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Histopathological spectrum of ophthalmic lesions in Chhattisgarh: study from a tertiary care centre

Ophthalmic pathology is a subspecialty of cellular pathology which deals with the diagnosis and characterization of eye diseases. 1 Malignant orbital tumors are generally treated by orbital exenteration. The term enucleation applies to the removal of the eye alone, sparing the conjunctiva and eyelids. The term evisceration refers to the evacuation of intraocular contents and replacement with space occupying material to preserve motility of a cosmetically acceptable prosthesis. 2 Ophthalmic pathologists study tissues excised by ophthalmologists through evisceration and enucleation and other ophthalmic biopsies. 3 The orbit is composed of the globe, extra ocular muscles, fat, vascular, nerve, glandular and connective tissues of neuroectodermal origin. 4 The neoplastic orbital lesions show wider range of pathological findings and further compounded by the patients’ fear of loss of vision pose as a major challenge to ophthalmologists. 5 Ophthalmic histology techniques differ from those of normal tissue in fixation, processing and sectioning. Ophthalmic pathologist should be trained ABSTRACT


INTRODUCTION
Ophthalmic pathology is a subspecialty of cellular pathology which deals with the diagnosis and characterization of eye diseases. 1 Malignant orbital tumors are generally treated by orbital exenteration. The term enucleation applies to the removal of the eye alone, sparing the conjunctiva and eyelids. The term evisceration refers to the evacuation of intraocular contents and replacement with space occupying material to preserve motility of a cosmetically acceptable prosthesis. 2 Ophthalmic pathologists study tissues excised by ophthalmologists through evisceration and enucleation and other ophthalmic biopsies. 3 The orbit is composed of the globe, extra ocular muscles, fat, vascular, nerve, glandular and connective tissues of neuroectodermal origin. 4 The neoplastic orbital lesions show wider range of pathological findings and further compounded by the patients' fear of loss of vision pose as a major challenge to ophthalmologists. 5 Ophthalmic histology techniques differ from those of normal tissue in fixation, processing and sectioning. Ophthalmic pathologist should be trained to identify disease processes unique to eye and to demonstrate them on a microscopic slide along with the pupil and optic nerve. 6 The present study is aimed to correlation morphological and clinico-pathological features of ophthalmic lesions, to know the pattern of prevalence of various ophthalmic lesions in Chhattisgarh, India. College, Raipur, India has approved this study. Informed written consent was collected from the patients or their relatives. All specimens were subjected to the fixation, grossing, processing and staining with Harris haematoxylin and Eosin stain. Microscopic evaluation was done on each specimen along with the clinical data on hand. The study was done to report the spectrum and frequency of different ocular and adnexal lesions in a tertiary care hospital in Chhattisgarh, India.

RESULTS
The site specific distributions of the ophthalmic biopsies were given in Figure 1. Of the 62 ophthalmic biopsies, 17 (27.42%) specimens were from globe lesions including retina and choroid, 16 (25.8%) from lacrimal gland, 14 (22.58%) from conjunctiva lesions, 13 (20.97%) from eye lid and 2 (3.23%) cases from cornea. The age range was from 5 months to 86 years with the mean age of 32.53 years.
Out of 62 biopsies evaluated, 33 (53.22%) were of male and 29 (46.78%) were of female [ Figure 2(A)]. About 38 (61.29%) ophthalmic biopsies were found to be nonneoplastic and 24 (38.71%) were neoplastic in nature [ (Figure 2(B)]. Frequencies of distribution of various non-neoplastic and neoplastic ocular lesions were documented in Table 1.     Photomocrographs of some the lesions showed focal to marked calcification and necrosis with or without optic nerve infiltration by tumor as depicted in Figure 3, 4 and 5. Second most common malignancy was squamous in origin; of which two cases of frank WDSCC (Figure 6), one squamous papilloma; remaining showed the spectrum of range from mild, moderate to markedly dysplastic epithelium. Sebaceous cell carcinoma was the commonest malignancy in patients with eye lid mass which is simulating the lipogranulomatous lesions like chalazion mainly when presented recurrently (Figure 7), the other malignancy was the basal cell carcinoma of eye lid. One case of NHL ( Figure 8) and another case of malignant melanoma of choroid were diagnosed in excised eye ball specimens. A single case was presented as firm to hard mass over upper eye lid and patient complaining of foreign body sensation; on histopathlogical examination it proved out to be a neurofibroma. One specimen of lacrimal sac lesion showed mass composed of rhinosporangim at various maturation stages and background elicited intense granulomatous-giant cell reaction (Figure 9).

