperkeratosis
Parakeratosis: presence
of many nuclei within
Nongranulomatous the keratin layer
inflammation
Nongranulomatous
inflammation
Solar elastosis
4
A 67-year-old woman presented with a 5-month history of a right eyelid lesion.
5
Diagnosis:â•‡ Squamous cell papilloma.
Clinical description:â•‡ Clinical examination reveals a partially keratinized papillomatous right upper eyelid
lesion.
Histological description:â•‡ Histopathology reveals a lesion covered by keratinized stratified squamous

epithelium and exhibiting acanthosis and papillary projections.
Keratin layer
Acanthotic skin
epithelium
Dermis
Pilar units
6
A 72-year-old woman presented with multiple eyelid lesions.
7
Diagnosis:â•‡ Verruca vulgaris.
Clinical description:â•‡ Clinical examination shows multiple keratinized lesions on the upper and lower
eyelids.
Histological description:â•‡ Histopathology reveals fronds of hyperkeratotic stratified squamous epithelium

lining a fibrovascular dermis.
Keratin
Keratin
Keratin
Fibrovascular core
8
A 61-year-old man presented with multiple skin tags. The skin tags were removed in the doctor’s
office.
9
Diagnosis:â•‡ Seborrheic keratosis (sessile).
Clinical description:â•‡ Multiple pigmented lesions with a “stuck-on” appearance are seen.
Histological description:â•‡ Histopathology reveals mildly acanthotic, keratinized, stratified squamous

epithelium with pseudohorn cysts (asterisks).
Surface keratin
Acanthotic, keratinized
*
* squamous epithelium
*
Dermis
Mild chronic nongranulomatous
inflammation
10
A 47-year-old woman presented with a left upper eyelid lesion. Excisional biopsy of the lesion showed
the following histological findings.
11
Diagnosis:â•‡ Xanthelasma.
Clinical description:â•‡ Clinical examination shows a yellow, elevated lesion on the left upper eyelid.
Histological description:â•‡ Histopathology reveals a collection of lipid-laden histiocytes within the dermis.
Skin epithelium
Foamy lipid-laden histiocytes

within the dermis
12
From Albert, Daniel M., Miller, Joan W., Azar, Dimitri T., and Blodi,
Barbara A. (eds). 2008. Albert & Jakobiec’s Principles and Practice of
Ophthalmology, 3rd ed. Philadelphia: Copyright Elsevier 2008.
A 62-year-old man presented with a left lower eyelid lesion.
13
Diagnosis:â•‡ Sebaceous cell adenoma.
Clinical description:â•‡ Clinical examination demonstrates a large cystic left lower eyelid lesion.
Histological description:â•‡ Histopathology demonstrates skin with keratinized squamous epithelium. In the
dermis, there are hyperplastic sebaceous glands forming multiple cavities containing proteinaceous material
(asterisks). Sebaceous adenoma of the skin may be associated with Muir–Torre syndrome.
Surface epithelium
*
*
* * *
*
*
*
*
14
The patient is a 48-year-old man with a 3-month history of a left lower eyelid lesion. The clinical
appearance is depicted above.
15
Diagnosis:â•‡ Inverted follicular keratosis.
Clinical description:â•‡ External examination reveals a keratinized left lower eyelid mass.
Histological description:â•‡ The excised lesion demonstrates hyperkeratosis, parakeratosis, and acanthosis. The
tissue has an overall inverted papillary pattern. Squamous eddies are seen.
Hyperkeratosis and
parakeratosis
Acanthosis
Squamous eddies
16
A 74-year-old woman presented with the skin changes seen above.
17
Diagnosis:â•‡ Rosacea.
Clinical description:â•‡ Facial and periocular erythema is noted.
Histological description:â•‡ Histopathology reveals keratinized, stratified squamous epithelium with

acanthosis and focal parakeratosis. Granulomatous inflammation surrounding some of the hair follicles is
present within the dermis.
Hair follicle Granulomatous

inflammation
18
A 57-year-old man presented with multiple pigmented lesions.
19
Diagnosis:â•‡ Seborrheic keratosis (papillomatous).
Clinical description:â•‡ Multiple brown skin tags in the left lower lid can be seen.
Histological description:â•‡ Histopathology reveals tissue lined by keratinized stratified squamous epithelium
with a few pilosebaceous units and focal basal epithelial pigmentation. There is hyperkeratosis and
papillomatous acanthosis. Scattered pseudohorn cysts (asterisks) are also present. Focal areas of chronic
inflammation are noted in the dermis.
*
*
Basal epithelial
pigmentation
Focal areas of
inflammation
20
A 53-year-old man presented with a 3-month history of a left lower eyelid lesion.
21
Diagnosis:â•‡ Keratoacanthoma.
Clinical description:â•‡ Histopathology reveals a skin lesion with central crater filled with keratin. The edges of
the lesion are rolled-up and elevated.
Histological description:â•‡ Histopathological evaluation reveals a keratinized stratified squamous surface

epithelium with a crater-shaped endophytic lesion filled with keratin. Acanthosis and parakeratosis are present.
Mild atypia and a few mitotic figures are noted.
Normal skin
epithelium
Central mass of Central mass of

keratin keratin
Acanthosis
Acanthosis
Normal skin
epithelium
22
From Albert, Daniel M., Miller, Joan W., Azar, Dimitri T., and Blodi, Barbara A. (eds). 2008. Albert
& Jakobiec’s Principles and Practice of Ophthalmology, 3rd ed. Philadelphia: Copyright Elsevier 2008.
An 81-year-old man presented with an enlarging lesion on his left brow.
23
Diagnosis:â•‡ Squamous cell carcinoma in situ.
Clinical description:â•‡ Clinical examination reveals an erythematous lesion with scaling.
Histological description:â•‡ Sections through the specimen show a thickened, keratinized, stratified squamous
epithelium with marked hyperkeratosis and parakeratosis. Nests of malignant squamous cells are present
(asterisks). Intraepithelial keratin pearls are also seen (short arrow).
Skin epithelium
Acanthosis
*
*
24
& Jakobiec’s Principles and Practice of Ophthalmology, 3rd ed. Philadelphia: Copyright Elsevier.
2008.
A 67-year-old man presented with a 3-month history of an eyelid lesion.
25
Diagnosis:â•‡ Invasive squamous cell carcinoma.
Clinical description:â•‡ Clinical examination reveals an ulcerated and scarred right upper eyelid lesion.
Histological description:â•‡ Sections through the specimen show keratinized, stratified squamous epithelium.
Nests of malignant squamous cells infiltrate the dermis (asterisks). Keratin pearls are also present (arrows).
Surface epithelium
* *
*
* *
26
A 69-year-old woman presented with an ulcerated skin lesion. She underwent excisional biopsy.
27
Diagnosis:â•‡ Morpheaform basal cell carcinoma.
Clinical description:â•‡ Clinical examination reveals an ulcerated left lower eyelid lesion.
Histological description:â•‡ Histopathology demonstrates keratinized stratified squamous epithelium overlying

a dermis infiltrated with bands and cords of flattened tumor cells.
Keratinized
surface
epithelium
Hair follicle
Cords of tumor cells
Sclerosed
dermis
28
Courtesy of Shahed Ghoghawala M.D. University of Wisconsin-Madison.
A 66-year-old man presented with a right lower eyelid lesion. The lesion had been present for over a
year and was increasing in size.
29
Diagnosis:â•‡ Sebaceous cell carcinoma with pagetoid spread.
Clinical description:â•‡ Clinical examination reveals cystic lesions in the right lower eyelid with an associated
madarosis.
Histological description:â•‡ Histopathology reveals tissue lined by keratinized stratified squamous epithelium.
Cords and lobules of foamy cells lined by basaloid cells are present within the dermis and subepithelium and
infiltrate into the epithelium (pagetoid spread). Higher magnification (bottom) demonstrates the foamy cells
in more detail.
Early pagetoid
spread
Foamy cells lined by
basaloid cells
30
A 65-year-old man presented with several pigmented nodules present on his upper and lower left
eyelids.
31
Diagnosis:â•‡ Pigmented basal cell carcinoma.
Clinical description:â•‡ Ulcerated left lower eyelid lesion surrounded by a few pigmented nodular lesions is
seen. A few pigmented lesions are also present in the left upper eyelid.
Histological description:â•‡ Histopathology reveals tissue lined by keratinized stratified squamous epithelium.
There are extensive islands of atypical basaloid cells with high nuclear to cytoplasmic ratio in the dermis. The
islands demonstrate peripheral palisading and retraction artifact (arrow). Dense pigmentation is present.
Differentiation from melanoma was confirmed on bleach sections (not shown).
32
& Jakobiec’s Principles and Practice of Ophthalmology, 3rd ed. Philadelphia. Copyright Elsevier 2008.
An 81-year-old man presented with eyelid lesions.
33
Diagnosis:â•‡ Merkel cell carcinoma.
Clinical description:â•‡ Slit-lamp examination demonstrates two elevated eyelid nodules in the right lower lid.
Histological description:â•‡ Histopathological examination reveals a skin with keratinized stratified squamous
epithelium. In the dermis, there are sheets of atypical and pleomorphic cells with finely dispersed chromatin
and inconspicuous nucleoli.
Keratinized skin
epithelium
Dermis infiltrated with atypical and pleomorphic cells
34
A 72-year-old man presented with a 6-month history of a growing eyelid mass.
35
Diagnosis:â•‡ Eccrine hidrocystoma.
Clinical description:â•‡ Clinical examination shows a large, translucent fluid-filled eyelid cyst.
Histological description:â•‡ Multilocular branching lumen (asterisks) filled with eosinophilic material is seen
on histopathology. The lumen is lined by a double layer of epithelium. No apical snouts are seen.
*
*
Lumen filled with
eosinophilic material
Dual epithelial
lining
36
A 53-year-old man presented with multiple cystic lesions in the medial canthus and upper eyelid. He
underwent excisional biopsy of the lesions.
37
Diagnosis:â•‡ Apocrine hidrocystoma.
Clinical description:â•‡ Multiple fluid filled, translucent vesicles in the medial canthus and upper eyelid.
Histological description:â•‡ Large intradermal cystic cavity lined by a double epithelial layer. The innermost
cells display apical snouts (decapitation bodies).
Surface
epithelium of skin
Intradermal
cystic cavity
Epithelial lining
Dual epithelial Apical snouts

lining
38
A 58-year-old man presented with a slow-growing right lower eyelid lesion. He later underwent an
excisional biopsy of the lesion.
39
Diagnosis:â•‡ Epithelial inclusion cyst.
Clinical description:â•‡ Raised white/opaque lesion is seen in the right lower eyelid margin.
Histological description:â•‡ Large cystic space lined by keratinized stratified squamous epithelium is seen
within the dermis. Unlike dermoid cysts, the epithelial lining does not have pilosebaceous units.
Surface epithelium of the

overlying skin
Cystic space
Keratinized stratified squamous

epithelial lining of the cyst
Cystic space
40
The patient is a 21-year-old woman who presented with multiple skin lesions under the right lower
eyelid.
41
Diagnosis:â•‡ Syringoma.
Clinical description:â•‡ Multiple flesh-colored skin lesions are seen.
Histological description:â•‡ Histopathology reveals keratinized stratified squamous epithelium overlying

numerous single and double-layered epithelial strands with cysts (asterisks) and some with “tadpole
configuration” (arrowheads) present throughout the dermis.
*
*
42
A 35-year-old woman presented with a 3-month history of an eyelid lesion.
43
Diagnosis:â•‡ Infundibular cyst.
Clinical description:â•‡ Clinical examination reveals a subcutaneous mass in the right upper eyelid.
Histological description:â•‡ The slides reveal tissue lined by a keratinized stratified squamous epithelium. A
follicular infundibular structure, filled with keratin, is seen within the dermis (circle).
Mild inflammation Keratin Surface epithelium
Dermis
44
An 84-year-old female presented with a 6-month history of a left upper eyelid lesion.
45
Diagnosis:â•‡ Pilomatrixoma.
Clinical description:â•‡ A raised, nodular lesion, with a few dilated vessels, is seen in the left upper eyelid.
Histological description:â•‡ Histopathology demonstrates islands of shadow cells and basophilic cells
intermixed with numerous epithelioid histiocytes. Calcium is present.
Calcification
Epithelioid histiocytes
Shadow cells
Basophilic cells
46
A 76-year-old woman presented with a rapidly growing left lower eyelid lesion.
47
Diagnosis:â•‡ Trichoepithelioma.
Clinical description:â•‡ A raised pearly lesion with a smooth surface is noted.
Histological description:â•‡ The slides reveal stratified squamous epithelium overlying a dermis with multiple
small nests of basaloid cells with peripheral palisading of their nuclei (asterisks).
Surface epithelium
* *
48
A 35-year-old woman presented with a 3-month history of an eyelid lesion.
49
Diagnosis:â•‡ Trichofolliculoma.
Clinical description:â•‡ Clinical examination reveals a cystic lesion in the right upper eyelid with a wisp of
lanugo hairs emanating from it.
Histological description:â•‡ The slides reveal tissue lined by a keratinized stratified squamous epithelium. A
follicular infundibular structure, surrounded by multiple small follicles (asterisks), containing keratin, and
communicating with the skin surface can be seen.
Area of communication
with surface *
*
50
A 43-year-old woman presented with a nodular right lower eyelid lesion.
51
Diagnosis:â•‡ Trichilemmoma.
Clinical description:â•‡ Clinical examination reveals a round, nodular, flesh-colored right lower eyelid skin
lesion.
Histological description:â•‡ The histopathology reveals hyperkeratotic stratified squamous epithelium with
marked parakeratosis and acanthosis. Areas of well-defined and plate-like clear cells (asterisk) and epithelial
down-growth into the dermis are seen. Areas of palisading are also seen.
Acanthosis
Peripheral palisading
52
An 18-year-old man presented with a 1-week history of a right upper eyelid nodule refractory to
treatment with warm compress and eyelid massage.
53
Diagnosis:â•‡ Chalazion.
Clinical description:â•‡ A red, elevated right upper eyelid mass is seen.
Histological description:â•‡ Granulomatous and nongranulomatous chronic inflammation is seen surrounding

a large lipid vacuole. Multinucleated giant cells are also seen.
Nongranulomatous
chronic inflammation
Lipid
vacuole
Multinucleated giant cell

Granulomatous
inflammation
54
A 38-year-old woman presented with multiple eyelid skin lesions.
55
Diagnosis:â•‡ Molluscum contagiosum.
Clinical description:â•‡ Clinical examination reveals multiple pearly flesh-colored dome-shaped lesions.
Histological description:â•‡ Histopathology reveals a discrete dome-shaped lesion with an umbilicated center.
Pear-shaped acanthotic lobules of epithelial cells filled with eosinophilic intracytoplasmic inclusion bodies
(Henderson–Patterson corpuscles) are seen. The inclusion bodies (circles) are deeply eosinophilic in the lower
cells and become less eosinophilic towards the level of the granular layer.
Acanthotic lobules of
epithelial cells
56
A 58-year-old woman presented with a right lower eyelid lesion. Excisional biopsy of the lesion shows
the following histological findings.
57
Diagnosis:â•‡ Intradermal nevus.
Clinical description:â•‡ Clinical examination reveals a pearly, flesh-colored, well-circumscribed raised lesion.
Histological description:â•‡ Histopathology reveals nests of benign melanocytic cells confined to the dermis. A
cell free region known as the “grenz zone” is seen beneath the epithelium.
Epithelium
Grenz zone
Nests of nevus cells within the dermis
58
A 33-year-old woman presented with an eyelid lesion. The lesion was removed and evaluated
histopathologically.
59
Diagnosis:â•‡ Compound nevus.
Clinical description:â•‡ A mostly flat, darkly pigmented lesion at the margin of the left lower eyelid is noted.
Histological description:â•‡ Nests and nodules of ovoid basaloid cells are present within the dermis as well as
at the junction between the epidermis and the dermis.
Keratinized stratified
squamous epithelium
of the skin (epidermis)
Junctional component
Dermal component of of the nevus
the nevus
Pilosebaceous units
60
A 62-year-old woman presented with a pigmented lesion in the right lower eyelid.
61
Diagnosis:â•‡ Malignant melanoma of the eyelid.
Clinical description:â•‡ Clinical examination reveals a slightly raised pigmented skin lesion.
Histological description:â•‡ Histopathology demonstrates skin infiltrated with pigmented atypical melanocytes
(arrows) consistent with melanoma.
62
Courtesy of Neal P. Barney, M.D. University of Wisconsin-Madison
A 44-year-old obese male presented with dry, irritated eyes.
63
Diagnosis:â•‡ Floppy eyelid syndrome.
Clinical description:â•‡ Upper eyelid laxity is apparent. The tarsal conjunctiva has a velvety appearance.
Histological description:â•‡ Biopsy shows multiple conjunctival papillae marked by elevated nodules
infiltrated with inflammatory cells (arrows) and containing fronds of vascular core (arrowheads).
Meibomian glands
within the tarsus
64
A 63-year-old man presented with a chief complaint of droopy eyelids. He underwent a functional
blepharoplasty.
65
Diagnosis:â•‡ Dermatochalasis.
Clinical description:â•‡ Bilateral ptosis and redundancy of the upper eyelid skin is noted on clinical
examination.
Histological description:â•‡ Histopathology reveals keratinized stratified squamous epithelium with associated
pilosebaceous units overlying a dermis with loosely arranged collagen fibers.
squamous epithelium Sebaceous gland
Pilar unit
Loosely arranged collagen fibers
66
A 3-year-old child was brought in by his mother for evaluation of abnormal eyelids.
67
Diagnosis:â•‡ Entropion with normal histology.
Clinical description:â•‡ Clinical examination demonstrates bilateral lower eyelid entropion.
Histological description:â•‡ The slides reveal tissue lined by keratinized stratified squamous epithelium with
associated pilosebaceous units, muscle, and fat (normal skin).
Keratinized squamous
epithelium
Pilar unit
Dermis
Striated muscles
68
A 44-year-old man presented with an eyelid lesion. The lesion had been present for many years
causing severe ptosis.
69
Diagnosis:â•‡ Cavernous hemangioma of the eyelid.
Clinical description:â•‡ Clinical examination shows a corrugated, reddish-purple elevated right upper eyelid
lesion.
Histological description:â•‡ Histopathology shows large, dilated vascular channels that are lined by a single
layer of flat endothelium. The vascular channels are filled with red blood cells.
Dilated vascular channels
Intervening septae
Endothelial lining
70
The patient is a 58-year-old woman who presented with a right upper eyelid lesion.
71
Diagnosis:â•‡ Eyelid varix.
Clinical description:â•‡ Clinical examination reveals a vascular cutaneous lesion on the right upper eyelid.
Histological description:â•‡ Histopathology demonstrates a few thin-walled dilated vascular channels lined by
a monolayer of endothelial cells and filled with red blood cells.
Lining of the vascular

channel
72
A 2-year-old infant has had the eyelid finding shown above since birth. He later underwent an
excisional biopsy of the right upper eyelid lesion.
73
Diagnosis:â•‡ Eyelid capillary hemangioma.
Clinical description:â•‡ An elevated reddish right upper eyelid swelling is seen.
Histological description:â•‡ Proliferation of lobulated capillaries, lined by a single layer of endothelial cells is
seen within the dermis. The capillaries are separated by fibrous septae.
Proliferating capillaries
Intervening fibrous septa
74
A 48-year-old man presented with redness and swelling of his right upper eyelid. He underwent
excisional biopsy of the eyelid.
75
Diagnosis:â•‡ Melkersson–Rosenthal syndrome.
Clinical description:â•‡ Right upper eyelid edema and erythema is noted.
Histological description:â•‡ Histopathology demonstrates skin tissue lined by keratinized stratified squamous
epithelium. Granulomatous inflammation is seen within the blood vessel lumen, a finding that is consistent
with Melkersson–Rosenthal syndrome.
squamous epithelium
Blood vessel lumen
Intravascular granulomatous
inflammation
76
A 2-year-old child presented with yellowish skin lesions present since birth.
77
Diagnosis:â•‡ Nevus sebaceous.
Clinical description:â•‡ Clinical examination reveals multiple elevated and flat skin lesions above the medial
canthus.
Histological description:â•‡ Histopathology reveals tissue lined by a keratinized stratified squamous

epithelium with associated hair follicles and numerous sebaceous glands. The lesion is hyperkeratotic,
acanthotic, and papillomatous with focal areas of parakeratosis.
Keratinized skin epithelium
Sebaceous glands
Sebaceous glands
78
A 64-year-old woman presented with multiple lesions on her face.
79
Diagnosis:â•‡ Face and eyelid cavernous hemangioma.
Clinical description:â•‡ Clinical examination reveals multiple flat and elevated vascular and pigmented skin
lesions.
Histological description:â•‡ Histopathological evaluation reveals lobules of blood-filled dilated vascular

channels lined by a flat endothelial layer.
Dilated blood-filled
vascular channels
Endothelial lining
80
A 56-year-old man presented with a growing eyelid mass. He later underwent excisional biopsy of the
eyelid lesions.
81
Diagnosis:â•‡ Angiolymphoid hyperplasia with eosinophilia (ALHE).
Clinical description:â•‡ Clinical examination reveals round, flesh-colored growths over the upper and lower
eyelids.
Histological description:â•‡ Histopathology reveals vascular proliferation (asterisks) with vessels

demonstrating intracytoplasmic vacuolization of their endothelium (arrowheads). Numerous eosinophils,
plasma cells, and lymphocytes are also seen.
Eosinophils
Plasma cells
*
*
*
82
Chapter 2â•… Orbit and optic nerve CASE 42 â•…
A 45-year-old woman presented with left upper eyelid fullness. Excisional biopsy of the lesion shows
the histological findings shown below.
83
Diagnosis:â•‡ Pleomorphic adenoma (benign mixed tumor).
Clinical description:â•‡ Mild fullness of the left upper eyelid is noted.
Histological description:â•‡ The tumor contains ductules and mesenchymal elements. The ductules are
composed of dual epithelial layers. There is differentiation of the outer epithelial layer into mesenchymal
elements such as fat, cartilage, and bone.
Mesenchymal matrix
Dual layer
Myoepithelial cells ducts
84
A 34-year-old woman presented with pain and swelling of her left upper eyelid for the past week.
The patient’s CT scan is shown above.
85
Diagnosis:â•‡ Dacryoadenitis.
Clinical description:â•‡ A CT scan of the orbit shows enlargement of the lacrimal gland consistent with
dacryoadenitis.
Histological description:â•‡ Histopathology reveals lacrimal gland tissue that contains aggregates of chronic
nongranulomatous, lymphocytic inflammation without necrosis (circles). CD3 and CD20 staining do not
show monoclonality (not shown).
Lacrimal gland acini
86
A 68-year-old patient presented with pain, diplopia, and proptosis. The patient’s MRI is shown above.
87
Diagnosis:â•‡ Adenoid cystic carcinoma.
Clinical description:â•‡ Magnetic resonance imaging shows a left orbital tumor with erosion of the left lateral
orbital wall.
Histological description:â•‡ Histopathology demonstrates tumor with classic “Swiss cheese” pattern, consisting
of cysts (asterisks) surrounded by basaloid cells (arrows). The tumor demonstrates perineural invasion.
*
Nerve bundle
88
A 59-year-old man presented with double vision and left eye proptosis.
89
Diagnosis:â•‡ Hemangiopericytoma.
Clinical description:â•‡ A well-circumscribed intraconal mass is seen on MRI.
Histological description:â•‡ The histopathology reveals dilated vascular channels with a “staghorn”
configuration within a cellular matrix composed of proliferated pericytes.
Cellular background
Dilated vascular channel

with “staghorn”
configuration
90
A 21-year-old man presented with increasing proptosis over the past 6 months. The photograph above
was taken during an orbital biopsy.
91
Diagnosis:â•‡ Cavernous hemangioma of the orbit.
Clinical description:â•‡ The intraoperative photograph demonstrates a well-circumscribed, vascular orbital

lesion.
Histological description:â•‡ Histopathology demonstrates well-circumscribed lesions composed of dilated

thick-walled blood vessels lined by endothelium. The vascular spaces are filled with blood.
Dilated blood-filled
vascular channels
92
A 64-year-old man recently developed the mass evident in his right eye.
93
Diagnosis:â•‡ Prolapsed orbital fat.
Clinical description:â•‡ Clinical examination reveals prolapsed orbital fat.
Histological description:â•‡ Histopathology demonstrates lobules of adipose tissue with intervening

fibrovascular septae consistent with prolapsed orbital fat.
94
Courtesy of Jason A. Sokol, MD. Director of Oculofacial Plastic and Orbital Surgery at Kansas
University Eye Center.
A 55-year-old man presented with diplopia for the past 6 months. The patient’s CT scan is shown
above.
95
Diagnosis:â•‡ Solitary fibrous tumor of the orbit.
Clinical description:â•‡ T1-weighted magnetic resonance imaging demonstrates an enhancing, well-

circumscribed lesion located superonasally in the right orbit.
Histological description:â•‡ Sections through the specimen contain a very cellular connective tissue with
spindle-shaped fibrocytes in a storiform pattern. Numerous fine vessels are seen coursing throughout the
specimen. Larger slit-like vessels are also present (asterisks).
96
Courtesy of Jason A. Sokol, M.D. Director of Oculofacial Plastic and Orbital Surgery at Kansas
A 10-year-old boy presented with a 2-month history of diplopia and exophthalmos of the right eye.
97
Diagnosis:â•‡ Rhabdomyosarcoma.
Clinical description:â•‡ Clinical examination reveals restriction of motility, mild proptosis, and right upper and
lower eyelid fullness.
Histological description:â•‡ Histopathological review of specimens using Masson trichrome reveals tissue
composed of pleomorphic spindle-shaped cells with large, round dark nuclei. There are noted to be several
areas where there are strap cells with markedly eosinophilic cytoplasm, the configuration of fibrils that reveal
cross striations compatible with primitive skeletal muscle.
Primitive skeletal
muscle
98
A 53-year-old patient presented with proptosis and double vision.
99
Diagnosis:â•‡ Schwannoma.
Clinical description:â•‡ T1-weighted magnetic resonance imaging shows a well-circumscribed intraconal mass
in the left orbit.
Histological description:â•‡ Section through the specimen shows scattered spindle-shaped cells growing in
whorl pattern. There are areas of loosely and randomly spaced collagen bundles. S-100 stain is positive
(not shown).
100
An 8-year-old boy presented with the above eyelid deformity.
101
Diagnosis:â•‡ Neurofibroma in a patient with neurofibromatosis.
Clinical description:â•‡ The clinical examination reveals an “S-shaped” eyelid deformity.
Histological description:â•‡ Histopathological evaluation shows multiple enlarged nerve bundles intertwined
with collagen consistent with neurofibroma (asterisks).
*
* *
*
* *
*
*
102
A 23-year-old man presented with diplopia and facial pain.
103
Diagnosis:â•‡ Fibrous dysplasia.
Clinical description:â•‡ Facial asymmetry with swelling of left side of the face is noted.
Histological description:â•‡ Histopathological examination reveals irregular trabeculae of immature woven

bone (resembling Chinese letters) in a fibrous background.
Woven bone shaped like

Chinese letters
Fibrous background
104
A 45-year-old patient presents with ocular pain and diplopia. The patient’s CT scan is shown above.
105
Diagnosis:â•‡ Eosinophilic granuloma.
Clinical description:â•‡ The CT scan demonstrates a chronic lytic superior orbital lesion.
Histological description:â•‡ Histopathology reveals two populations of cells. One population of cells is
eosinophils (arrows) and the other population is epithelioid giant cells.
106
A 49-year-old female presented with eye pain and restricted ocular motility.
107
Diagnosis:â•‡ Wegener’s granulomatosis.
Clinical description:â•‡ CT scan demonstrates a left orbital mass with erosion through the medial orbital wall.
Patient tested positive for cANCA.
Histological description:â•‡ Histopathology reveals areas of necrosis surrounded by epithelioid cells as well as
lymphocytes, plasma cells, and a few neutrophils (asterisks).
*
*
*
Necrosis
*
* *
108
A 1-year-old child presented with ptosis and a right superior orbital mass, depicted above.
He underwent an orbital biopsy.
109
Diagnosis:â•‡ Juvenile xanthogranuloma with primary orbital involvement.
Clinical description:â•‡ Clinical examination reveals a right upper eyelid swelling causing ptosis in this
1-year-old patient.
Histological description:â•‡ Orbital biopsy reveals a histiocytic cell tumor containing numerous Touton
multinucleated giant cells (arrows).
110
A 19-year-old woman presented with a 4-month history of left upper eyelid fullness. She underwent
anterior orbitotomy.
111
Diagnosis:â•‡ Dermoid cyst.
Clinical description:â•‡ Left upper eyelid swelling and fullness is noted temporally.
Histological description:â•‡ A large cystic cavity filled with keratin is seen (top). Higher magnification
(bottom) shows that the cystic cavity is lined by keratinized stratified squamous epithelium and associated
pilosebaceous units.
Lining of the cyst with

associated pilosebaceous
units
Keratin-filled cystic space
Keratinized
stratified squamous
epithelium
Pilar unit with hair

shaft inside
112
A 36-year-old woman presented with pain, redness, and swelling of her right upper eyelid.
The material in the upper canaliculi was expressed and examined microscopically.
113
Diagnosis:â•‡ Canaliculitis secondary to Actinomyces.
Clinical description:â•‡ Granular calcified material is being expressed from the upper punctum.
Histological description:â•‡ Clusters of Gram-positive filaments are seen in a matrix of calcified mineralized
tissue.
Collections of Gram-positive
filaments consistent with
Actinomyces
Mineralization
114
A 27-year-old diabetic man presented with right eyelid swelling and a frozen globe.
115
Diagnosis:â•‡ Orbital infection with mucormycosis.
Clinical description:â•‡ Swelling of the upper and lower eyelids with pigmented discharge is noted on clinical
examination.
Histological description:â•‡ Nonseptate filamentous fungi consistent with Mucor are seen (arrows).
116
A 37-year-old man presented with epiphora, swelling, and pain in the left medial canthus area. He
underwent a dacryocystorhinostomy.
117
Diagnosis:â•‡ Dacryocystitis.
Clinical description:â•‡ Clinical examination revealed redness and swelling along the left medial canthus. The
overlying skin is ulcerated.
Histological description:â•‡ Histopathology reveals tissue lined by nonkeratinized, pseudostratified columnar

epithelium with mucus glands. Chronic nongranulomatous inflammation consisting of lymphocytes and
plasma cells is seen infiltrating the stroma (arrowheads). Gram stain reveals small clusters of Gram-positive
cocci (not shown).
Nonkeratinized pseudostratified
columnar epithelium
Stroma
118
Printed with permission from Azari A.A., Kanavi M.R., Saipe N., Lee V., Lucarelli M., Potter H.D., Albert D.M. Transitional Cell
Carcinoma of the Lacrimal Sac Presenting With Bloody Tears. JAMA Ophthalmology 2013; 131(5):689–690.
A 54-year-old man presented with swelling of the right lower eyelid and bloody tears for the past 6
months.
Printed with permission from Azari A.A., Kanavi M.R., Saipe N., Lee V., Lucarelli M., Potter H.D., Albert D.M. Transitional Cell Carcinoma of the
Lacrimal Sac Presenting With Bloody Tears. JAMA Ophthalmology 2013; 131(5):689–690.
119
Diagnosis:â•‡ Transitional cell carcinoma of the lacrimal sac.
Clinical description:â•‡ The CT scan shows a heterogeneous, well-circumscribed mass in the right lacrimal sac
fossa. Intraoperative photograph reveals a large mass within the lacrimal sac.
Histological description:â•‡ Histopathological examination reveals papillary proliferation of transitional cells

(left). Nuclear pleomorphism and few mitotic figures are noted (center). Immunohistochemistry for HPV-16 is
diffusely positive, suggesting HPV involvement (right).
120
A 58-year-old man presented with a 6-month history of double vision. He later underwent an orbital
biopsy.
121
Diagnosis:â•‡ Orbital lymphoma (small B-lymphocytic lymphoma).
Clinical description:â•‡ CT scan shows infiltration of the right orbit. The tumor appears to be conforming to the
lateral orbital wall.
Histological description:â•‡ Histopathology demonstrates dense infiltrate of small, round, uniform, basophilic
cells. Immunohistochemistry was strongly positive for CD20 (not shown).
122
An 85-year-old woman with a history of breast cancer presented with diplopia and a “smaller left eye.”
123
Diagnosis:â•‡ Breast cancer with orbital cancer.
Clinical description:â•‡ Clinical examination demonstrates left eye enophthalmos and narrowing of the
palpebral fissure.
Histological description:â•‡ Histopathology reveals tissue infiltrated with epithelial cells in an “Indian-file”
arrangement (arrows). These cells are round with eosinophilic cytoplasm and round to irregular nuclei
displaying moderate atypia, including pleomorphism, an enlarged nucleus-to-cytoplasm ratio, and prominent
nucleoli. There are occasional areas of duct formation (asterisks).
* *
124
A 37-year-old obese woman presented with decreased vision and chronic headaches.
125
Diagnosis:â•‡ Papilledema due to idiopathic intracranial hypertension.
Clinical description:â•‡ Dilated fundus examination shows swelling of the optic nerve head surrounded by
hemorrhages.
Histological description:â•‡ Histopathology demonstrates swelling and anterior displacement of the optic
nerve head.
Vitreous
Anteriorly displaced
optic nerve head
Sclera
Retina
rosa
na crib
Choroid Lami
Optic nerve
126
A 29-year-old man was referred for evaluation of optic nerve edema.
127
Diagnosis:â•‡ Optic nerve drusen.
Clinical description:â•‡ Close inspection of the optic nerve head reveals deposition of hyaline material within
the optic nerve head.
Histological description:â•‡ Calcified deposits are seen within the optic nerve head anterior to the lamina
cribrosa.
Drusen
Lamina cribrosa
Sclera
Sclera
Optic nerve
128
A 32-year-old woman presented with a sudden onset of decreased vision and the above MRI findings.
129
Diagnosis:â•‡ Optic neuritis.
Clinical description:â•‡ Magnetic resonance imaging demonstrates enhancement of the left optic nerve
consistent with optic neuritis.
Histological description:â•‡ Histopathology demonstrates a cross-sectional view of the optic nerve. An area of
lymphoplasmacytic inflammation is seen within the optic nerve near a central retinal vessel.
Dura
Optic nerve
Central retinal vessel
Inflammation
Subarachnoid space
130
A 47-year-old woman presented with mild blurring of the vision in her right eye.
131
Diagnosis:â•‡ Optic nerve sheath meningioma.
Clinical description:â•‡ Axial CT scan imaging shows calcification of the optic nerve posteriorly and the classic
“tram-tracking” appearance anteriorly.
Histological description:â•‡ Histopathology demonstrates proliferation of meningothelial cells surrounding

the optic nerve. Many calcified psammoma bodies are present (asterisks).
Dura mater
∗
∗
∗ ∗ Proliferating meningothelial cells
Subarachnoid space
Optic nerve
132
A 14-year-old girl presented with progressive proptosis over the past 9 months.
133
Diagnosis:â•‡ Optic nerve glioma.
Clinical description:â•‡ Left eye proptosis and restricted extraocular motility is noted.
Histological description:â•‡ The tumor demonstrates proliferation of pilocytic glial cells and astrocytes
(arrowhead). Rosenthal fibers (eosinophilic bundles of fibrils), which are pathognomonic for this condition
are seen.
Rosenthal fibers
134
Chapter 3â•… Cornea and conjunctiva CASE 68 â•…
A 41-year-old woman presented with a longstanding history of corneal findings, as shown above.
135
Diagnosis:â•‡ Lattice dystrophy.
Clinical description:â•‡ The slit-lamp exam demonstrates linear bands of corneal opacification.
Histological description:â•‡ Histopathology reveals amorphous deposits that stain positive with Congo red
(previous page) and show birefringence (green and orange) under the polarized light.
136
Courtesy of Neal P. Barney, M.D. University of Wisconsin-Madison.
A 23-year-old man presented with corneal opacities, as shown above. He later underwent a
penetrating keratoplasty.
137
Diagnosis:â•‡ Granular dystrophy.
Clinical description:â•‡ Anterior stromal opacities are seen with clear intervening spaces. The corneal opacity
does not involve the peripheral cornea.
Histological description:â•‡ Staining with Masson trichrome demonstrates subepithelial as well as anterior
stromal corneal infiltrates (arrows). The deposits are composed of hyaline and stain red with Masson
trichrome.
Epithe
lium
Stroma
138
A 32-year-old woman presented with decreased vision. She later underwent penetrating keratoplasty.
139
Diagnosis:â•‡ Avellino corneal dystrophy.
Clinical description:â•‡ Slit-lamp examination reveals multiple confluent well-circumscribed stromal opacities.
Histological description:â•‡ The histopathology has features of both lattice and granular dystrophy. PAS stain
deposits (arrow, top) that also stain positive with Congo red and demonstrate dichroism under the polarized
light (not shown), typical of lattice dystrophy. Masson trichrome staining shows hyaline deposits in the
anterior stroma, as seen in granular dystrophy (bottom). Hyaline deposits are shown with arrows.
Epithelium
Stroma
Epithelium
Stroma
140
Chapter 3â•… Cornea and conjunctiva
71
CASE
â•…
A 19-year-old patient presented with decreased vision and photophobia.
141
Diagnosis:â•‡ Macular dystrophy.
Clinical description:â•‡ Confluent corneal opacities extending to the limbus without clear intervening spaces
are seen on the slit-lamp examination.
Histological description:â•‡ Infiltrates are seen at all levels. Alcian blue demonstrates positive staining of the
mucopolysaccharide deposits.
Corneal deposits
Corneal deposits
142
A 38-year-old woman with a history of ocular pain, and foreign body sensation, worse in the
morning, presented with the above slit-lamp examination finding.
143
Diagnosis:â•‡ Anterior basement membrane dystrophy.
Clinical description:â•‡ The slit-lamp examination demonstrates the typical “map” dystrophy within the
anterior cornea.
Histological description:â•‡ Histopathology demonstrates reduplicated epithelial basement membrane. There

is also separation of the epithelial basement membrane from the underlying Bowman’s layer in some areas
(arrowhead).
Corneal epithelium
Reduplicated epithelial
basement membrane
Bowman’s layer
Stroma
144
A 56-year-old patient with a past ocular history of longstanding retinal detachment presented with
decreased vision and ocular pain.
145
Diagnosis:â•‡ Band keratopathy.
Clinical description:â•‡ Cornea is deposited with plaques of calcified material.
Histological description:â•‡ von Kossa stain demonstrates calcium deposits within the epithelial basement
membrane and Bowman’s layer. The surface epithelium is attenuated and absent in some areas.
ts
e p osi an’s
d m er
l c ium e Bow ial lay
Ca in th ithel
h p
wit sube
a n d
eal
c orn
ce m
rfa eliu
Su epith
a
st rom
rneal
Co
146
A 6-year-old patient with bilateral corneal opacity underwent penetrating keratoplasty and
conjunctival biopsy.
147
Diagnosis:â•‡ Cystinosis.
Clinical description:â•‡ Clinical examination reveals punctate areas of opacity within the corneal stroma.
Histological description:â•‡ Histopathology reveals goblet cells containing nonkeratinized stratified squamous
epithelium. Cystine crystals (circles) are seen within the conjunctival stroma.
Goblet cells
Conjunctival epithelium
Conjunctival stroma
148
From Albert, Daniel M., Miller, Joan W., Azar, Dimitri T., and Blodi, Barbara A. (eds). 2008. Albert & Jakobiec’s Principles and Practice of
A 43-year-old patient presented with dry eyes and foreign body sensation.
149
Diagnosis:â•‡ Salzmann’s nodular degeneration.
Clinical description:â•‡ The slit-lamp examination reveals multiple bluish-gray elevated anterior corneal
nodules.
Histological description:â•‡ Examination of the histopathological sections reveals thick, fibrous tissue
(asterisks) interposed between Bowman’s membrane and the irregular epithelium.
Epithelium Bowman’s
membrane
Stroma
150
A 53-year-old man presented with bilateral decreased vision with the above external appearance.
He had similar findings in his other eye.
151
Diagnosis:â•‡ Spheroidal degeneration.
Clinical description:â•‡ The slit-lamp photograph demonstrates many spheroidal deposits within the stroma of
the cornea.
Histological description:â•‡ Sections through the specimen show amorphous deposits of varying size in the
anterior stroma and epithelium (arrows) that are markedly positive with elastin stain (bottom). Extensive
subepithelial fibrosis is seen. The epithelium is of variable thickness and shows intracellular edema.
Epithelium
Stromal fibrosis
152
A 25-year-old man presented with decreased vision and the above ophthalmic examination finding.
153
Diagnosis:â•‡ Keratoconus.
Clinical description:â•‡ Cone-shape deformity of the cornea along with the classic Munson’s sign (V-shaped
deformity of the lower eyelid in downward gaze) is demonstrated.
Histological description:â•‡ Histopathology demonstrates a thinned cornea with attenuated epithelium.