Figure 8: Photomicrograph of non-hodgkin's lymphoma. Monomorphic population of malignant round cells were seen (H and E-400X).
The conjuctival lesions attributed mainly by inflammatory infiltrates, some were cystic in nature showing sebaceous cyst, inclusion cyst etc. Among infectious, two cases were showing conjuctival mass composed of rhinosporidium and one case composed of chronic inflammatory cells along with Langhan's type of giant cells with granuloma (tubercular in nature). Eye lid mass mainly cystic in nature namely two cases of epidermal inclusion cyst; sebaceous cyst and dermoid cyst had reported one case each. Chalazion was reported in two cases of lid and its most strong differential was sebaceous cell carcinoma; one lid mass was also showing rhinosporidiosis. Two cases involving whole globe, composed of mixed chronic inflammatory infiltrates, one diagnosed as panohthalmitis and other as endophthalmitis. One case of glaucoma showed retinal detachment and another traumatic case showed retinal detachment along with detachment of sclera. One case of corneal ulcer was also diagnosed showed complete destruction of corneal membrane.

DISCUSSION
Neoplastic lesions of ocular and adnexa have relatively high morbidity and mortality. Diagnosing the accurate lesions and for commenting on extent and type of lesion along with surgical margin which can guide for further therapy of patients. In the present study non-neoplastic lesions were outnumbered of neoplastic lesions. Nonneoplastic lesions constituted by chronic dacryoadenits followed by benign and inflammatory lesions of conjunctiva. Out of all non -neoplastic lesions, four cases (6.45%) were showed infection from Rhinospordium Seeberi. Ocular rhinosporidiosis due to this organism are not so common in India, occur particularly in endemic areas. It affects predominantly one of the mucous membranes of the nose and nasopharynx but occasionally other structures, such as conjunctiva, lacrimal sac, eyelids etc. Our study document different ocular and adnexal structures involved by rhinosporidium i.e. conjunctiva in two cases, lid mass in one case and lacrimal sac in one case. A great deal of research related ocular biopsies revealed that the ocular rhinosporidiosis is one of the major ocular infections in different areas. The most common site of ocular rhinosporidiosis is the lower palpebral conjunctiva in Tamil Nadu nasal and nasopharyngeal sac in Orissa, lacrimal sac in Chhattisgarh. [7][8][9][10] In our study, among all the neoplastic lesions retinoblastoma was found the commonest malignancy. Retinoblastoma was the commonest malignancy first decade of age. 11 The overall incidence was 11.2 for children aged 0 to 4 years and 5.3 for children aged 0 to 9 years per 1,000,000 person-years, 5.9 per 100,000 live births, and 5.3 per 100,000 live births. 12 Most common presenting complaint was leukocoria in patients of retinoblastoma; most of the studies reported the same clinical presentation, also some patients complaining of loss of vision and proptosis similar to other studies. [13][14][15][16] Our study report extensive necrosis in 9.09% cases of retinoblastoma, but much higher frequency of necrosis (25.58%) was reported in another study. 17 On histopathology optic nerve invasion was found in 81.8% cases of retinoblastoma, but much lower frequency of optic nerve invasion (32%) was reported. 18 Other histopathlogical findings like rosette, perivascular pseudorosette, fleurette formation, calcification, necrosis and haemmorrhage etc. were similarly found as other studies. Squamous origin of neoplasic lesions were found in our study is showing coherence with the other studies. [19][20][21]

CONCLUSION
In summary our study revealed that the retinoblastoma is the commonest ocular malignancy and most of them are presented with either lekocoria or blindness. Furthermore, diagnosing sebaceous cell carcinoma is difficult because it simulates chalazion which is a benign lesion. Among non-neoplastic disorder, chronic dacryoadenitis (adnexal) followed by benign lesions of conjuctiva (ocular) and few of them get infected due a fungal organism called Rhinosporidium Seeberi, which is endemic in some regions of our Chhattisgarh, India. So in our region, all ophthalmic lesions removed surgically should be sent for histopathological examination to establish the correct diagnosis which helps in further guidance of therapy to patients.