Multiple breaks (arrowheads) within the Bowman’s layer are seen. The endothelium is well preserved.
Bowman’s layer
Attenuated epithelium
Stromal thinning
and scarring
Well-preserved
endothelium
154
A 72-year-old man presented with dry eyes and the above clinical picture.
155
Diagnosis:â•‡ Corneal dellen.
Clinical description:â•‡ Slit-lamp examination reveals corneal thinning just inside the limbus.
Histological description:â•‡ Histopathology reveals corneal thinning with artifactuous breaks in the Descemet’s
membrane.
Epithelial attenuation
Stroma
Descemet’s
membrane
156
A 55-year-old man presented with poor vision, which could not be improved with refraction.
157
Diagnosis:â•‡ Keratoglobus.
Clinical description:â•‡ The slit-lamp examination shows generalized thinning and globular protrusion of the
cornea.
Histological description:â•‡ The cornea is thin centrally as well as peripherally. The epithelium is attenuated
with loss of Bowman’s layer in some areas.
Severely attenuated
epithelium
Loss of Bowman’s
layer
158
A 69-year-old woman presented with decreased vision, worse upon waking up. After failing medical
therapy, she underwent a penetrating keratoplasty.
159
Diagnosis:â•‡ Fuchs’ endothelial dystrophy.
Clinical description:â•‡ Slit-lamp examination reveals marked corneal edema with a “beaten bronze”
appearance to the posterior cornea.
Histological description:â•‡ An edematous cornea with loss of normal stromal cleft is seen. Anvil-shaped
excrescences consistent with guttae are seen.
Edematous cornea
Guttae
Thickening of the
Descemet’s membrane
160
A 16-month-old infant presented with decreased vision and nystagmus.
161
Diagnosis:â•‡ Congenital hereditary endothelial dystrophy (CHED).
Clinical description:â•‡ Slit-lamp examination reveals mild corneal haze.
Histological description:â•‡ Histopathology reveals a thickened cornea with loss of natural stromal clefts. The
Descemet’s membrane is thick and the endothelial cell layer is absent.
Corneal epithelium
Corneal stromal edema with

increased thickness
162
A 4-year-old girl with decreased vision since birth presented with the above corneal finding on
slit-lamp examination. She later underwent a penetrating keratoplasty.
163
Diagnosis:â•‡ Posterior polymorphous dystrophy.
Clinical description:â•‡ Slit-lamp examination reveals multiple scalloped corneal opacities located posteriorly.
Histological description:â•‡ Histopathology demonstrates a multilayer endothelium.
Corneal stroma
Multilayered
endothelium
164
A 32-year-old man with no ocular complaints presented for a routine eye examination.
165
Diagnosis:â•‡ Hassall–Henle bodies.
Clinical description:â•‡ A slit-lamp examination reveals a normal cornea.
Histological description:â•‡ Histopathology demonstrates peripheral guttae in this otherwise normal cornea.
Corneal stroma
Descemet’s
membrane
Guttae
166
A 77-year-old terminally ill patient was seen as an inpatient with the above slit-lamp examination
finding.
167
Diagnosis:â•‡ Wilson’s disease.
Clinical description:â•‡ Slit-lamp examination reveals a pigmented Descemet’s membrane consistent with
Kayser–Fleischer ring.
Histological description:â•‡ Histopathology demonstrates a dark band of copper deposit on the posterior
aspect of the Descemet’s membrane (short arrows).
Endothelium Stroma
168
A 2-year-old boy with a history of Goldenhar syndrome presented with a limbal mass.
169
Diagnosis:â•‡ Limbal dermoid.
Clinical description:â•‡ Slit-lamp examination reveals an elevated yellow mass with associated cilia straddling
the temporal limbus.
Histological description:â•‡ Histopathology reveals tissue lined by keratinized stratified squamous epithelium
with associated pilosebaceous units. The underlying dermis is fibrotic.
squamous epithelium
Fibrotic dermis
Sebaceous gland Pilar units
170
A 63-year-old woman with a history of rheumatoid arteritis presented with central corneal thinning.
171
Diagnosis:â•‡ Descemetocele.
Clinical description:â•‡ Slit-lamp examination shows a central area of corneal thinning consistent with
Descemetocele.
Histological description:â•‡ Histopathology shows complete loss of the stroma centrally. Only Descemet’s
membrane and an attenuated epithelium remain in this area.
Epithelium
Epithelium
Stroma
172
A 32-year-old contact lens wearer presented with a longstanding central corneal ulcer. The ulcer was
treated with fortified antibiotic eye drops with no response. Corneal cultures were negative for
bacteria, fungus, and acanthamoeba. Therapeutic penetrating keratoplasty was performed.
173
Diagnosis:â•‡ Acanthamoeba keratitis.
Clinical description:â•‡ Central corneal infiltrate is seen. There are multiple satellite lesions surrounding the
main infiltrate. The remaining cornea is edematous.
Histological description:â•‡ The corneal tissue is infiltrated with round, double wall cysts of acanthamoeba
(arrows). Infiltration with neutrophils is also seen.
174
Courtesy of Sarah M. Nehls, M.D. University of Wisconsin-Madison.
A 63-year-old farmer presented with a corneal ulcer and hypopyon. The condition worsened despite
topical antifungal therapy. He subsequently underwent a penetrating keratoplasty.
175
Diagnosis:â•‡ Fungal keratitis secondary to Aspergillus.
Clinical description:â•‡ Slit-lamp examination reveals a central corneal infiltrate with feathery edges. A 3-mm
hypopyon is present.
Histological description:â•‡ Gomori methenamine silver (GMS) stain demonstrates septated branching
filamentous fungi. The branching is at 45-degree angles (circles) consistent with Aspergillus.
176
A 36-year-old man presented with ocular pain and photophobia. The slit-lamp examination is seen
above. Later he developed corneal scarring and decreased vision.
177
Diagnosis:â•‡ Herpes simplex virus (HSV) keratitis.
Clinical description:â•‡ Corneal dendritic lesions with terminal bulbs are seen.
Histological description:â•‡ A marked inflammatory response in the posterior cornea is present. The
Descemet’s membrane is fragmented. Epithelioid and multinucleated giant cells are also present in the area of
Descemet’s membrane.
Marked inflammation in the posterior

corneal stroma
Multinucleated giant cell
Fragmented Descemet’s membrane
178
A 42-year-old man with AIDS presented with decreased vision and corneal changes.
179
Diagnosis:â•‡ Microsporidial keratitis.
Clinical description:â•‡ Slit-lamp examination demonstrates multiple punctate corneal opacities.
Histological description:â•‡ Histopathological evaluation of the corneal tissue demonstrates anterior stromal
deposits consistent with microsporidia (arrows).
Bowman’s layer
Stroma
180
A 53-year-old man with a history of corneal transplant presented with a corneal infiltrate not
responding to topical antibiotics. He had several previous penetrating keratoplasties.
181
Diagnosis:â•‡ Bacterial keratitis due to MRSA (methicillin resistant Staphylococcus aureus).
Clinical description:â•‡ Slit-lamp examination demonstrates a central corneal infiltrate with an overlying
epithelial defect.
Histological description:â•‡ Corneal tissue is infiltrated with numerous neutrophils (top). Gram stain
demonstrates scattered clusters of Gram-positive cocci (arrows).
Corneal inflammation
182
Printed with permission from Azari A.A., Nehls S., Ghoghawala S.Y., Lee V., Kanavi M.R., Potter
H.D. Rhizopus Keratitis Following Corneal Trauma. JAMA Ophthalmology 2013; 131(6):776.
A 48-year-old man presented with a central corneal ulcer after trauma with a metal wire.
Printed with permission from Azari A.A., Nehls S., Ghoghawala S.Y., Lee V., Kanavi M.R., Potter H.D. Rhizopus Keratitis Following Corneal Trauma.
JAMA Ophthalmology 2013; 131(6):776.
183
Diagnosis:â•‡ Rhizopus keratitis.
Clinical description:â•‡ Slit-lamp examination shows a central necrotic corneal ulcer with an overlying
epithelial defect.
Histological description:â•‡ Branching filamentous fungi are seen demonstrating an exquisite pattern of
autofluorescence (top). Microscopic evaluation demonstrates multiple branching nonseptate hyphae
(arrows, bottom).
Printed with permission from Azari A.A., Nehls S., Ghoghawala S.Y., Lee V., Kanavi
M.R., Potter H.D. Rhizopus Keratitis Following Corneal Trauma. JAMA Ophthalmology
2013; 131(6):776.
184
A 43-year-old woman with past history of ocular shingles presented with a nonhealing corneal ulcer.
185
Diagnosis:â•‡ Herpes zoster keratitis.
Clinical description:â•‡ Nonhealing corneal ulcer.
Histological description:â•‡ Histopathology reveals central corneal thinning (double headed arrow) with
marked inflammation. An overlying epithelial defect, consistent with neurotrophic ulcer, is present.
Corneal epithelium
Stroma
186
A 45-year-old woman presented with decreased vision and corneal neovascularization as shown above.
187
Diagnosis:â•‡ Interstitial keratitis.
Clinical description:â•‡ Slit-lamp examination demonstrates a round area of corneal opacity with
neovascularization.
Histological description:â•‡ Marked inflammation, vascularization, and scarring are seen in the posterior third
of the cornea.
Scarring and
inflammation
Blood vessels
188
Courtesy of Matthew J. Thompson, Tower Clock Eye Center, Green Bay,

WI.
A 77-year-old man presented with corneal neovascularization and opacity unresponsive to topical and
subconjunctival steroids. He subsequently underwent an enucleation.
189
Diagnosis:â•‡ Corneal squamous cell carcinoma.
Clinical description:â•‡ Examination with the slit-lamp demonstrates corneal scar and whitening.
Histological description:â•‡ Histopathology shows an edematous cornea infiltrated with epithelioid cells with
severe atypia (arrows, top) staining with cytokeratin AE1/AE3, a marker for squamous cells (arrows, bottom).
190
A 65-year-old man presented with the above corneal changes 6 months after a complicated cataract
surgery.
191
Diagnosis:â•‡ Epithelial ingrowth.
Clinical description:â•‡ Epithelial ingrowth causing corneal haze is evident. The leading edge of the epithelial
ingrowth has scalloped borders.
Histological description:â•‡ Growth of nonkeratinized stratified squamous epithelium on the posterior surface
of the cornea as well as anterior iris is shown.
Epithelial ingrowth
Iris stroma Iris dilator Posterior pigmented iris

muscle epithelium
192
A 68-year-old man with a history of Fuchs’ endothelial dystrophy was seen in the clinic on
postoperative day 1, after a Descemet’s stripping endothelial keratoplasty (DSEK).
193
Diagnosis:â•‡ Corneal button demonstrating a failed DSEK procedure obtained after full thickness corneal
transplant.
Clinical description:â•‡ Slit-lamp examination reveals an eye after DSEK surgery with graft in a good central
position. A small air bubble remains superiorly, but usually resolves in 2–3 days.
Histological description:â•‡ Histopathology demonstrates a traditional full thickness corneal transplant

performed after failed DSEK surgery. Host Descemet’s membrane is present at the donor–recipient interface.
Host epithelium Retained host Descemet’s

membrane at the interface
Host cornea
Donor cornea
Donor Descemet’s
membrane
194
A 43-year-old man with progressive keratoconus presented with the above clinical picture 1 month
postoperatively. Many years later, he required a corneal transplant.
195
Diagnosis:â•‡ Intrastromal corneal ring segments (INTACS) in an eye with a history of keratoconus.
Clinical description:â•‡ Slit-lamp examination demonstrates two INTACS placed superiorly and inferiorly.
Histological description:â•‡ Histopathology demonstrates a thinned cornea with an intrastromal defect where
the INTACS were placed (asterisk).
∗
Epithelium
Stroma
196
A 48-year-old male patient has a longstanding history of corneal edema and decreased vision no
longer amenable to medical therapy. He underwent penetrating keratoplasty.
197
Diagnosis:â•‡ Pseudophakic bullous keratopathy.
Clinical description:â•‡ Slit-lamp examination demonstrates marked corneal haze and edema.
Histological description:â•‡ The cornea is thickened. Areas of separation between the epithelium and the
Bowman’s layer are seen (asterisk).
Surface epithelium
Increase in
corneal thickness
Corneal stroma
198
Chapter 3â•… Cornea and conjunctiva CASE 100 0â•…
A 48-year-old man presented with decreased vision and photophobia 2 years following a corneal
transplant.
199
Diagnosis:â•‡ Failed corneal graft.
Clinical description:â•‡ A hazy and edematous cornea with areas of neovascularization is seen.
Histological description:â•‡ The corneal tissue is edematous with loss of natural stromal clefts. Areas of
inflammation, particularly at the edges of the transplant, are apparent.
Peripheral
Thickened cornea inflammation
Peripheral with loss of
inflammation natural clefts
200
A 48-year-old man presented with irregular astigmatism uncorrected with rigid gas permeable lenses.
He underwent penetrating keratoplasty.
201
Diagnosis:â•‡ Previous radial keratotomy.
Clinical description:â•‡ Multiple radially oriented linear corneal scars consistent with radial keratotomy are seen.
Histological description:â•‡ Histopathology demonstrates multiple partial thickness corneal scars (arrowheads).
202
A 54-year-old male presented with corneal clouding 2 months after injury with a softball. The corneal
clouding did not resolve and he underwent a penetrating keratoplasty.
203
Diagnosis:â•‡ Corneal blood staining.
Clinical description:â•‡ Corneal blood staining and opacification are seen.
Histological description:â•‡ Red blood cells are seen scattered within an edematous cornea.
Thickened
cornea
204
The patient is a 20-year-old man with history of chemical burn of the left eye from propionic acid.
He underwent stem cell transplant. The specimen below was removed from his corneal surface.
205
Diagnosis:â•‡ Corneal conjunctivalization secondary to stem cell deficiency.
Clinical description:â•‡ Clinical examination reveals corneal haze and pannus secondary to stem cell deficiency.
Histological description:â•‡ Histopathology reveals goblet cells containing nonkeratinized stratified squamous
epithelium of the conjunctiva overlying a loose, highly vascularized (asterisks) substantia propria with
lymphoplasmacytic infiltrate (arrowheads).
Goblet cells within the conjunctival

epithelium
*
* * *
Conjunctival stroma
206
A 38-year-old man presented with tearing, redness, and pain in his left eye after working in his garage.
207
Diagnosis:â•‡ Corneal foreign body.
Clinical description:â•‡ A foreign body with a surrounding rust ring is seen embedded within the cornea.
Histological description:â•‡ The cornea demonstrates profound scarring and inflammation. There is loss of
keratocytes and stromal disorganization within the anterior two-thirds of the cornea. Foreign body material
is noted.
Corneal scarring and disorganization
Corneal foreign body
Inflammation
208
A 12-year-old boy with a history of forceps delivery presented with the above corneal finding. He
underwent a penetrating keratoplasty many years later.
209
Diagnosis:â•‡ Vertical breaks in the Descemet’s membrane in a patient with a history of forceps delivery.
Clinical description:â•‡ Vertical breaks in the Descemet’s membrane are noted.
Histological description:â•‡ Histopathology reveals a scarred corneal stroma. The surface epithelium is largely
missing. There is a break in the Descemet’s membrane with scrolling of this membrane.
Scrolled up edges of
210
A 42-year-old woman presented with a new conjunctival lesion as shown above. She underwent
excisional biopsy of her conjunctival lesion.
211
Diagnosis:â•‡ Primary acquired melanosis (PAM) without atypia.
Clinical description:â•‡ A flat pigmented lesion on the superior bulbar conjunctiva is seen.
Histological description:â•‡ Histopathology reveals conjunctiva with mild acanthosis. There is an increased
number of bland-appearing pigmented melanocytes along the basal epithelial layer (arrowheads). There is no
atypia, no melanocytic nesting nor intraepithelial spread.
Goblet cells
Conjunctival stroma
Pigment-laden macrophages
212
From Albert, Daniel M., Miller, Joan W., Azar, Dimitri T., and Blodi, Barbara A. (eds) 2008. Albert
A 49-year-old woman presented with darkly pigmented conjunctival lesions as shown above. She later
underwent conjunctival biopsy.
213
Diagnosis:â•‡ Benign acquired melanosis (BAM), also known as racial melanosis.
Clinical description:â•‡ The clinical examination reveals multiple pigmented conjunctival lesions.
Histological description:â•‡ Histopathology demonstrates tissue lined by nonkeratinized stratified squamous

epithelium with an increased number of bland-appearing pigmented melanocytes along the basal epithelial
layer (arrows).
Conjunctival stroma
214
A 48-year-old Caucasian woman presented with the pigmented lesions as shown above.
215
Diagnosis:â•‡ Primary acquired melanosis (PAM) with atypia.
Clinical description:â•‡ Conjunctival pigmentation is seen in the lateral limbus spanning an area
approximating four clock hours.
Histological description:â•‡ Histopathological evaluation demonstrates involvement of the superficial

(arrows), as well as deep (arrowheads) epithelium, with pigmented melanocytes.
216
A 14-year-old girl presented with a slow-growing conjunctival lesion. The lesion has continued to
enlarge in recent years.
217
Diagnosis:â•‡ Conjunctival nevus.
Clinical description:â•‡ A raised, cystic, pigmented bulbar conjunctival lesion is seen on clinical examination.
Histological description:â•‡ Histopathology reveals a nonkeratinized stratified squamous epithelium. Nests of

melanocytes (arrowheads) are seen below the epithelium. Multiple epithelial-lined cysts are also present
(asterisks).
Nonkeratinized stratified
squamous epithelium
* *
218
An 84-year-old man presented with a 2-year history of a left caruncular lesion. He underwent
excisional biopsy of the lesion.
219
Diagnosis:â•‡ Caruncular nevus.
Clinical description:â•‡ Slit-lamp examination reveals a pigmented caruncular lesion.
Histological description:â•‡ The slides reveal nonkeratinized stratified squamous epithelium with goblet cells
and associated pilosebaceous units. Nests of melanocytic cells with variable pigmentation are seen within the
stroma.
Epithelium Goblet cells
Nests of melanocytic
cells with pigmentation
Pilar unit Sebaceous
gland
220
A 66-year-old man presented with a darkly pigmented conjunctival lesion. An excisional biopsy was
performed.
221
Diagnosis:â•‡ Conjunctival melanoma arising from nevus.
Clinical description:â•‡ Anterior segment examination reveals a raised, darkly pigmented conjunctival lesion
with feeder vessels.
Histological description:â•‡ The conjunctival epithelium (asterisk) and stroma is infiltrated with melanocytic
cells (arrows) with associated epithelial inclusion cysts. Some of these melanocytic cells are arranged in nests,
while others demonstrate marked pleomorphism and prominent nucleoli.
Epithelial
inclusion
cyst
222
An 87-year-old woman presented with the above clinical picture. Two years earlier the patient was
diagnosed with a skin melanoma in her thumb.
223
Diagnosis:â•‡ Metastatic conjunctival melanoma.
Clinical description:â•‡ Slit-lamp examination demonstrates a large raised conjunctival mass.
Histological description:â•‡ The conjunctival tissue is infiltrated with clusters of large atypical melanocytes
with prominent nucleoli and pigmentation.
224
A 23-year-old man presented with a 2-year history of a slow growing left eye lesion. He underwent
excisional biopsy of the eyelid lesion.
225
Diagnosis:â•‡ Pterygium and nevus occurring in the same area.
Clinical description:â•‡ Clinical examination reveals a vascularized, balloon-like mass straddling the limbus,
nasally.
Histological description:â•‡ Histopathological examination demonstrates conjunctival epithelium with solar

elastosis, consistent with a pterygium (left side, asterisk), and proliferation of melanocytic cells in the stroma
and epithelial–stromal interface, consistent with a junctional nevus (right side, arrows).
* Stroma
226
A 44-year-old Hispanic man presented with a growing lesion in his left eye.
227
Diagnosis:â•‡ Pterygium.
Clinical description:â•‡ The clinical examination reveals a vascular “insect wing-like” growth over the nasal
cornea.
Histological description:â•‡ Histopathology reveals a lesion with nonkeratinized stratified epithelium. Solar
elastotic changes are present within the stroma (asterisks). A fragment of the cornea is also present.
Corneal epithelium
*
* *
228
A 32-year-old man presented with a raised conjunctival lesion.
229
Diagnosis:â•‡ Pinguecula.
Clinical description:â•‡ Clinical examination reveals an elevated lesion with mild leukoplakia.
Histological description:â•‡ Histopathology demonstrates solar elastotic changes (asterisk) within the
conjunctival stroma.
va
*
ti
nc Sclera
nju
Co
Ciliary body
Cornea
Iris
Sclera
230
A 79-year-old woman presented with ocular discomfort and epiphora.
231
Diagnosis:â•‡ Oncocytoma.
Clinical description:â•‡ Slit-lamp examination shows an elevated round caruncular lesion.
Histological description:â•‡ Low power histopathology (top) reveals tissue lined by goblet-cell-containing
nonkeratinized, stratified squamous epithelium with associated pilosebaceous units. Underlying the surface
epithelium, sheets of epithelial cells forming ductal and glandular structures (arrowheads) that contain PAS
positive material within their lumen are seen (asterisks, bottom). The epithelial cells exhibit a granular
eosinophilic cytoplasm.
Surface epithelium Pilosebaceous units
*
*
232
A 31-year-old man presented with increased redness and discomfort in his right eye. A biopsy was
performed. The hematoxylin and eosin stain is on the left; the Congo red stain is on the right.
233
Diagnosis:â•‡ Conjunctival amyloidosis.
Clinical description:â•‡ The slit-lamp examination demonstrates a yellow elevated lesion on the inferior bulbar
conjunctiva.
Histological description:â•‡ The slides reveal a specimen covered by conjunctival epithelium. There are
numerous, large amorphous eosinophilic deposits in the stroma (top). The eosinophilic material stains with
Congo red (bottom) and displays dichroism under polarized light (not shown).
Large eosinophilic
deposits staining positive
with Congo red
234
Chapter 3â•… Cornea and conjunctiva
118
CASE
â•…
A 7-year-old boy presented with left eye discomfort and excessive tearing.
235
Diagnosis:â•‡ Conjunctival squamous papilloma.
Clinical description:â•‡ Slit-lamp examination demonstrates several papillomatous conjunctival lesions located
nasally.
Histological description:â•‡ Histopathology reveals tissue lined by nonkeratinized stratified squamous

epithelium containing goblet cells. There are multiple papillary fronds (circles) of acanthotic nonkeratinized
stratified squamous epithelium.
Goblet cells Stroma
236
A 26-year-old Native American man presented with a conjunctival lesion.
237
Diagnosis:â•‡ Hereditary benign intraepithelial dyskeratosis (HBID).
Clinical description:â•‡ A clinical photograph demonstrates a limbal leukoplakic lesion in this patient.
Histological description:â•‡ Histopathology demonstrates hyperkeratosis, acanthosis, parakeratosis, and

dyskeratosis (keratin within the individual epithelial cells, shown with asterisks in the bottom image).
Hyperkeratosis
* *
Acanthosis
*
* *
*
238
A 44-year-old man presented with a newly-formed lesion in his left eye. The lesion appeared
approximately 3 months ago and it has been increasing in size.
239
Diagnosis:â•‡ Conjunctival intraepithelial neoplasia (CIN).
Clinical description:â•‡ An elevated erythematous lesion with multiple pin-point blood vessels (strawberry
lesion) is seen.
Histological description:â•‡ Histopathology demonstrates a sharp transition from normal to acanthotic

epithelium. The involved epithelium is markedly acanthotic and loss of polarity is noted. Other features
may include solar elastosis of the stroma and mitotic figures (not shown).
Sharp transition from

normal to acanthotic
epithelium
240
Courtesy of Robert J. Peralta, MD Ophthalmic Plastic & Reconstructive Surgery, Silkiss Eye Surgery.
The patient is a 68-year-old man with a 4-month history of a rapidly growing conjunctival lesion.
241
Diagnosis:â•‡ Invasive conjunctival squamous cell carcinoma.
Clinical description:â•‡ Anterior segment examination reveals an elevated lesion with a large feeder vessel. The
lesion is arising from the conjunctiva and encroaching upon the cornea.
Histological description:â•‡ There is a loss of polarity in the epithelium with marked atypia and
pleomorphism. Nests of malignant squamous cells arising from the surface epithelium infiltrate the stroma
(asterisks).
elium
ce epith
Surfa
*
* * * *
242
A 57-year-old man presented with conjunctival lesions of an unknown duration. He later underwent
excision of the conjunctival lesions.
243
Diagnosis:â•‡ Conjunctival fibrous histiocytoma.
Clinical description:â•‡ Clinical examination reveals a red, elevated conjunctival lesion.
Histological description:â•‡ Densely packed sheets of fibroblasts in a collagenous matrix are seen in a storiform
pattern. Vacuolated histiocytes are noted in between the fibroblasts.
244
Printed with permission from Lee V., Azari A.A., Nehls S., Potter H.D.,
Albert D.A. Leiomyoma of the Lower Eyelid. JAMA Ophthalmology 2013;
131(8):1085.
A 55-year-old woman presented with eyelid swelling associated with irritation, excessive tearing, and
mattering for over 1 month.
A B C
Printed with permission from Lee V., Azari A.A., Nehls S., Potter H.D., Albert D.A. Leiomyoma of the Lower Eyelid. JAMA Ophthalmology 2013;
131(8):1085.
245
Diagnosis:â•‡ Leiomyoma of the conjunctiva.
Clinical description:â•‡ Slit-lamp examination reveals an extensive red, elevated conjunctival lesion.
Histological description:â•‡ (A) Histopathological evaluation demonstrates conjunctival tissue with an area of
smooth muscle bundles. Higher magnification demonstrates fascicles composed of fusiform cells with cigar-
shaped end nuclei (B). Cytoplasmic staining with muscle-specific actin stain is observed (C).
A B C
246
A 63-year-old man presented with a rapidly growing conjunctival mass. The conjunctival mass was
removed and submitted for histopathological evaluation.
247
Diagnosis: â•‡ Conjunctival mucosa-associated lymphoid tissue-type (MALT-type) lymphoma.
Clinical description:â•‡ Clinical examination reveals a red, elevated conjunctival lesion with classic “salmon
patch” appearance.
Histological description:â•‡ Histopathological examination reveals proliferation of lymphocytes arranged

in sheets.
248
A 66-year-old woman presented with fullness under her right lower eyelid. She later underwent an
excisional conjunctival biopsy.
249
Diagnosis:â•‡ Burkitt’s lymphoma.
Clinical description:â•‡ Clinical examination reveals a “salmon-patch” conjunctival lesion in the left lower
fornix in this patient.
Histological description:â•‡ Histopathology reveals tissue infiltrated with sheets of lymphocytes with presence
of many tingible body macrophages. Tingible body macrophages are demonstrated with arrows. Note the
“starry sky” appearance. Immunohistochemical staining confirmed the diagnosis of Burkitt’s lymphoma.
250
A 42-year-old woman presented with foreign body sensation and a conjunctival mass for the past
6 months.
251
Diagnosis:â•‡ Benign reactive lymphoid hyperplasia (BRLH).
Clinical description:â•‡ Slit-limp examination shows a multilobulated red elevated conjunctival lesion.
Histological description:â•‡ Histopathology demonstrates tissue with a nonkeratinized stratified squamous

surface epithelium overlying multiple lymphoid follicles (asterisks). The follicles are composed of a germinal
center and a mantle zone surrounding them. The follicular centers contain cleaved and noncleaved medium
sized lymphoid cells with mitotic figures and tingible body macrophages (arrowheads).
Conjunctival
epithelium
*
*
* * *
Germinal center
Mantle zone
252
A 26-year-old woman presented with ocular irritation and foreign body sensation. She underwent
excisional biopsy of the conjunctival lesion shown above.
253
Diagnosis:â•‡ Conjunctival inclusion cyst.
Clinical description:â•‡ An elevated, well-circumscribed, fluid-filled conjunctival mass is seen.
Histological description:â•‡ A large cystic space lined by nonkeratinized stratified squamous epithelium is seen
within the conjunctival stroma. The cystic space is filled with exudative material.
Large cystic cavity filled

with exudates
Nonkeratinized stratified
squamous epithelium
lining the cyst
254
A 43-year-old woman presented with ocular irritation for the past 4 months. She later underwent an
excisional biopsy of the conjunctival lesion.
255
Diagnosis:â•‡ Conjunctival lymphangiectasia.
Clinical description:â•‡ Clinical examination demonstrates thin-walled translucent cystic spaces on the
temporal aspect of the bulbar conjunctiva.
Histological description:â•‡ Histopathological examination reveals conjunctiva with multi-loculated cystic

spaces (asterisks) in the substantia propria (stroma) lined by thin walls and flattened endothelial cells.
*
* *
Conjunctival stroma
*
*
256
A 43-year-old woman presented with a mass under her right upper eyelid. The mass was excised and
evaluated histopathologically.
257
Diagnosis:â•‡ Lipodermoid.
Clinical description:â•‡ Slit-lamp examination reveals a fatty, elevated, supratemporal subconjunctival lesion.
Also noted is the rigid gas-permeable contact lens worn by the patient.
Histological description:â•‡ Histopathology reveals tissue covered by stratified squamous epithelium. The
stroma is collagenous and contains aggregates of lipid cells.
Surface epithelium
Lipid aggregates
258
A 22-year-old man with a past ocular history significant for conjunctival laceration presented with a
red exuberant conjunctival mass.
259
Diagnosis:â•‡ Pyogenic granuloma.
Clinical description:â•‡ A well-circumscribed, red, elevated lesion with a smooth surface arising from the bulbar
conjunctiva.
Histological description:â•‡ The histopathology demonstrates an exuberant tissue with an edematous stroma.
Acute and chronic nongranulomatous inflammation and radiating blood vessels are present.
Edematous stroma
Radiating blood vessels
260
A 23-year-old man presented with discharge from his left eye for the past 3 days.
261
Diagnosis:â•‡ Bacterial conjunctivitis.
Clinical description:â•‡ Clinical examination demonstrates conjunctival redness, hyperemia, and mild
discharge.
Histological description:â•‡ Histological examination reveals tissue lined by goblet-cell-containing,

nonkeratinized epithelium. The conjunctival stroma is infiltrated with lymphocytes and plasma cells (circle).
Goblet cell in
conjunctival
epithelium
262
A 46-year-old patient presented with ocular pain and redness.
263
Diagnosis:â•‡ Onchocerciasis.
Clinical description:â•‡ Slit-lamp examination reveals marked conjunctival redness and chemosis.
Histological description:â•‡ Histopathological examination reveals a cross-sectional view of the Onchocerca

volvulus.
264
A 10-year-old healthy boy presented with ocular irritation and a large eyelid lesion.
265
Diagnosis:â•‡ Ligneous conjunctivitis.
Clinical description:â•‡ Slit-lamp examination shows a solid “woody” lesion in the superior tarsal conjunctiva.
Histological description:â•‡ Histopathology demonstrates amorphous eosinophilic substance within the

conjunctival stroma. The conjunctival surface epithelium is not present in this section.
Amorphous eosinophilic
substance
266
A 32-year-old African American woman with a history of shortness of breath presented with a
conjunctival lesion, as shown above.
267
Diagnosis:â•‡ Conjunctival sarcoidosis.
Clinical description:â•‡ Slit-lamp examination reveals a red, elevated subconjunctival lesion in the nasal bulbar
conjunctiva of the right eye.
Histological description:â•‡ Histopathology demonstrates diffuse infiltration of the conjunctival stroma by

sheets of mononuclear inflammatory cells and tubercles of epithelioid and giant cells. No significant caseation
is present.
Lymphoplasmocytic
inflammation
Granuloma
Granuloma
Granuloma
Granuloma
Granuloma
268
Courtesy of Heather D. Potter, M.D. University of Wisconsin-Madison.
The patient is a 57-year-old woman with a history of eye rubbing. She underwent an excisional biopsy
of the left tarsal conjunctiva.
269
Diagnosis:â•‡ Lichen simplex chronicus.
Clinical description:â•‡ Clinical examination after the eversion of the left upper eyelid demonstrates thickening
and laceration of the tarsal conjunctiva.
Histological description:â•‡ Histopathology demonstrates tissue lined by metaplastic conjunctiva showing

squamatization composed of uniform keratinocytes with compact ortho- and parakeratosis. A mild
lymphocytic infiltrate is seen in the substantia propria. There is loss of collagen density in the tarsus. Glandular
structures are also noted in the substantia propria (asterisk).
Keratinized conjunctival
epithelium with parakeratosis
Acanthosis
Dermis with mild inflammation
270
A 65-year-old woman with chronic ocular discomfort and decreased vision underwent a conjunctival
biopsy.
271
Diagnosis:â•‡ Ocular cicatricial pemphigoid.
Clinical description:â•‡ The clinical image demonstrates corneal opacity, trichiasis, madarosis, and
symblepharon formation.
Histological description:â•‡ Histopathology demonstrates marked conjunctival inflammation (top).

Immunohistochemistry demonstrates a linear band of IgG in the conjunctival epithelial basement membrane.
Conjunctival stroma
Nongranulomatous
conjunctival inflammation
Linear lgG band
272
A 54-year-old woman presented with dry eyes and foreign body sensation. The patient had been using
artificial tears with no relief. She underwent excision of the superior bulbar conjunctiva.
273
Diagnosis:â•‡ Superior limbic keratoconjunctivitis.
Clinical description:â•‡ Marked vascular dilation, hyperemia, and thickening is seen in the superior bulbar
conjunctiva.
Histological description:â•‡ The specimen consists of conjunctival tissue showing areas of epithelial thickening,
degeneration, and complete loss of goblet cells. Nuclear pseudoinclusions and abnormal aggregations of
chromatin are seen within many cells. A nongranulomatous mixed inflammatory infiltrate is seen within the
substantia propria and epithelium.
Epithelial thickening
Inflammation within
the substantia propria
274
A 6-year-old boy presented with bilateral itching of the eyes and foreign body sensation. A few similar
episodes in the past were treated with topical steroids.
275
Diagnosis:â•‡ Vernal keratoconjunctivitis.
Clinical description:â•‡ The clinical examination demonstrates presence of giant papillae on the tarsal
conjunctiva when the upper eyelid is everted.
Histological description:â•‡ Histopathological examination reveals conjunctiva with stratified squamous

epithelium. The epithelium shows focal areas with lymphocytic and eosinophilic infiltration. Marked diffuse
eosinophilic infiltration (some are shown with arrows) as well as chronic lymphoplasmacytic inflammation is
seen within a vascular (asterisks) stroma.
*
*
*
* * *
276
Chapter 4â•… Uveal tract tumors CASE 139 â•…
A 48-year-old woman presented with decreased vision over the past 8 months. The fundus image and
ultrasound findings are depicted above.
277
Diagnosis:â•‡ Choroidal hemangioma.
Clinical description:â•‡ An elevated subretinal lesion demonstrating high internal reflectivity on A-scan is seen.
Histological description:â•‡ Histopathology reveals dilated vascular channels that are lined by a single layer of
flat endothelium. The vascular channels are filled with red blood cells.
Dilated vascular channels
Endothelial lining of
blood vessels
278
A 28-year-old woman presented with a pigmented choroidal mass.
279
Diagnosis:â•‡ Choroidal nevus.
Clinical description:â•‡ Dilated fundus examination demonstrates a darkly pigmented choroidal mass.
Histological description:â•‡ Proliferation of melanocytic cells is seen within the choroid. The cells appear
benign and mitotic figures are not present.
Pigmented cells within

the choroid
RPE cells
Proliferation of
melanocytes is seen
within the choroid
Sclera
280
A 47-year-old woman presented with multiple iris lesions. No iris lesions were present in her
other eye.
281
Diagnosis:â•‡ Iris nevi.
Clinical description:â•‡ Elevated, nodular pigmented lesions are seen.
Histological description:â•‡ Multiple areas of melanocytic proliferation consistent with nevi are seen on the iris
surface (arrows).
Iris sphincter muscle
Posterior pigmented
iris epithelium
Anterior lens
capsule
282
A 70-year-old woman under treatment for ovarian carcinoma presented with bilateral decreased
vision for the past 2 months.
283
Diagnosis:â•‡ Bilateral diffuse uveal melanocytic proliferation (BDUMP), a paraneoplastic syndrome.
Clinical description:â•‡ The fundus examination reveals bilateral patchy pigmented subretinal lesions.
Histological description:â•‡ Histopathological examination of collette following enucleation at autopsy reveals

diffuse thickening of the choroid and increase in uveal melanocytic cells.
Diffuse
thickening of
the choroid
is noted
Increase in uveal
melanocytic cells
is seen
284
A 67-year-old man presented with a new iris lesion, as shown above.
285
Diagnosis:â•‡ Iris cyst.
Clinical description:â•‡ Ultrasound demonstrates a posterior cystic iris lesion.
Histological description:â•‡ Histopathology reveals a large cystic cavity within the posterior pigmented iris
epithelium.
Cornea
Iris
Sclera
Cyst
Ciliary body Posterior pigmented iris

epithelium
286
An 8-year-old boy presented with the above eyelid deformity.
287
Diagnosis:â•‡ Lisch nodule in neurofibromatosis type 1.
Clinical description:â•‡ Clinical examination reveals an “S-shaped” eyelid deformity.
Histological description:â•‡ Nodular aggregates of melanocytes, consistent with a Lisch nodule, are seen in the
anterior iris.
Cornea
Iris
Lisch nodule
Lens
Ciliary body
288
A 5-year-old boy presented with an iris lesion, present for the past 8 months.
289
Diagnosis:â•‡ Juvenile xanthogranuloma presenting with an iris mass.
Clinical description:â•‡ Slit-lamp examination demonstrates a localized iris plaque.
Histological description:â•‡ Histopathology reveals tissue infiltrated with inflammatory cells and Touton
multinucleated giant cells (arrows).
290
A 66-year-old man with insulin dependent diabetes mellitus presented with blurry vision.
291
Diagnosis:â•‡ Lacy iris vacuolization in a patient with diabetes mellitus.
Clinical description:â•‡ The dilated fundus examination shows numerous retinal hemorrhages as well as
neovascularization at the head of the optic nerve.
Histological description:â•‡ Histopathology reveals lacy vacuolization (arrows) of the posterior pigmented iris
epithelium.
Iris
Lens
292
A 59-year-old man presented with gradual loss of vision. He later underwent enucleation.
293
Diagnosis:â•‡ Choroidal melanoma (epithelioid type).
Clinical description:â•‡ A large elevated choroidal lesion is seen on dilated fundus examination.
Histological description:â•‡ A mushroom-shaped mass is seen arising from the choroid. The tumor cells
demonstrate considerable cytoplasm (arrows) with a large nucleus and prominent nucleoli (arrowheads). The
cell boundaries are distinct, and there is lack of cohesion between the tumor cells. An exudative retinal
detachment is also present (asterisk).
Break in the
Bowman’s layer
* Mushroom-shaped
Subretinal
choroidal mass
exudates
294
A 58-year-old woman presented with loss of vision. The clinical examination findings are depicted
above. She later underwent an enucleation.
295
Diagnosis:â•‡ Ciliary body melanoma (epithelioid type).
Clinical description:â•‡ A large elevated ciliary body mass on dilated fundus examination is seen.
Histological description:â•‡ Histopathology demonstrates a large mass proliferating from the ciliary body
(top). Large epithelioid cells with abundant cytoplasm, large nuclei, and distinct nucleoli are seen. The cell
borders are distinct and the cells are discohesive.
Epithelioid cell with

large cytoplasm
Large nucleus with

prominent nucleoli
296
Courtesy of Justin Gottlieb, MD, University of Wisconsin-Madison.
A 37-year-old woman presented with the above incidental finding.
297
Diagnosis:â•‡ Spindle cell melanoma.
Clinical description:â•‡ Dilated fundus examination shows a large elevated pigmented choroidal mass in the
posterior pole.
Histological description:â•‡ Proliferation of spindle cells with elongated nucleus and inconspicuous nucleoli.
Cell boundaries are indistinct with a syncytial pattern.
298
A 58-year-old woman presented with a pigmented iris lesion in her left eye.
299
Diagnosis:â•‡ Iris melanoma.
Clinical description:â•‡ A slightly elevated pigmented iris lesion is noted on the slit-lamp examination.
Histological description:â•‡ Histopathology reveals infiltration of the iris tissue with atypical melanocytes. The
cells demonstrate a large nuclear to cytoplasmic ratio.
Posterior pigmented iris

epithelium
300
Printed with permission from Lewis, David A., Nehls, Sarah, etâ•¯al. Ciliary Body Medulloepithelioma
in a 10-Year-Old Boy. Arch Ophthalmol. 2012 Jul;130(7):881.
A 10-year-old boy presented with decreased vision and an intraocular mass.
301
Diagnosis:â•‡ Medulloepithelioma.
Clinical description:â•‡ A cystic vascular nonpigmented mass is seen in the anterior chamber.
Histological description:â•‡ Histopathological evaluation demonstrates cystic spaces filled with hyaluronic acid
(asterisk) surrounded by primitive neuroepithelial cells arranged in sheets, cords, tubules, and rosette-like
formations.
Ciliary body mass
Pigmented
epithelium of
the ciliary
body
302
A 59-year-old woman with a history of choroidal melanoma treated with plaque therapy.
She subsequently developed a blind painful eye with LP vision and the eye was enucleated.
303
Diagnosis:â•‡ Choroidal melanoma after plaque therapy.
Clinical description:â•‡ Dilated fundus examination reveals a pigmented choroidal lesion surrounded by
atrophic changes in the retina and choroid.
Histological description:â•‡ A pigmented tumor is seen arising from the choroid and involving the retina. The
tumor is highly necrotic and it is composed of epithelioid cells and pigment-laden macrophages. The retina
overlying the tumor is severely atrophic. The sclera overlying the tumor shows areas of inflammation and
fragmentation.
Atrophic retina
Necrotic tumor
Scleral thinning and
fragmentation
Sclera
Scleral inflammation
304
A 49-year-old man presented with decreased vision. A choroidal mass was noted on dilated fundus
examination. The ultrasound findings are depicted above. He later underwent an enucleation.
305
Diagnosis:â•‡ Balloon cell melanoma.
Clinical description:â•‡ Dilated fundus examination reveals an elevated dome-shaped choroidal mass with an
overlying retinal detachment.
Histological description:â•‡ Numerous balloon cells (arrows) exhibiting abundant clear cytoplasm are seen.
306
An 81-year-old man presented complaining of a gradual decrease in his peripheral vision.
307
Diagnosis:â•‡ Ring melanoma of the ciliary body (epithelioid type).
Clinical description:â•‡ Dilated fundus examination reveals a large ciliary body mass.
Histological description:â•‡ Histopathological examination demonstrates tumor arising from the ciliary body
(top). Large epithelioid cells with abundant cytoplasm, large nuclei, and prominent nucleoli are seen. The cells
have well-defined borders and they are discohesive.
Epithelioid cell with

large cytoplasm
Large nucleus with

prominent nucleoli
308
The patient is a 54-year-old man with a history of choroidal mass in his left eye. The patient’s past
medical history is significant for renal cell carcinoma.
309
Diagnosis:â•‡ Metastatic renal cell carcinoma to choroid.
Clinical description:â•‡ The dilated fundus examination reveals an elevated choroidal mass superior to the
optic nerve head.
Histological description:â•‡ Histopathology reveals a tumor that is composed of rounded-to-polygonal-shaped

cells with abundant clear cytoplasm (clear cells) (some of which are shown with arrows) consistent with renal
cell carcinoma. The stroma of the tumor is highly vascular.
310
A 68-year-old woman with a history of breast cancer presented with loss of vision in her left eye.
311
Diagnosis:â•‡ Metastatic breast cancer to choroid.
Clinical description:â•‡ Dilated fundus examination reveals a large elevated choroidal lesion within the center
of the macula.
Histological description:â•‡ Histopathology reveals the choroidal tissue infiltrated with epithelial cells, some
exhibiting “Indian-file” arrangement (arrows). These cells are round with eosinophilic cytoplasm. Areas of duct
formation are also seen (asterisks).
Retina
*
*
* *
Sclera *
312
Chapter 5â•…Retina and vitreous CASE 157 â•…
An 82-year-old man presented with decreased vision and the above OCT findings following a
complicated cataract surgery.
313
Diagnosis:â•‡ Cystoid macular edema.
Clinical description:â•‡ Large cystic cavities are seen within the outer plexiform layer.
Histological description:â•‡ Large amounts of exudates are seen within the outer plexiform layer.
Inner nuclear layer
Outer nuclear layer
e
n th
w ithi layer
es
dat iform
Exu r plex
e
out
Choroid
Sclera
314
A 73-year-old man presented with decreased vision in his right eye. The fundus appearance and OCT
findings are depicted above.
315
Diagnosis:â•‡ Epiretinal membrane (macular pucker).
Clinical description:â•‡ Fundus examination demonstrates macular puckering. OCT shows the well-delineated
epiretinal membrane.
Histological description:â•‡ Traction from the epiretinal membrane (ERM) has resulted in retinal folds.
Vitreous cavity
Internal limiting
membrane and ERM
Folded retina
Choroid
Sclera
316
A 78-year-old woman presented with decreased vision in her left eye.
317
Diagnosis:â•‡ Macular hole.
Clinical description:â•‡ Dilated fundus examination reveals a round well-delineated macular hole.
Histological description:â•‡ Histopathology is consistent with a macular hole.
Retina
Retina
Macular hole covered by a thin band of gliotic

tissue
Choroid
Sclera
318
A 72-year-old man presented with loss of vision in his right eye. The ultrasound findings are depicted
above. The eye later underwent an enucleation.
319
Diagnosis:â•‡ Funnel-shaped retinal detachment.
Clinical description:â•‡ Ultrasound reveals a funnel-shaped retinal detachment.
Histological description:â•‡ A funnel-shaped retinal detachment is evident on histopathology. The retina

remains attached to the optic nerve and ora serrata.
Cornea
Lens
Detached retina
Optic nerve
320
A 71-year-old man with a longstanding history of hypertension presented for a routine eye
examination.
321
Diagnosis:â•‡ Cotton-wool spots.
Clinical description:â•‡ Fundus examination reveals multiple fluffy white patches.
Histological description:â•‡ Cytoid bodies which are swelled axons are seen (circles). The cytoid bodies form
as a result of nerve fiber layer ischemia and infarction.
Ganglion cell layer
Outer nuclear layer

Inner nuclear layer
Nerve fiber layer

Outer plexiform layer
Inner plexiform layer
Photoreceptors
322
A 67-year-old man with a history of hypertension presented with decreased vision. Dilated fundus
examination reveals the above findings.
323
Diagnosis:â•‡ Central retinal vein occlusion.
Clinical description:â•‡ The fundus image demonstrates swelling of the optic nerve. Scattered hemorrhages in
all retinal layers give it the classic “blood and thunder” appearance.
Histological description:â•‡ Histopathology shows retinal hemorrhages in all retinal layers (asterisks).
Inner nuclear layer
∗ Nerve fiber layer
∗ ∗
∗
Photoreceptors
Outer nuclear layer
Choroid
Sclera
324
A 77-year-old woman presented with sudden loss of vision in her left eye and the fundus image
shown above. Visual acuity was 20/20 OD and LP OS.
325
Diagnosis:â•‡ Central retinal artery occlusion (CRAO).
Clinical description:â•‡ The fundus examination demonstrates a cherry red spot typical for CRAO.
Histological description:â•‡ Atrophy and ischemia of the inner retinal layers are most evident, although all
layers are affected.
Severe atrophy of the

inner retinal layers
Relative preservation
of the outer retina
RPE
Choroid
326
Courtesy of William R. Nunery, M.D. University of Louisville, Louisville KY.
A 2-year-old boy with a 6-month history of leukocoria was brought in by his mother.
327
Diagnosis:â•‡ Retinoblastoma.
Clinical description:â•‡ Clinical examination demonstrates marked leukocoria.
Histological description:â•‡ The slides reveal an enucleated globe with a large basophilic mass arising from the
outer retina causing a complete retinal detachment and subretinal exudation (long arrow). Homer-Wright
rosettes (short arrow), and Flexner-Wintersteiner rosettes (arrowhead) are seen.
Subretinal exudates
328
A 16-year-old boy presented with progressive loss of vision.
329
Diagnosis:â•‡ Retinitis pigmentosa.
Clinical description:â•‡ Fundus images reveal severely attenuated retinal vessel, waxy pallor of the optic disc,
and “bone spicule” pigmentation in the periphery.
Histological description:â•‡ There is severe and diffuse atrophy of the retinal photoreceptors, retinal pigmented
epithelium, and outer nuclear layer. The retina is focally gliotic and there is a diffuse migration of the retinal
pigmented epithelial cells around the hyalinized retinal vessels (arrowheads).
Attenuated retina
Choroid
330
A 21-year-old woman presented with the above incidental retinal finding.
331
Diagnosis:â•‡ Congenital hypertrophy of the retinal pigment epithelium (CHRPE).
Clinical description:â•‡ Dilated fundus examination reveals multiple areas of grouped pigmented lesions giving
a “bear track” appearance.
Histological description:â•‡ Histopathology demonstrates hypertrophy and increased pigmentation of the

retinal pigment epithelium.
Hypertrophied retinal
pigment epithelial layer
332
A 58-year-old man with no ocular complaints and normal visual acuity was seen for a routine eye
examination. A slit-lamp image through his dilated pupil is shown.
333
Diagnosis:â•‡ Asteroid hyalosis.
Clinical description:â•‡ The dilated slit-lamp examination reveals small round-to-oval asteroid bodies
suspended in the vitreous.
Histological description:â•‡ Histopathology demonstrates round, Alcian blue positive spheres (asterisks)
consistent with asteroid bodies within the vitreous. Many of the asteroid bodies are attached to the vitreous.
*
Vitreous strands
*
Vitreous *
334
A 12-year-old boy presented with decreased vision and the above fundus finding.
335
Diagnosis:â•‡ Coats’ disease.
Clinical description:â•‡ Fundus image demonstrates retinal exudates.
Histological description:â•‡ Histopathology demonstrates retinal detachment and subretinal exudates. Dilated
telangiectatic blood vessels are also present.
Subretinal
exudates
Telangiectatic
blood vessels
336
A 79-year-old man presented for a routine eye examination, with the above retinal finding.
337
Diagnosis:â•‡ Senile retinoschisis.
Clinical description:â•‡ Fundus examination demonstrates smooth elevation of the retina inferiorly.
Histological description:â•‡ Histopathology demonstrates splitting of the retina at the level of the outer
plexiform layer (OPL).
Inner retina
Splitting at the level of OPL
Outer retina
Sclera
338
A 33-year-old man presented with the above incidental finding on dilated fundus examination.
339
Diagnosis:â•‡ Von Hippel–Lindau disease.
Clinical description:â•‡ The fundus examination reveals dilated retinal vessels feeding a retinal
hemangioblastoma in a patient with Von Hippel–Lindau disease.
Histological description:â•‡ Histopathology demonstrates dilated vascular channels overlying the optic nerve
(asterisks).
* *
Sclera
Optic nerve
340
A 71-year-old renal transplant patient presented with decreased vision. Dilated fundus examination
demonstrated the above findings.
341
Diagnosis:â•‡ Cryptococcal retinitis.
Clinical description:â•‡ Dilated fundus examination demonstrates multifocal retinal infiltrates in this renal
transplant patient.
Histological description:â•‡ Histopathological examination demonstrates many well encapsulated

cryptococcus organisms (arrows).
342
A 72-year-old woman presented with decreased vision and ocular pain. Doppler echocardiography
was suspicious for endocarditis.
343
Diagnosis:â•‡ Endogenous endophthalmitis.
Clinical description:â•‡ Dilated fundus examination shows multiple cream-colored infiltrates within the
vitreous.
Histological description:â•‡ Histopathology demonstrates an enucleated eye with suprachoroidal hemorrhage,

subretinal hemorrhage, and retinal detachment (top, asterisk). Gram stain demonstrates clusters of Gram-
positive organisms within the vitreous (bottom).
344
A 64-year-old patient presented with decreased vision and eye pain 3 days after a routine cataract
surgery.
345
Diagnosis:â•‡ Hypopyon with probable secondary endophthalmitis.
Clinical description:â•‡ Slit-lamp examination reveals conjunctival hyperemia along with a hypopyon. Radial
corneal scars consistent with previous radial keratotomy are seen.
Histological description:â•‡ Histopathology demonstrates marked inflammation in the anterior chamber and
the vitreous.
Marked intraocular Cornea

inflammation
Lens fragments
Ciliary body
346
Courtesy of James A. Eadie, M.D. University of Wisconsin-Madison.
A 46-year-old man presented with a 1-week history of decreased vision, photophobia and ocular pain.
On ophthalmic examination, he had variable amounts of vitritis in addition to the retinal findings
shown above.
347
Diagnosis:â•‡ Acute retinal necrosis (ARN).
Clinical description:â•‡ Vitritis is seen, and the retina shows necrosis and opacification.
Histological description:â•‡ Histopathology demonstrates necrosis and disorganization of all the retinal layers.
Retinal necrosis
and atrophy
Sclera
Necrosis and
atrophy of all
retinal layers
Choroid
Sclera
348
A 43-year-old woman from the Midwest United States presented with decreased vision.
349
Diagnosis:â•‡ Ocular histoplasmosis.
Clinical description:â•‡ A dilated fundus examination reveals multiple punched out chorioretinal lesions in the
periphery and within the macula. Hemorrhages and scarring are also present within the macular region.
Histological description:â•‡ Histopathological evaluation reveals the Histoplasma capsulation organisms

(arrows).
350
A 22-year-old man presented with a history of decreased vision in his left eye.
Courtesy of Mozhgan R. Kanavi, MD. Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences,
Tehran, Iran.
351
Diagnosis:â•‡ Toxoplasma chorioretinitis.
Clinical description:â•‡ Dilated fundus examination demonstrates extensive chorioretinal scarring in the
macular region in this patient.
Histological description:â•‡ Histopathology reveals disorganized retinal tissue with the presence of occasional
toxoplasma cysts (arrows).
Courtesy of Mozhgan R. Kanavi, MD. Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences,
Tehran, Iran.
352
A 58-year-old patient presents with decreased vision, photophobia, and pain in his right eye.
The patient had a history of a left ruptured globe 9 years ago. The fluorescein angiogram of the
right eye is shown above.
353
Diagnosis:â•‡ Sympathetic ophthalmia.
Clinical description:â•‡ Fluorescein angiogram demonstrates multiple areas of leakage consistent with serous
retinal detachment.
Histological description:â•‡ Histopathological examination reveals marked granulomatous inflammation,

consisting of histiocytes and multinucleated giant cells, within the choroid. The choriocapillaris is relatively
spared.
RPE
Histiocytes
Multinucleated giant cells
Sclera
354
A 77-year-old patient with a history of chronic leukemia presented with decreased vision.
355
Diagnosis:â•‡ Leukemia.
Clinical description:â•‡ Dilated fundus examination reveals vitreous haze and multiple nodular choroidal
infiltrates.
Histological description:â•‡ Histopathology demonstrates exudative retinal detachment. Infiltration of the

choroid and subretinal space with many leukemic cells is seen.
Leukemic cells infiltrating the

subretinal space
Retina Subretinal
exudates
Choroid
Sclera
356
An 85-year-old woman presented for a routine eye examination. The appearance of the fundus is
shown above. Fundus examination of her right eye revealed similar findings.
357
Diagnosis:â•‡ Drusen.
Clinical description:â•‡ The fundus examination reveals numerous yellow deposits within the macula
consistent with drusen.
Histological description:â•‡ Histopathology demonstrates multiple PAS-positive sub-RPE material consistent

with drusen (asterisks).
∗ Neurosensory retina
id
oro
Ch
Drusen
RPE
Sclera ∗
∗
358
Chapter 6â•… Glaucoma and other disorders CASE 180 â•…
From Kanski JJ. Signs in Ophthalmology: Causes and Differential

Diagnosis. Intraocular Pressure and Angle. Philadelphia: Copyright
Elsevier 2010.
An elderly woman presented with elevated IOP and the above slit-lamp appearance.
359
Diagnosis:â•‡ Pseudoexfoliation syndrome.
Clinical description:â•‡ The slit-lamp examination demonstrates the presence of pseudoexfoliative material on
the anterior lens capsule.
Histological description:â•‡ Histopathology demonstrates deposition of amorphous pseudoexfoliative material

on the anterior lens capsule resembling iron filings aligned on a magnet (arrows).
Lens epithelium
ule
Anterior lens caps
Lens
360
A 68-year-old woman presented with decreased vision, photophobia, and eye pain after a complicated
cataract surgery.
361
Diagnosis:â•‡ Phacoantigenic uveitis.
Clinical description:â•‡ Slit-lamp examination demonstrates corneal edema with presence of many keratic
precipitates and anterior chamber haze.
Histological description:â•‡ Histopathology demonstrates zonular pattern of granulomatous inflammation,

composed of neutrophils, lymphocytes, and plasma cells as well as epithelioid cells surrounding the lens.
Remnants of broken lens capsule are also seen.
Lens capsule
Lens
Neutrophils
Lymphocytes and
plasma cells
Epithelioid cells
362
A 58-year-old man with a past medical history of hypertension and insulin-dependent diabetes
mellitus presented with decreased vision and eye pain. IOP was measured to be 65â•¯mmHg.
363
Diagnosis:â•‡ Neovascular glaucoma.
Clinical description:â•‡ Clinical examination demonstrates florid iris rubeosis.
Histological description:â•‡ Histopathology reveals an iris tissue with ectropion uveae. Marked iris
neovascularization (arrowheads) and peripheral anterior synechiae closing the angle are present.
Cornea
Descemet's membrane
Ectropion uveae
Peripheral anterior
synechiae closing the
angle
364
A 16-year-old patient presented with the above gonioscopic findings following a blunt eye trauma.
365
Diagnosis:â•‡ Iridodialysis.
Clinical description:â•‡ Gonioscopic examination reveals separation of the iris from its base.
Histological description:â•‡ Histopathology demonstrates a detached iris.
Cornea
Detached iris
Sclera
Ciliary body
366
A 19-year-old patient presented to his ophthalmologist following a blunt ocular trauma.
367
Diagnosis:â•‡ Angle recession.
Clinical description:â•‡ Gonioscopic examination reveals widening of the ciliary body band consistent with
angle recession.
Histological description:â•‡ Histopathology demonstrates a tear into the face of the ciliary body resulting in a
cleavage between circular and longitudinal ciliary body muscles (arrow).
Sclera
Iris
Ciliary body
368
A 56-year-old man sustained an ocular injury. He later developed an elevated IOP and ocular pain.
369
Diagnosis:â•‡ Hemorrhagic glaucoma.
Clinical description:â•‡ Slit-lamp examination demonstrates hyphema with layering of the blood in the
anterior chamber.
Histological description:â•‡ Histopathological evaluation shows blood in the anterior chamber and within the
angle (arrows).
Cornea
Anterior chamber
Iris
Posterior chamber
370
A 55-year-old man presented with decreased vision and ocular pain. An intraocular mass was
discovered on examination.
371
Diagnosis:â•‡ Melanocytic glaucoma.
Clinical description:â•‡ Ultrasound reveals a large choroidal lesion most consistent with choroidal melanoma.
Histological description:â•‡ Histopathology demonstrates numerous pigment-laden macrophages within the

trabecular meshwork and the anterior chamber.
Sclera Cornea
Ciliary body Anterior chamber
Pigment-laden macrophages
372
The patient is a 72-year-old man with gradual loss of vision despite maximum medical and surgical
therapy.
373
Diagnosis:â•‡ Optic disc cupping secondary to glaucoma.
Clinical description:â•‡ The optic nerve head is severely cupped with only a small rim of normal tissue
remaining.
Histological description:â•‡ An excavated optic nerve head is evident on this histopathologic section (arrows)
as well as atrophy of the optic nerve.
Sclera
374
A 77-year-old man with a history of angle closure glaucoma presented with decreased vision and
restricted visual fields. A few years later he underwent enucleation.
375
Diagnosis:â•‡ Schnabel’s cavernous dystrophy.
Clinical description:â•‡ Dilated fundus examination shows a pale optic nerve with severe excavation and
cupping.
Histological description:â•‡ Histopathology reveals Schnabel’s cavernous degeneration of the retrolaminar

optic nerve exhibiting spongiform changes (asterisks).
Lamina cribrosa
Subretinal exudates
Subretinal exudates
Sclera
Sclera
*
Optic nerve
* *
* *
*
376
The above eye was removed from a stillborn fetus with multiple abnormalities.
377
Diagnosis:â•‡ Synophthalmos (Cyclopia).
Clinical description:â•‡ The enucleated specimen shows fused globes.
Histological description:â•‡ Histopathology demonstrates globes fused medially (asterisks) sharing a common
optic nerve.
Cornea Iris Cornea
*
* Lens
Iris
*
*
Vitreous cavity
* Vitreous cavity
Retina Retina
Optic nerve
378
From Albert, Daniel M., Miller, Joan W., Azar, Dimitri From Albert, Daniel M., Miller, Joan W., Azar, Dimitri T., and Blodi, Barbara A. (eds). 2008.
T., and Blodi, Barbara A. (eds). 2008. Albert & Albert & Jakobiec’s Principles and Practice of Ophthalmology, 3rd ed. Philadelphia: Copyright
Jakobiec’s Principles and Practice of Ophthalmology, Elsevier 2008.
3rd ed. Philadelphia: Copyright Elsevier 2008.
A 36-year-old patient with a history of chronic headache presented with decreased vision.
379
Diagnosis:â•‡ Vogt–Koyanagi–Harada (VKH) syndrome.
Clinical description:â•‡ Dilated fundus examination and OCT show multiple serous retinal detachments.
Histological description:â•‡ Histopathology reveals collection of epithelioid cells under the RPE. The choroidal
tissue is infiltrated with lymphoplasmacytic inflammation. Retinal inflammation is also present but not
shown.
RPE cells
a
om
ranul
Eg
-RP
Sub
n
matio
flam
l in
roida
Cho
380
A 75-year-old woman presented with sudden loss of vision and a right afferent pupillary defect.
381
Diagnosis:â•‡ Temporal (giant cell) arteritis.
Clinical description:â•‡ The fundus examination reveals optic nerve edema.
Histological description:â•‡ The temporal artery demonstrates thickening of intima, discontinuity in internal
elastic lamina and granulomatous inflammation within the intima and media. Multinucleated giant cells are
also seen.
tima
Thickened in
Nongranulomatous
inflammation within
the adventitia Giant cell
382
A 79-year-old woman presented with hypotony with the above ultrasound finding after a complicated
cataract surgery.
383
Diagnosis:â•‡ Suprachoroidal hemorrhage.
Clinical description:â•‡ Ultrasound demonstrates blood in the suprachoroidal space.
Histological description:â•‡ Large amounts of hemorrhage are seen in the suprachoroidal space. Total retinal
detachment is present.
384
A 67-year-old woman presented with decreased vision and difficulty driving at night. A slit-lamp view
of the lens is shown above.
385
Diagnosis:â•‡ Posterior subcapsular cataract.
Clinical description:â•‡ Dilated slit-lamp examination demonstrates a posterior subcapsular opacity.
Histological description:â•‡ Histopathology shows collection of morgagnian globules (asterisks) in the

posterior aspect of the lens (arrow).
Lens
*
*
Posterior lens capsule
386
An 87-year-old man presented with difficulty seeing at both distance and near.
387
Diagnosis:â•‡ Hypermature cataract.
Clinical description:â•‡ Slit-lamp examination shows a white mature cataract in this patient.
Histological description:â•‡ Histological examination reveals an enlarged lens with morgagnian globules
(asterisks) consistent with cataract.
Iris Anterior lens capsule
Cataractous lens
*
*
* *
388
A 55-year-old man with a history of chronic diarrhea presented with decreased vision for the past
4 months.
389
Diagnosis:â•‡ Crohn’s disease.
Clinical description:â•‡ Exudates forming a macular star are seen on the dilated fundus examination.
Histological description:â•‡ Intestinal biopsy reveals inflammation within the lamina propria. Peyer’s patches,
which are a normal finding, are also seen.
Inflammation within
lamina propria
Intestinal villi
Peyer’s patches
390
From Albert, Daniel M., Miller, Joan W., Azar, Dimitri T., and Blodi, Barbara A. (eds). 2008. Albert & Jakobiec’s Principles and Practice of
An 8-year-old patient presented with decreased vision and amblyopia.
391
Diagnosis:â•‡ Anterior polar cataract.
Clinical description:â•‡ Slit-lamp examination reveals an anteriorly located lens opacity in the pupillary space.
Histological description:â•‡ Histopathology reveals calcification and cellular proliferation under the anterior
lens capsule.
Cornea
Anterior lens capsule
Calcified material
Lens
Iris
392
A 66-year-old man with a history of multiple myeloma presented with decreased vision, headaches,
and jaw claudication.
393
Diagnosis:â•‡ Amyloid deposits in the temporal artery.
Clinical description:â•‡ The fundus image shows optic nerve edema with a small peripapillary hemorrhage and
a supratemporal cotton-wool spot. The visual field is significant for a complete superior altitudinal defect.
Histological description:â•‡ Histopathology demonstrates infiltration of amorphous material within the tunica
intima, tunica media, and tunica adventitia (left). Higher magnification shows giant cells surrounding the
amorphous eosinophilic deposits (center). Amyloid staining with Congo red produces birefringence under
polarized light (right).
394
A 28-year-old man presented with a blind painful left eye.
395
Diagnosis:â•‡ Phthisis bulbi.
Clinical description:â•‡ Clinical examination reveals left enophthalmos and exotropia in this patient.
Histological description:â•‡ Histopathological examination reveals marked osseous RPE metaplasia producing
a cancellous bone shell in the vitreous cavity. The retina is detached, disorganized, and atrophic. The sclera is
thickened and folded and a mild chronic lymphocytic infiltrate is present.
Cornea Site of a
previous buckle
Osseous
metaplasia
Thickened sclera
396
A 22-year-old man presented with pain and decreased vision after blunt trauma to his eye.
397
Diagnosis:â•‡ Hyphema.
Clinical description:â•‡ Layering of blood is noted within the anterior chamber.
Histological description:â•‡ Histopathology demonstrates marked hemorrhage in the anterior chamber.
Cornea
Blood in anterior chamber
Lens
Iris
398
An unconscious 4-month-old infant was brought to ER by her caregiver.
399
Diagnosis:â•‡ Abusive head trauma (a.k.a shaken baby syndrome).
Clinical description:â•‡ Dilated fundus examination reveals massive retinal hemorrhages affecting all layers.
Histological description:â•‡ Histopathology reveals hemorrhages affecting all retinal layers and the optic nerve
sheath. The retinal hemorrhages extend to the ora serrata (asterisks).
* *
Optic nerve sheath

hemorrhage
Nerve fiber layer
Photoreceptors
400
Index of cases
Chapter 1: Eyelid 40 Face and eyelid cavernous 72 Anterior basement membrane

1 Basal cell carcinoma, 1–2 hemangioma, 79–80 dystrophy, 143–144
2 Actinic keratosis, 3–4 41 Angiolymphoid hyperplasia with 73 Band keratopathy, 145–146
3 Squamous cell papilloma, 5–6 eosinophilia (ALHE), 81–82 74 Cystinosis, 147–148
4 Verruca vulgaris, 7–8 75 Salzmann’s nodular degeneration,
5 Seborrheic keratosis (sessile), 9–10 Chapter 2: Orbit and optic nerve 149–150
6 Xanthelasma, 11–12 42 Pleomorphic adenoma (benign 76 Spheroidal degeneration, 151–152
7 Sebaceous cell adenoma, 13–14 mixed tumor), 83–84 77 Keratoconus, 153–154
8 Inverted follicular keratosis, 15–16 43 Dacryoadenitis, 85–86 78 Corneal Dellen, 155–156
9 Rosacea, 17–18 44 Adenoid cystic carcinoma, 87–88 79 Keratoglobus, 157–158
10 Seborrheic keratosis 45 Hemangiopericytoma, 89–90 80 Fuchs’ endothelial dystrophy,
(papillomatous), 19–20 46 Cavernous hemangioma of the 159–160
11 Keratoacanthoma, 21–22 orbit, 91–92 81 Congenital hereditary endothelial
12 Squamous cell carcinoma in situ, 47 Prolapsed orbital fat, 93–94 dystrophy (CHED), 161–162
23–24 48 Solitary fibrous tumor of the orbit, 82 Posterior polymorphous dystrophy,
13 Invasive squamous cell carcinoma, 95–96 163–164
25–26 49 Rhabdomyosarcoma, 97–98 83 Hassall-Henle bodies, 165–166
14 Morpheaform basal cell carcinoma, 50 Schwannoma, 99–100 84 Wilson’s disease, 167–168
27–28 51 Neurofibroma in a patient with 85 Limbal dermoid, 169–170
15 Sebaceous cell carcinoma with neurofibromatosis, 101–102 86 Descemetocele, 171–172
pagetoid spread, 29–30 52 Fibrous dysplasia, 103–104 87 Acanthamoeba keratitis,
16 Pigmented basal cell carcinoma, 53 Eosinophilic granuloma, 105–106 173–174
31–32 54 Wegener’s granulomatosis, 107–108 88 Fungal keratitis secondary to
17 Merkel cell carcinoma, 33–34 55 Juvenile xanthogranuloma with Aspergillus, 00003#sc0110
18 Eccrine hidrocystoma, 35–36 primary orbital involvement, 89 Herpes simplex virus (HSV)
19 Apocrine hidrocystoma, 37–38 109–110 keratitis, 177–178
20 Epithelial inclusion cyst, 39–40 56 Dermoid cyst, 111–112 90 Microsporidial keratitis,
21 Syringoma, 41–42 57 Canaliculitis secondary to 179–180
22 Infundibular cyst, 43–44 Actinomyces, 113-114 91 Bacterial keratitis due to MRSA
23 Pilomatrixoma, 45–46 58 Orbital infection with (methicillin resistant Staphylococcus
24 Trichoepithelioma, 47–48 mucormycosis, 115–116 aureus), 181–182
25 Trichofolliculoma, 49–50 59 Dacryocystitis, 117–118 92 Rhizopus keratitis, 183–184
26 Trichilemmoma, 51–52 60 Transitional cell carcinoma of the 93 Herpes zoster keratitis, 185–186
27 Chalazion, 53–54 lacrimal sac, 119–120 94 Interstitial keratitis, 187–188
28 Molluscum contagiosum, 55–56 61 Orbital lymphoma (small 95 Corneal squamous cell carcinoma,
29 Intradermal nevus, 57–58 B-lymphocytic lymphoma), 121–122 189–190
30 Compound nevus, 59–60 62 Breast cancer with orbital cancer, 96 Epithelial ingrowth, 191–192
31 Malignant melanoma of the eyelid, 123–124 97 Failed DSEK, 193–194
61–62 63 Papilledema due to idiopathic 98 Intrastromal corneal ring segments
32 Floppy eyelid syndrome, 63–64 intracranial hypertension, 125–126 (INTACS), 195–196
33 Dermatochalasis, 65–66 64 Optic nerve drusen, 127–128 99 Pseudophakic bullous keratopathy,
34 Entropion with normal histology, 65 Optic neuritis, 129–130 197–198
67–68 66 Optic nerve sheath meningioma, 100 Failed corneal graft, 199–200
35 Cavernous hemangioma of the 131–132 101 Previous radial keratotomy,
eyelid, 69–70 67 Optic nerve glioma, 133–134 201–202
36 Eyelid varix, 71–72 102 Corneal blood staining, 203–204
37 Eyelid capillary hemangioma, Chapter 3: Cornea and conjunctiva 103 Corneal conjunctivalization,
73–74 68 Lattice dystrophy, 135–136 205–206
38 Melkersson-Rosenthal syndrome, 69 Granular dystrophy, 137–138 104 Corneal foreign body, 207–208
75–76 70 Avellino corneal dystrophy, 139–141 105 Vertical breaks in the Descemet’s
39 Nevus sebaceous, 77–78 71 Macular dystrophy, 141–142 membrane, 209–210
401
Index of cases
106 Primary acquired melanosis (PAM) Chapter 4: Uveal tract tumors 170 Von Hippel-Lindau disease, 339–340
without atypia, 211–212 139 Choroidal hemangioma, 277–278 171 Cryptococcal retinitis, 341–342
107 Benign acquired melanosis (BAM), 140 Choroidal nevus, 279–280 172 Endogenous endophthalmitis,
213–214 141 Iris nevi, 281–282 343–344
108 Primary acquired melanosis (PAM) 142 Bilateral diffuse uveal melanocytic 173 Hypopyon with probable secondary
with atypia, 215–216 proliferation (BDUMP), 283–284 endophthalmitis, 345–346
109 Conjunctival nevus, 217–218 143 Iris cyst, 285–286 174 Acute retinal necrosis (ARN),
110 Caruncular nevus, 219–220 144 Lisch in neurofibromatosis type 1, 347–348
111 Conjunctival melanoma arising 287–288 175 Ocular histoplasmosis, 349–350
from nevus, 221–222 145 Juvenile xanthogranuloma 176 Toxoplasma chorioretinitis, 351–352
112 Metastatic conjunctival melanoma, presenting with an iris mass, 177 Sympathetic ophthalmia, 353–354
223–224 289–290 178 Leukemia, 355–356
113 Pterygium and nevus occurring in 146 Lacy iris vacuolization in a patient 179 Drusen, 357–358
the same area, 225–226 with diabetes mellitus, 291–292
114 Pterygium, 227–228 147 Choroidal melanoma (epithelioid Chapter 6: Glaucoma and other disorders
115 Pinguecula, 229–230 type), 293–294 180 Pseudoexfoliation syndrome,
116 Oncocytoma, 231–232 148 Ciliary body melanoma (epithelioid 359–360
117 Conjunctival amyloidosis, 233–235 type), 295–296 181 Phacoantigenic uveitis, 361–362
118 Conjunctival squamous papilloma, 149 Spindle cell melanoma, 297–298 182 Neovascular glaucoma, 363–364
235–236 150 Iris melanoma, 299–300 183 Iridodialysis, 365–366
119 Hereditary benign intraepithelial 151 Medulloepithelioma, 301–302 184 Angle recession, 367–368
dyskeratosis (HBID), 237–238 152 Choroidal melanoma after plaque 185 Hemorrhagic glaucoma, 369–370
120 Conjunctival intraepithelial therapy, 303–304 186 Melanocytic glaucoma, 371–372
neoplasia (CIN), 239–240 153 Balloon cell melanoma, 305–306 187 Optic disc cupping secondary to
121 Invasive conjunctival squamous cell 154 Ring melanoma of the ciliary body glaucoma, 373–374
carcinoma, 241–242 (epithelioid type), 307–308 188 Schnabel’s cavernous dystrophy,
122 Conjunctival fibrous histiocytoma, 155 Metastatic renal cell carcinoma to 375–376
243–244 choroid, 309–310 189 Synophthalmos (Cyclopia),
123 Leiomyoma of the conjunctiva, 156 Metastatic breast cancer to choroid, 377–378
245–246 311–312 190 Vogt-Koyanagi-Harada (VKH)
124 Conjunctival mucosa-associated syndrome, 379–380
lymphoid tissue-type (MALT-type) Chapter 5: Retina and vitreous 191 Temporal (giant cell) arteritis,
lymphoma, 247–248 157 Cystoid macular edema, 313–314 381–382
125 Burkitt’s lymphoma, 249–250 158 Epiretinal membrane (macular 192 Suprachoroidal hemorrhage,
126 Benign reactive lymphoid pucker), 315–316 383–384
hyperplasia (BRLH), 251–252 159 Macular hole, 317–318 193 Posterior subcapsular cataract,
127 Conjunctival inclusion cyst, 253–254 160 Funnel-shaped retinal detachment, 385–386
128 Conjunctival lymphangiectasia, 319–320 194 Hypermature cataract, 387–388
255–256 161 Cotton-wool spots, 321–322 195 Crohn’s disease, 389–390
129 Lipodermoid, 257–258 162 Central retinal vein occlusion, 196 Anterior polar cataract, 391–392
130 Pyogenic granuloma, 259–260 323–324 197 Amyloid deposits in temporal artery,
131 Bacterial conjunctivitis, 261–262 163 Central retinal artery occlusion 393–394
132 Onchocerciasis, 263–264 (CRAO), 325–326 198 Phthisis bulbi, 395–396
133 Ligneous conjunctivitis, 265–266 164 Retinoblastoma, 327–328 199 Hyphema, 397–398
134 Conjunctival sarcoidosis, 267–268 165 Retinitis pigmentosa, 329–330 200 Abusive head trauma, 399–400
135 Lichens simplex chronicus, 269–270 166 Congenital hypertrophy of the
136 Ocular cicatricial pemphigoid, retinal pigment epithelium
271–272 (CHRPE), 331–332
137 Superior limbic keratoconjunctivitis, 167 Asteroid hyalosis, 333–334
273–274 168 Coats’ disease, 335–336
138 Vernal keratoconjunctivitis, 275–276 169 Senile retinoschisis, 337–338
402
Index
Page numbers followed by “f” indicate Asteroid bodies, attached to vitreous, 334, Breast cancer, 311
figures. 334f metastatic, to choroid, 311f–312f, 312
Asteroid hyalosis, 333f–334f, 334 with orbital cancer, 123f–124f, 124
A Astigmatism, irregular, 201, 201f Burkitt’s lymphoma, 249f–250f, 250
Atypical basaloid cells, 32
Abusive head trauma, 399f–400f, 400 Avellino corneal dystrophy, 139f–140f, C
Acanthamoeba keratitis, 173f–174f, 174 140
Acanthosis, 4, 16f, 18, 22f, 24f, 52f, 238f, Calcification, in pilomatrixoma, 46f
270f Calcified material, 392f
B
Acanthotic epithelium, 240, 240f Calcified mineralized tissue, Gram-positive
Acanthotic lobules, of epithelial cells, 56f Bacterial conjunctivitis, 261f–262f, 262 filaments in, 114, 114f
Acanthotic skin epithelium, 6f Bacterial keratitis, 181f–182f, 182 Canaliculitis secondary to Actinomyces, 113f,
Acquired immunodeficiency syndrome Balloon cell melanoma, 305f–306f, 114
(AIDS), 179, 179f 306 Capillary hemangioma, of eyelid, 73f–74f,
Actinic keratosis, 3f–4f, 4 Band keratopathy, 145f–146f, 146 74
Actinomyces, canaliculitis secondary to, 113f, Basal cell carcinoma, 1f–2f, 2 Cardiac echo-Doppler, 343
114 morpheaform, 27f–28f, 28 Caruncular lesion, 219, 219f
Acute nongranulomatous inflammation, pigmented, 31f–32f, 32 elevated round, 232
260 Basal epithelial pigmentation, 20f pigmented, 220–221, 221f
Acute retinal necrosis, 347f–348f, 348 Basaloid cells Caruncular nevus, 219f–220f, 220
Adenoid cystic carcinoma, 87f–88f, 88 in adenoid cystic carcinoma, 88f Cataract
Adenoma, pleomorphic, 83f–84f, 84 foamy cells lined by, 30f anterior polar, 391f–392f, 392
Adipose tissue, lobules of, 94, 94f islands of, 2f hypermature, 387f–388f, 388
Afferent pupillary defect, 381 with peripheral palisading of nuclei, posterior subcapsular, 385f–386f, 386
Alcian blue staining, 142 48f Cataract surgery, 191, 191f, 313, 345, 361
ALHE. see Angiolymphoid hyperplasia with Basophilic cells, 46f complications of, 383
eosinophilia (ALHE). “Beaten bronze” appearance, 160 Cataractous lens, 388f
Amblyopia, 391 Benign acquired melanosis (BAM), Cavernous hemangioma
Amorphous eosinophilic substance, 266f 213f–214f, 214 of eyelid, 69f–70f, 70, 79f–80f, 80
Amyloid deposits, in temporal artery, Benign mixed tumor. see Pleomorphic of face, 79f–80f, 80
393f–394f, 394 adenoma. of orbit, 91f–92f, 92
Amyloidosis, conjunctival, 233f–234f, Benign reactive lymphoid hyperplasia CD3 staining, in dacryoadenitis, 86
234 (BRLH), 251f–252f, 252 CD20 staining, in dacryoadenitis, 86
Angiolymphoid hyperplasia with Bilateral diffuse uveal melanocytic Cells, rounded-to-polygonal-shaped, with
eosinophilia (ALHE), 81f–82f, 82 proliferation (BDUMP), 283f–284f, abundant clear cytoplasm, 310f
Angle closure glaucoma, 375 284 Central corneal thinning, 186
Angle recession, 367f–368f, 368 Biopsy Central retinal artery occlusion (CRAO),
Anterior basement membrane dystrophy, excisional, with left upper eyelid 325f–326f, 326
143f–144f, 144 fullness, 83 Central retinal vein occlusion, 323f–324f,
Anterior chamber, 370f, 372f orbital 324
blood in, 398f histiocytic cell tumor in, 110 Chalazion, 53f–54f, 54
Anterior corneal nodules, 150 with increasing proptosis, 91, 91f Chemical burn, 205, 205f
Anterior lens capsule, 360f, 388f, 392f Blood, in anterior chamber, 398f Chorioretinal scarring, 352
Anterior orbitotomy, with left upper eyelid Blood vessel lumen, 76f Chorioretinitis, Toxoplasma, 351f–352f, 352
fullness, 111, 111f Blood vessels Choroidal hemangioma, 277f–278f, 278
Anterior polar cataract, 391f–392f, 392 dilated thick-walled, in cavernous Choroidal inflammation, 380f
Anterior stromal opacities, 138 hemangioma of the orbit, 92 Choroidal mass, 305, 309, 309f
Apical snouts, 38f radiating, 260, 260f Choroidal melanoma
Apocrine hidrocystoma, 37f–38f, 38 Bowman’s layer, 144f, 146, 180f after plaque therapy, 303f–304f, 304
Aspergillus, fungal keratitis secondary to, loss of, 158 epithelioid type, 293f–294f, 294
176 Bowman’s membrane, 150 Choroidal nevus, 279f–280f, 280
403
Index
Choroidal tissue, infiltrated with epithelial Conjunctival intraepithelial neoplasia orbital lymphoma and, 122
cells, exhibiting “Indian-file” (CIN), 239f–240f, 240 right lacrimal sac fossa and, 120
arrangement, 312, 312f Conjunctival melanoma, from nevus, showing enlargement of lacrimal gland,
Chronic lymphoplasmacytic inflammation, 221f–222f, 222 86
276 Conjunctival mucosa-associated lymphoid showing left orbital mass with erosion,
Chronic lytic superior orbital lesion, in tissue-type (MALT-type) lymphoma, 108
eosinophilic granuloma, 106 247f–248f, 248 Cyclopia. see Synophthalmos.
CHRPE. see Congenital hypertrophy of the Conjunctivitis Cystic carcinoma, adenoid, 87f–88f, 88
retinal pigment epithelium bacterial, 261f–262f, 262 Cystic cavity, in dermoid cyst, 112, 112f
(CHRPE). ligneous, 265f–266f, 266 Cystic space, 40f
Ciliary body, 366f, 368f, 372f Connective tissue, with spindle-shaped Cystine crystals, 148
Ciliary body melanoma (epithelioid type), fibrocytes, 96 Cystinosis, 147f–148f, 148
295f–296f, 296 Cornea, 135f, 364f, 370f, 372f, 392f Cystoid macular edema, 313f–314f, 314
CIN (conjunctival intraepithelial central thinning, 186, 186f Cysts
neoplasia), 239f–240f, 240 clouding, 203, 203f in adenoid cystic carcinoma, 88, 88f
Coats’ disease, 335f–336f, 336 deposited, 146 epithelial inclusion, 39f–40f, 40
Collagen fibers, 66f edematous, 190, 197–198, 197f, 200, infundibular, 43f–44f, 44
Compound nevus, 59f–60f, 60 204, 204f keratinized stratified squamous
Cone-shape deformity, of cornea, 154 foreign body, 208, 208f epithelial lining of, 40f
Congenital hereditary endothelial haze, 198, 200, 206 pseudohorn, 10f
dystrophy (CHED), 161f–162f, neovascularization, 187–189, 187f, Cytoid bodies, 322, 322f
162 189f Cytoplasmic antineutrophil cytoplasmic
Congenital hypertrophy of the retinal squamous cell carcinoma, 189f–190f, antibody (cANCA), in Wegener’s
pigment epithelium (CHRPE), 331f 190 granulomatosis, 108
Congo red stain, 136, 136f, 140–141, transplant, 181, 181f, 194, 194f–195f,
233–235, 233f–234f 199, 199f D
Conjunctiva Corneal blood staining, 203f–204f, 204
amyloidosis, 233f–234f, 234 Corneal conjunctivalization, 205f–206f, Dacryoadenitis, 85f–86f, 86
biopsy, 147, 213, 213f, 219, 221f, 271 206 Dacryocystitis, 117f, 118
bulbar, 256, 256f, 260, 268, 273–274 Corneal Dellen, 155f–156f, 156 Dacryocystorhinostomy, in dacryocystitis,
epithelial basement membrane, 272 Corneal dendritic lesions, 178 117f
fibrous histiocytoma, 243f–244f, 244 Corneal epithelium, 144f, 186f, 228f Deformity, eyelid, 101, 101f
inclusion cyst, 253f–254f, 254 Corneal findings, 135, 209, 209f Dermatochalasis, 65f–66f, 66
invasive, squamous cell carcinoma, Corneal foreign body, 207f–208f, 208 Dermis
241f–242f, 242 Corneal graft, failed, 199f–200f, 200 in basal cell carcinoma, 2
laceration, 259, 259f Corneal opacities, 136–138, 136f–137f, in entropion, 68f
leiomyoma of, 245f–246f, 246 188–189, 204 granulomatous inflammation in, 18f
lesion, 211, 211f, 213–215, 213f–215f, bilateral, 147, 147f hyperplastic sebaceous glands, 14
217, 217f, 229, 229f, 237, 237f, multiple scalloped, 164 in infundibular cyst, 44f
239, 239f, 241, 241f, 243, 243f, Corneal scars, 177, 177f, 202, 208f in intradermal nevus, 58f
250, 253, 253f, 255, 255f, 267, Corneal tissue, 174, 174f, 180, 182, 200 malignant squamous cells, 26f
267f Corneal ulcer in Merkel cell carcinoma, 34f
elevated, 246 central, 173, 173f, 175, 175f, 183, sclerosed, 28f
lymphangiectasia, 255f–256f, 256 183f in seborrheic keratosis, sessile, 10f
mass, 247, 247f, 251, 251f, 257, 257f, necrotic, 184 in squamous cell papilloma, 6f
259, 259f non-healing, 185–186, 185f in xanthelasma, 12f
nevus, 217f–218f, 218 Cotton-wool spots, 321f–322f, 322 Dermoid cyst, 111f, 112
pigmentation, 216 CRAO. see Central retinal artery occlusion Descemetocele, 171f–172f, 172
sarcoidosis, 267f–268f, 268 (CRAO). Descemet’s membrane, 156, 162, 168, 178,
squamous papilloma, 235f–236f, 236 Crohn’s disease, 389f–390f, 390 194, 364f
superior bulbar, 212, 212f Cryptococcal retinitis, 341f–342f, 342 fragmented, 178f
superior tarsal, 266 Cryptococcus organisms, encapsulated, 342, vertical breaks in, 209f–210f, 210
tarsal, 270 342f Descemet’s stripping endothelial
tissue, 224 CT scan keratoplasty (DSEK), 193–194,
Conjunctival epithelium, 148f, 212f, 214f, chronic lytic superior orbital lesion and, 193f
222, 226f, 228f, 234f, 252f, 254f, 106 Dilated fundus examination, in
256f, 262f, 268f, 272f, 276f of diplopia, 95, 95f papilledema, 126
Conjunctival hyperemia, 346 of left upper eyelid, 85, 85f Dilated pupil, 333, 333f
404
Index
Diplopia, 95, 95f Epithelial inclusion cyst, 39f–40f, 40 Focal parakeratosis, 18

with breast cancer, 123, 123f Epithelial ingrowth, 191f–192f, 192 Follicular keratosis, inverted, 15f–16f, 16
and exophthalmos of the right eye, 97, Epithelial lining, 38f Foreign body sensation, 143, 143f, 149,
97f Epithelioid cells, 362f 149f, 251, 251f, 253, 273, 273f, 275,
and facial pain, 103, 103f giant, in eosinophilic granuloma, 106, 275f
ocular pain and, 105, 105f 106f Fuchs’ endothelial dystrophy, 159f–160f,
with pain and proptosis, 87, 87f with large cytoplasm, 296, 296f 160, 193, 193f
Double vision Epithelioid histiocytes, 46f Fundus examination, 284, 322, 326, 338,
and left eye proptosis, 89, 89f Epithelium, 138f, 140f, 152f, 158, 196f, 340, 357–358, 382
in orbital lymphoma, 121f, 122 220f see also Dilated fundus examination.
proptosis and, 99, 99f acanthotic skin, 6f Fungal keratitis, 175f–176f, 176
Droopy eyelids, 65–66 corneal, 162f Funnel-shaped retinal detachment,
Drusen, 357f–358f, 358 irregular, 150 319f–320f, 320
optic nerve, 128, 128f Erythematous lesion, 240
Dry eyes, 149, 149f, 155, 155f, 273, 273f Excisional biopsy, 221, 225, 255 G
Dual epithelial layers, pleomorphic conjunctival, 249, 249f, 269
adenoma, 84 with left upper eyelid fullness, 83 Giant cell, 382f
Duct formation, 312, 312f Exophthalmos of right eye, diplopia and, multinucleated, 54f, 178f
Ductules, in pleomorphic adenoma, 84 97, 97f Glandular structures, 270
Dystrophy Exudative retinal detachment, 294, 294f Glaucoma
anterior basement membrane, 144 Eye angle closure, 375
Avellino corneal, 140 dry irritated, 63–64 hemorrhagic, 369f–370f, 370
congenital hereditary endothelial, 162 enucleated, 344 melanocytic, 371f–372f, 372
Fuchs’ endothelial, 160 itching, 275, 275f neovascular, 363f–364f, 364
granular, 138 lesion, 225, 225f, 227, 227f, 265, 265f optic disc cupping secondary to,
lattice, 136f pain, 107, 107f, 207, 207f, 361, 363 373f–374f, 374
macular, 142 redness, 207, 207f, 233, 233f, 263, Glioma, optic nerve, 133f–134f, 134
263f Goblet cells, 148f, 206f, 212f, 220, 220f,
rubbing, 269, 269f 262f, 274
E
tearing, 207, 207f, 235, 235f, 245, Goldenhar syndrome, 169, 169f
Eccrine hidrocystoma, 35f–36f, 36 245f Gomori methenamine silver (GMS) stain,
Ectropion uveae, 364f Eyelid 176
Edema capillary hemangioma, 73f–74f, 74 Gonioscopic examination
cystoid macular, 313f–314f, 314 cavernous hemangioma, 69f–70f, 70 in angle recession, 368
optic nerve, 127, 127f deformity, 101, 101f, 287, 287f in iridodialysis, 366
Edematous cornea, 160 droopy, 65–66 Gram-positive cocci, 182
Endogenous endophthalmitis, 343f–344f, floppy, 63f–64f, 64 Gram-positive filaments, in calcified
344 lesion, 1–2, 1f, 225 mineralized tissue, 114, 114f
Endophthalmitis malignant melanoma of, 61f–62f, 62 Gram-positive organisms, in vitreous, 344,
endogenous, 343f–344f, 344 swelling, 245, 245f 344f
hypopyon with probable secondary, varix, 71f–72f, 72 Granular calcified material, in canaliculitis
345f–346f, 346 secondary to Actinomyces, 114
Endothelial cell layer, 162 Granular dystrophy, 137f–138f, 138,
F
Endothelial lining, 70f, 80f 140–141
Endothelium, 154 Facial asymmetry, in fibrous dysplasia, 104 Granuloma, 268f
intracytoplasmic vacuolization of, 82f Facial pain, diplopia and, 103, 103f eosinophilic, 105f, 106
multilayer, 164 Failed corneal graft, 199f–200f, 200 Granulomatous inflammation, 18f, 54f
Entropion, 67f–68f, 68 Fibrotic dermis, 170f intravascular, 76f
Enucleation Fibrous dysplasia, 103f, 104 Grenz zone, 58f
retinal detachment, 319 Fibrovascular core, 8f Guttae, 160, 166
Schnabel’s cavernous dystrophy, 375 Fibrovascular septae, with prolapsed orbital
Eosinophilic granuloma, 105f, 106 fat, 94, 94f H
Eosinophils, 82f Filamentous fungi, branching, 184, 184f
in eosinophilic granuloma, 106, 106f Flexner-Wintersteiner rosettes, 328, 328f Hair follicle, 18f, 28f
Epiphora, 231, 231f Floppy eyelid syndrome, 63f–64f, 64 Hassall-Henle bodies, 165f–166f, 166
Epiretinal membrane (macular pucker), Florid iris rubeosis, 364 Head trauma, abusive, 399f–400f, 400
315f–316f, 316 Fluorescein angiogram, sympathetic Headaches, 379
Epithelial cells, acanthotic lobules of, 56f ophthalmia, 353 chronic, 125, 125f
405
Index
Hemangioma Interstitial keratitis, 187f–188f, 188 Keratitis

cavernous Intervening fibrous septa, 74f bacterial, due to MRSA (methicillin
of eyelid, 69f–70f, 70, 79f–80f, 80 Intervening septae, 70f resistant Staphylococcus aureus),
of face, 79f–80f, 80 Intestinal biopsy, in Crohn’s disease, 182
of orbit, 91f–92f, 92 390 herpes simplex virus (HSV), 178
choroidal, 277f–278f, 278 Intestinal villi, 390f herpes zoster, 186
Hemangiopericytoma, 89f–90f, 90 Intracellular edema, 152 interstitial, 188, 188f
Hemorrhages Intraconal mass, in T1-weighted magnetic microsporidial, 180
central retinal vein occlusion, 324 resonance imaging, 100 Rhizopus, 184
of optic nerve sheath, 400f Intradermal cystic cavity, 38f Keratoacanthoma, 21f–22f, 22
retinal, 400 Intradermal nevus, 57f–58f, 58 Keratoconjunctivitis
suprachoroidal, 383f–384f, 384 Intraepithelial keratin pearls, 24 superior limbic, 273f–274f, 274
Hemorrhagic glaucoma, 369f–370f, 370 Intraocular mass, 301, 301f, 371 vernal, 275f–276f, 276
Henderson-Patterson corpuscles, 56 Intraocular pressure (IOP), neovascular Keratoconus, 153f–154f, 154, 195–196,
Hereditary benign intraepithelial glaucoma, 363 195f
dyskeratosis (HBID), 237f–238f, 238 Intrastromal corneal ring segments Keratoglobus, 157f–158f, 158
Herpes simplex virus (HSV) keratitis, (INTACS), 195f–196f, 196 Keratopathy
177f–178f, 178 Intravascular granulomatous inflammation, band, 145f–146f, 146
Herpes zoster keratitis, 185f–186f, 186 76f pseudophakic bullous, 197f–198f, 198
Hidrocystoma Invasive squamous cell carcinoma, 25f–26f, Keratoplasty, penetrating, 137, 137f, 139,
apocrine, 37f–38f, 38 26 139f, 147, 159, 159f, 163, 173, 175,
eccrine, 35f–36f, 36 Inverted follicular keratosis, 15f–16f, 16 181, 181f, 197, 201, 201f, 203, 203f,
Histiocytic cell tumor, orbital biopsy and, Iridodialysis, 365f–366f, 366 209, 209f
110 Iris, 370f, 392f Keratosis
Histoplasma capsulation organisms, 350, cyst, 285f–286f, 286 actinic, 3f–4f, 4
350f detached, 366f inverted follicular, 15f–16f, 16
Histoplasmosis, ocular, 349f–350f, 350 lesion, 285, 285f, 289, 289f seborrheic, 9f–10f, 10, 19f–20f, 20
Homer-Wright rosettes, 328, 328f multiple, 281, 281f
Hyalosis, asteroid, 333f–334f, 334 pigmented, 299, 299f L
Hyaluronic acid, cystic spaces filled with, melanoma, 299f–300f, 300
302, 302f neovascularization, 364 Lacrimal gland tissue, in dacryoadenitis, 86,
Hyperemia, conjunctival, 346 Iris dilator muscle, 192f 86f
Hyperkeratosis, 4, 4f, 16f, 24, 238f Iris nevi, 281f–282f, 282 Lacrimal sac, transitional cell carcinoma of,
Hypermature cataract, 387f–388f, 388 Irregular trabeculae, of immature woven 119f, 120
Hyperplastic sebaceous glands, 14 bone, 104, 104f Lacy iris vacuolization, in patient with
Hypertension, 321, 323, 363 diabetes mellitus, 291f–292f, 292
Hyphae, multiple branching nonseptate, Lamina cribrosa, 376f
J
184 in optic nerve drusen, 128, 128f
Hyphema, 397f–398f, 398 Juvenile xanthogranuloma Lanugo hairs, 50
Hypopyon, 175–176 presenting with iris mass, 289f–290f, Lattice dystrophy, 135f–136f, 136, 140–141
with probable secondary 290 Left eye proptosis, 89, 89f
endophthalmitis, 345f–346f, 346 with primary orbital involvement, 109f, Left upper eyelid fullness, 83, 83f
Hypotony, 383 110 with dermoid cyst, 111, 111f
in pleomorphic adenoma, 84
K Leiomyoma, of conjunctiva, 245f–246f,
I
246
Immunohistochemistry, 250, 272 Kayser-Fleischer ring, 168 Lens, 362f, 386f, 392f
Inclusion bodies, 56 Keratin cataractous, 388f
Inclusion cyst, conjunctival, 253f–254f, 254 central mass of, 22f Lens capsule, 362f
Increasing proptosis, 91, 91f in infundibular cyst, 44f anterior, 360f, 388f, 392f
Inflammation surface, 10f posterior, 386f
choroidal, 380f in verruca vulgaris, 8f Lens epithelium, 360f
within lamina propria, 390f Keratinized skin epithelium, 34f, 78f Leukemia, 355f–356f, 356
Inflammatory infiltrate, nongranulomatous Keratinized squamous epithelium, Leukocoria, 327
mixed, 274 acanthotic, 10f Leukoplakia, mild, 230
Infundibular cyst, 43f–44f, 44 Keratinized stratified squamous epithelium, Lichens simplex chronicus, 269f–270f, 270
Insulin-dependent diabetes mellitus, 291, 66f, 76f, 170, 170f Ligneous conjunctivitis, 265f–266f, 266
291f, 363 Keratinized surface epithelium, 28f Limbal dermoid, 169f–170f, 170
406
Index
Lipid-laden histiocytes, 12f ring, of ciliary body (epithelioid type), conjunctival, 217f–218f, 218
Lipid vacuole, 54f 307f–308f, 308 melanoma arising from, 221f–222f,
Lipodermoid, 257f–258f, 258 skin, 223, 223f 222
Lisch in neurofibromatosis type 1, spindle cell, 297f–298f, 298 intradermal, 57f–58f, 58
287f–288f, 288 Melkersson-Rosenthal syndrome, 75f–76f, junctional, 226
Lisch nodule, 288, 288f 76 pterygium and, 225f–226f, 226
Lower eyelid fullness, right upper and, in Merkel cell carcinoma, 33f–34f, 34 sebaceous, 77f–78f, 78
rhabdomyosarcoma, 98 Mesenchymal elements, in pleomorphic Nongranulomatous inflammation, 4f, 10f
Lymphangiectasia, conjunctival, 255f–256f, adenoma, 84 within the adventitia, 382f
256 Metastatic conjunctival melanoma, chronic, 54f
Lymphocytes, 362f 223f–224f, 224 Nonkeratinized pseudostratified columnar
Lymphocytic inflammation without Methicillin resistant Staphylococcus aureus epithelium, 118, 118f
necrosis, in dacryoadenitis, 86, 86f (MRSA), 182, 182f Nuclear pleomorphism, 120, 120f
Lymphoma Microsporidial keratitis, 179f–180f, 180 Nucleoli, 294f
Burkitt’s, 249f–250f, 250 Mild lymphocytic infiltrate, 270, 270f Nucleus, large, with prominent nucleoli,
conjunctival mucosa-associated Mild proptosis, in rhabdomyosarcoma, 98 296, 296f
lymphoid tissue-type (MALT- Molluscum contagiosum, 55f–56f, 56 Nystagmus, 161
type), 247f–248f, 248 Monoclonality, in CD3 and CD20 staining,
orbital, 121f–122f, 122 86 O
Lymphoplasmacytic infiltrate, 206 Morgagnian globules, 386, 388
Lymphoplasmacytic inflammation, 268f Morpheaform basal cell carcinoma, Occlusion, central retinal vein, 323f–324f,
27f–28f, 28 324
Motility, restriction of, in Ocular cicatricial pemphigoid, 271f–272f,
M
rhabdomyosarcoma, 98 272
Macrophages, pigment-laden, 372f Mucopolysaccharide deposits, 142 Ocular discomfort, 231, 231f
Macular dystrophy, 141f–142f, 142 Mucor, nonseptate filamentous fungi, 116, chronic, 271, 271f
Macular edema, cystoid, 313f–314f, 314 116f Ocular histoplasmosis, 349f–350f, 350
Macular hole, 317f–318f, 318 Mucormycosis, orbital infection with, Ocular injury, 369
Macular pucker. see Epiretinal membrane. 115f–116f, 116 Ocular irritation, 255, 255f, 265, 265f
Magnetic resonance imaging (MRI) Muir-Torre syndrome, 14 Ocular pain, 143, 143f, 145, 177f, 263,
adenoid cystic carcinoma, 87f–88f, 88 Multi-loculated cystic spaces, 256, 256f 263f, 343, 347, 369, 371
hemangiopericytoma, 90 Multilocular branching lumen, 36 and diplopia, 105, 105f
optic neuritis, 130 Multinucleated giant cell, 54f Ocular shingles, 185, 185f
Malignant melanoma, of eyelid, 61f–62f, Multiple epithelial-lined cysts, 218, 218f Onchocerca volvulus, 264, 264f
62 Munson’s sign, 154 Onchocerciasis, 263f–264f, 264
“Map” dystrophy, 144 Myoepithelial cells, in pleomorphic Oncocytoma, 231f–232f, 232
Masson trichrome adenoma, 84f Ophthalmia, sympathetic, 353f–354f, 354
in rhabdomyosarcoma, 98 Ophthalmic examination, 153, 153f, 165,
staining, 138, 140–141 165f
N
Medial canthus, multiple cystic lesions in, OPL. see Outer plexiform layer (OPL).
37–38 Necrosis Optic disc cupping, 373f–374f, 374
Medulloepithelioma, 301f–302f, 302 acute retinal, 347f–348f, 348 Optic nerve, 376f
Meibomian glands, within tarsus, 64f in Wegener’s granulomatosis, 108f dilated vascular channels in, 340, 340f
Melanocytic cells Neovascular glaucoma, 363f–364f, 364 retrolaminar, degeneration of, 376
nests of, 220, 220f Neovascularization, of iris, 364 Optic nerve drusen, 128, 128f
proliferation of, 280, 280f Nerve bundle, in adenoid cystic carcinoma, Optic nerve edema, 127, 127f
Melanocytic glaucoma, 371f–372f, 372 88f Optic nerve glioma, 133f–134f, 134
Melanoma Nerve fiber layer, 400f Optic nerve head, 374
balloon cell, 305f–306f, 306 Neuritis, optic, 129f–130f, 130 Optic nerve sheath hemorrhage, 400f
choroidal Neurofibroma, with neurofibromatosis, Optic nerve sheath meningioma, 131f–
after plaque therapy, 303f–304f, 101f–102f, 102 132f, 132
304 Neurofibromatosis, neurofibroma with, Optic neuritis, 129f–130f, 130
epithelioid type, 293f–294f, 294 101f–102f, 102 Ora serrata, retinal hemorrhage to, 400
ciliary body, 295f–296f, 296 Neurotrophic ulcer, 186 Orbital biopsy
conjunctival, from nevus, 221f–222f, Neutrophils, 362f histiocytic cell tumor in, 110
222 Nevus increasing proptosis and, 91, 91f
malignant, of eyelid, 61f–62f, 62 caruncular, 219f–220f, 220 Orbital cancer, breast cancer with,
metastatic conjunctival, 223f–224f, 224 compound, 59f–60f, 60 123f–124f, 124
407
Index
Orbital fat, prolapsed, 93f, 94 Primitive skeletal muscle, in Right upper and lower eyelid fullness, in
Orbital infection with mucormycosis, rhabdomyosarcoma, 98, 98f rhabdomyosarcoma, 98
115f–116f, 116 Progressive proptosis, 133 Ring melanoma, of ciliary body (epithelioid
Orbital lymphoma, 121f–122f, 122 Prolapsed orbital fat, 93f, 94 type), 307f–308f, 308
Orbital mass, 109, 109f Proliferated pericytes, hemangiopericytoma Rosacea, 17f–18f, 18
Osseous metaplasia, 396f and, 90, 90f Rosenthal fibers, 134, 134f
Outer plexiform layer (OPL), of retina, 338, Proliferating capillaries, 74f
338f Proptosis, 87, 87f S
Ovarian carcinoma, 283 and double vision, 99, 99f
increasing, 91, 91f S-100 stain, in schwannoma, 100
left eye, 89, 89f “S-shaped” eyelid deformity, 102
P
mild, in rhabdomyosarcoma, 98 “Salmon patch” conjunctival lesion, 248,
Pagetoid spread, 30, 30f progressive, 133 250
Pain, ocular, 143, 263, 263f Pseudoexfoliation syndrome, 359f–360f, Salzmann’s nodular degeneration,
PAM (Primary acquired melanosis), 212, 360 149f–150f, 150
212f, 216, 216f Pseudohorn cysts, 10f Sarcoidosis, conjunctival, 267f–268f, 268
Papillary proliferation, of transitional cells, Pseudophakic bullous keratopathy, Scars, corneal. see Corneal scars.
120, 120f 197f–198f, 198 Schnabel’s cavernous dystrophy, 375f–376f,
Papilledema, due to idiopathic intracranial Pterygium, 227f–228f, 228 376
hypertension, 125f–126f, 126 and nevus at the same area, 225f–226f, Schwannoma, 99f–100f, 100
Papillomatous acanthosis, 20 226 Sclera, 366f, 368f, 372f, 374f, 376f
Parakeratosis, 4, 4f, 16f, 22, 24, 270, 270f Ptosis, 109, 109f in phthisis bulbi, 396
Paraneoplastic syndrome, 283f–284f, 284 Pyogenic granuloma, 259f–260f, 260 Sclerosed dermis, 28f
PAS stain, 140–141 Sebaceous cell adenoma, 13f–14f, 14
Perineural invasion, in adenoid cystic Sebaceous cell carcinoma, 29f–30f, 30
R
carcinoma, 88, 88f Sebaceous gland, 66f, 78f, 170f, 220f
Peripheral anterior synechiae, 364f Racial melanosis, 213f–214f, 214 hyperplastic, 14
Peripheral palisading, 52f Radial corneal scars, 346 Seborrheic keratosis
of nuclei, 2f Reduplicated epithelial basement papillomatous, 19f–20f, 20
Peyer’s patches, 390f membrane, 144f sessile, 9f–10f, 10
Phacoantigenic uveitis, 361f–362f, 362 Renal cell carcinoma, metastatic, to Senile retinoschisis, 337f–338f, 338
Photophobia, 141, 141f, 177, 199, 199f, choroid, 309f–310f, 310 Severe atypia, 190
347, 353, 361 Restricted ocular motility, 107, 107f Shadow cells, 46f
Phthisis bulbi, 395f–396f, 396 Retina, in phthisis bulbi, 396 Skin epithelium, 12f, 24f
Pigment laden macrophages, 212f Retinal detachment, 145, 145f, 344, 344f acanthotic, 6f
Pigmented basal cell carcinoma, 31f–32f, exudative, 356, 356f keratinized, 34f
32 funnel-shaped, 319f–320f, 320 normal, 22f
Pilar unit(s), 6f, 66f, 68f, 170f, 220f Retinal exudates, 336 Skin melanoma, 223, 223f
Pilomatrixoma, 45f–46f, 46 Retinal hemangioblastoma, 340 Skin tags, 9–10
Pilosebaceous units, 60f, 220, 232, 232f Retinal hemorrhages, to ora serrata, 400 Slit-lamp examination, 136, 140, 142–144,
Pinguecula, 229f–230f, 230 Retinal necrosis, acute, 347f–348f, 348 150, 152, 156, 158, 160, 162–164,
Plasma cells, 82f, 362f Retinal pigment epithelium (RPE), 380f 166–167, 167f, 170, 172, 176–177,
Pleomorphic adenoma, 83f–84f, 84 congenital hypertrophy of, 331f–332f, 180, 182, 184, 188, 190, 194, 196,
Pleomorphic spindle-shaped cells, in 332 198, 220, 224, 232, 234, 236, 246,
rhabdomyosarcoma, 98 Retinal vein occlusion, central, 323f–324f, 252, 258, 264, 266, 268
Pleomorphism cells, 34f 324 in anterior polar cataract, 392
Posterior chamber, 370f Retinitis, cryptococcal, 341f–342f, 342 asteroid hyalosis, 334
Posterior pigmented iris epithelium, 192f Retinitis pigmentosa, 329f–330f, 330 in hemorrhagic glaucoma, 370
Posterior polymorphous dystrophy, Retinoblastoma, 327f–328f, 328 in hypermature cataract, 388
163f–164f, 164 Retinoschisis, senile, 337f–338f, 338 hypopyon with probable secondary
Posterior subcapsular cataract, 385f–386f, Retraction artifact, 32, 32f endophthalmitis, 346
386 Retrolaminar optic nerve, degeneration of, in Merkel cell carcinoma, 34
Previous radial keratotomy, 201f–202f, 202 376 in phacoantigenic uveitis, 362
Primary acquired melanosis (PAM) Rhabdomyosarcoma, 97f, 98 in posterior subcapsular cataract, 386
with atypia, 215f–216f, 216 Rheumatoid arteritis, 171, 171f in pseudoexfoliation syndrome, 360
without atypia, 211f–212f, 212 Rhizopus keratitis, 183f–184f, 184 Slit-lamp image, 333
Primary orbital involvement, juvenile Right eyelid swelling, 115, 115f Small B-lymphocytic lymphoma. see
xanthogranuloma with, 109f, 110 Right lacrimal sac fossa, CT scan and, 120 Orbital lymphoma.
408
Index
Solar elastosis, 4f Superior limbic keratoconjunctivitis, V

Solar elastotic changes, 230, 230f, 240 273f–274f, 274
Solitary fibrous tumor of the orbit, 95f–96f, Superior tarsal conjunctiva, 266 V-shaped deformity, 154
96 Suprachoroidal hemorrhage, 344, Vacuolated histiocytes, 244, 244f
Spheroidal degeneration, 151f–152f, 152 383f–384f, 384 Vascular channels, 70f
Spindle cell melanoma, 297f–298f, 298 Supratemporal subconjunctival lesion, 258 dilated, 278, 278f
Spindle-shaped fibrocytes, connective tissue Surface epithelium, 14f, 26f, 40f, 44f, 48f with “staghorn” configuration, 90,
with, 96 keratinized, 28f 90f
Squamous cell carcinoma of skin, 38f dilated blood-filled, 80f
corneal, 190, 190f Surface keratin, 10f lining of, 72f
invasive, 25f–26f, 26 Swelling Vascular “insect wing-like” growth, 228
conjunctival, 241f–242f, 242 pain and, of left upper eyelid, 85 Vascular orbital lesion, in cavernous
nests of malignant, 242 of right lower eyelid, 119, 119f hemangioma of the orbit, 92
in situ, 23f–24f, 24 “Swiss cheese” pattern, tumor with, 88, 88f Vernal keratoconjunctivitis, 275f–276f, 276
Squamous eddies, 16f Sympathetic ophthalmia, 353f–354f, 354 Verruca vulgaris, 7f–8f, 8
Squamous papilloma, 5f–6f, 6 Synophthalmos, 377f–378f, 378 Vision
conjunctival, 235f–236f, 236 Syringoma, 41f–42f, 42 decreased, 125, 125f, 139, 141, 141f,
“Staghorn” configuration, dilated vascular 145, 151, 151f, 159, 161, 161f,
channels with, 90, 90f 163, 163f, 177, 179, 187, 187f,
T 197, 197f, 199, 199f, 271, 271f,
Stem cell
deficiency, corneal conjunctivalization T1-weighted magnetic resonance imaging 277, 277f, 301, 301f, 305, 313,
secondary to, 205f–206f, 206 in schwannoma, 100 315, 317, 335, 341, 343, 347, 349,
transplant, 205, 205f in solitary fibrous tumor of the orbit, 96 351, 353, 355, 361, 363, 371, 375,
Steroids, 189 “Tadpole configuration,” dermis, 42, 42f 379, 385, 389, 391, 393, 397
Storiform pattern, in solitary fibrous tumor Tarsal conjunctiva, 64 and intraocular mass, 301, 301f
of the orbit, 96 Temporal artery, 382 double, 89, 89f
Stratified squamous epithelium, 148, 258, amyloid deposits in, 393f–394f, 394 gradual decrease of, 307
258f, 276 Temporal (giant cell) arteritis, 381f–382f, loss of, 293, 293f, 295, 295f, 311, 311f,
nonkeratinized, 192, 192f, 206, 214, 382 319, 325, 329, 373
218, 218f, 220, 220f, 228, 232, Touton multinucleated giant cells, 290, mild blurring of, 131
232f, 236, 252, 254, 254f 290f poor, 157, 157f
acanthotic, 236, 236f in histiocytic cell tumor, 110, 110f VKH syndrome. see Vogt-Koyanagi-Harada
Striated muscles, 68f Toxoplasma chorioretinitis, 351f–352f, 352 (VKH) syndrome.
Stroma, 138f, 140f, 144f, 180f, 186f, 196f, Toxoplasma cysts, 352f Vogt-Koyanagi-Harada (VKH) syndrome,
226f Transitional cell carcinoma, of the lacrimal 379f–380f, 380
conjunctival, 148f, 212f, 214f, 230, 230f, sac, 119f, 120 Von Hippel-Lindau disease, 339f–340f, 340
254, 254f, 256f, 262, 266, 268, Trauma, head, 399f–400f, 400 von Kossa stain, 146
272f Trichilemmoma, 51f–52f, 52
corneal, 146f, 148, 178f, 198f Trichoepithelioma, 47f–48f, 48 W
scarred, 210, 210f Trichofolliculoma, 49f–50f, 50
edematous, 260, 260f Tumor cells Wegener’s granulomatosis, 107f, 108
fibrosis, 152f cords of, 28f Wilson’s disease, 167f–168f, 168
iris, 192f cytoplasm of, 294f
loss of, 172 X
opacities, 140 U
solar elastosis, 240 Xanthelasma, 11f–12f, 12
substantia propria, 256, 256f Ultrasound
Subretinal exudates, 376f in melanocytic glaucoma, 372
Subretinal hemorrhage, 344 in suprachoroidal hemorrhage, 384
Substantia propria, 270, 274, 274f Uveitis, phacoantigenic, 361f–362f, 362
409

Ocular Pathology Case Reviews - Azari, Amir (SRG) PDF

Uploaded by

Copyright:

Available Formats

Ocular Pathology Case Reviews - Azari, Amir (SRG) PDF

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Ocular Pathology Case Reviews - Azari, Amir (SRG) PDF

Uploaded by

Copyright:

Available Formats

Ocular Pathology

Daniel M. Albert, MD, MS

London,â•‡ New York,â•‡ Oxford,â•‡ Philadelphia,â•‡ St Louis,â•‡ Sydney,â•‡ Torontoâ•‡ 2015

No part of this publication may be reproduced or transmitted in any form or by any

e-book ISBN: 978-0-323-28796-8

CHAPTER 2: ORBIT AND OPTIC NERVE 83

CHAPTER 3: CORNEA AND CONJUNCTIVA 135

CHAPTER 4: UVEAL TRACT TUMORS 277

CHAPTER 5: RETINA AND VITREOUS 313

CHAPTER 6: GLAUCOMA AND OTHER DISORDERS 359

Index of Cases 401

This book is dedicated to

Diagnosis:â•‡ Basal cell carcinoma.

Islands of basaloid cells

Diagnosis:â•‡ Actinic keratosis.

A 67-year-old woman presented with a 5-month history of a right eyelid lesion.

Diagnosis:â•‡ Squamous cell papilloma.

Histological description:â•‡ Histopathology reveals a lesion covered by keratinized stratified squamous

A 72-year-old woman presented with multiple eyelid lesions.

Diagnosis:â•‡ Verruca vulgaris.

Histological description:â•‡ Histopathology reveals fronds of hyperkeratotic stratified squamous epithelium

Diagnosis:â•‡ Seborrheic keratosis (sessile).

Histological description:â•‡ Histopathology reveals mildly acanthotic, keratinized, stratified squamous

Foamy lipid-laden histiocytes

A 62-year-old man presented with a left lower eyelid lesion.

Diagnosis:â•‡ Sebaceous cell adenoma.

Diagnosis:â•‡ Inverted follicular keratosis.

A 74-year-old woman presented with the skin changes seen above.

Clinical description:â•‡ Facial and periocular erythema is noted.

Histological description:â•‡ Histopathology reveals keratinized, stratified squamous epithelium with

Hair follicle Granulomatous

A 57-year-old man presented with multiple pigmented lesions.

Diagnosis:â•‡ Seborrheic keratosis (papillomatous).

Histological description:â•‡ Histopathological evaluation reveals a keratinized stratified squamous surface

Central mass of Central mass of

An 81-year-old man presented with an enlarging lesion on his left brow.

Diagnosis:â•‡ Squamous cell carcinoma in situ.

Clinical description:â•‡ Clinical examination reveals an erythematous lesion with scaling.

A 67-year-old man presented with a 3-month history of an eyelid lesion.

Diagnosis:â•‡ Invasive squamous cell carcinoma.

Diagnosis:â•‡ Morpheaform basal cell carcinoma.

Histological description:â•‡ Histopathology demonstrates keratinized stratified squamous epithelium overlying

Cords of tumor cells

Courtesy of Shahed Ghoghawala M.D. University of Wisconsin-Madison.

Diagnosis:â•‡ Sebaceous cell carcinoma with pagetoid spread.

Diagnosis:â•‡ Pigmented basal cell carcinoma.

An 81-year-old man presented with eyelid lesions.

Diagnosis:â•‡ Merkel cell carcinoma.

Dermis infiltrated with atypical and pleomorphic cells

A 72-year-old man presented with a 6-month history of a growing eyelid mass.

Diagnosis:â•‡ Eccrine hidrocystoma.

Diagnosis:â•‡ Apocrine hidrocystoma.

Dual epithelial Apical snouts

Diagnosis:â•‡ Epithelial inclusion cyst.

Surface epithelium of the

Keratinized stratified squamous

Clinical description:â•‡ Multiple flesh-colored skin lesions are seen.

Histological description:â•‡ Histopathology reveals keratinized stratified squamous epithelium overlying

A 35-year-old woman presented with a 3-month history of an eyelid lesion.