IMPRESSION CYTOLOGIC ANALYSIS OF SUPERIOR LIMBIC KERATOCONJUNCTIVITIS:

NEW DIAGNOSTIC AID

Jayangshu SenguptaCornea Services, Priyamvada Birla Aravind Eye Hospital Kolkata, India

Nibaran GangopadhyayHead-Eye Care, Sanjiban Hospital, Howrah, India

Merle FernandezDirector & Cornea Consultant, Vizag-LVPEI,AP, India

The authors have no financial interest in the subject matter of the poster

IMPRESSION CYTOLOGIC ANALYSIS OF SUPERIOR LIMBIC KERATOCONJUNCTIVITIS:

NEW DIAGNOSTIC AID

Conjunctival impression cytology Simple, noninvasive technique Sample the superficial layers of epithelium for analysis.Gold standard procedure for analysis of squamous

metaplasia and goblet cell loss. Light microscopy- remains most commonly used in clinical practice.

Superior Limbic KeratoconjunctivitisDisorder of unknown etiologyRole of impression cytology as a diagnostic modality

remains largely unknown.

IMPRESSION CYTOLOGIC ANALYSIS OF SUPERIOR LIMBIC KERATOCONJUNCTIVITIS:

NEW DIAGNOSTIC AID

To demonstrate the morphological changes induced in the

conjunctival epithelium in presence of SLK using the process of

impression cytology.

Prospective, non-comparative, observational case series50 eyes(26 patients) were analyzed

2 eyes with inadequate samples were not analyzedJanuary 2008 – December 2008

IMPRESSION CYTOLOGIC ANALYSIS OF SUPERIOR LIMBIC KERATOCONJUNCTIVITIS:

NEW DIAGNOSTIC AID

Diagnostic criteriaLocalized superior bulbar congestionwith conjunctivochalasis +/- filament Localized punctuate Rose BengalstainingPapillary changes over upper tarsal conjunctivaBilateral involvement.

Exclusion criteriaUse of contact lensSchirmers II value<5mm Prior steroid

therapy-topical/systemic(within previous 3 months)

EvaluationDetailed historySlit lamp examination Schirmer testTear film break up time Rose Bengal staining Fluorescein stain scoreSystemic examination

IMPRESSION CYTOLOGIC ANALYSIS OF SUPERIOR LIMBIC KERATOCONJUNCTIVITIS:

NEW DIAGNOSTIC AID

Standard technique of impression cytology

Haematoxylin- PAS staining Grossly labeled as normal/abnormalepithelial cell morphologycohesion of cellskeratinization nuclear characteristics goblet cell density.

Abnormal specimens graded Tsengs classification system(Scheffer C.G.Tseng Ophthalmology 92:728-733,1985)

Goblet cells

Normal epithelial pattern

Abnormal Impression

IMPRESSION CYTOLOGIC ANALYSIS OF SUPERIOR LIMBIC KERATOCONJUNCTIVITIS:

NEW DIAGNOSTIC AID

Age Range was found to be 36 to 55 yrs

M:F ratio of 1:12

Co morbidity factors were found in 4 patients

Hypothyroid

Rheumatoid Arthritis 1 patient each

Post Lasik

High Prolactin level

All samples from superior bulbar portion of conjunctiva demonstrated Grade V squamous metaplasia

IMPRESSION CYTOLOGIC ANALYSIS OF SUPERIOR LIMBIC KERATOCONJUNCTIVITIS:

NEW DIAGNOSTIC AID

Increase in cell size

Lack of cohesiveness

with increased intercellular

spaces and folded edges

Keratinisation

Complete  absence of goblet

cells

Pyknotic nucleus

IMPRESSION CYTOLOGIC ANALYSIS OF SUPERIOR LIMBIC KERATOCONJUNCTIVITIS:

NEW DIAGNOSTIC AID

Snake chromatin100%

Due to alteration in the nuclear and cytoplasmic skeleton

Knop E, Reale E Fine structure and significance of snake like chromatin in conjunctival epithelial cells. Invest. Ophthalmol. Visual Sci 35:711, 1994Margarita Calonge, Yolanda Diebold, Victoria Saez et al Impression cytology of the ocular surface: a review Experimental Eye Research78:457, 2004

Snake like chromatin

IMPRESSION CYTOLOGIC ANALYSIS OF SUPERIOR LIMBIC KERATOCONJUNCTIVITIS:

NEW DIAGNOSTIC AID

Multinucleation

(100 perent)

Balloon degeneration

(96%)

Balloon degeneration Multinucleation

IMPRESSION CYTOLOGIC ANALYSIS OF SUPERIOR LIMBIC KERATOCONJUNCTIVITIS:

NEW DIAGNOSTIC AID

Multilobulated nuclei

(70%),

Spindle configuration

(68%)

Dumb-bell configuration

(60%).

Multilobulation Spindle Configuration

Dumb- bell Dumb- bell

IMPRESSION CYTOLOGIC ANALYSIS OF SUPERIOR LIMBIC KERATOCONJUNCTIVITIS:

NEW DIAGNOSTIC AID

Hallmark of squamous metaplasia from histopathological specimens Extensive nuclear pyknosis Condensation of masses of chromatin The shrinkage of the nuclear envelope from its surrounding cytoplasm

Though electron microscopy of histological samples in patients with SLK better demonstrates such nuclear changes, conjunctival impression cytology in SLK conclusively demonstrates Localized squamous metaplasia of high grade Complete lack of goblet cells Characteristic nuclear changes like balloon degeneration, condensed chromatin,

snake like chromatin, multi lobulated and strangulated nuclei

Formation of snake like chromatin is characteristic Probably an indicator of mechanical stress on the ocular surface like blink related

micro-trauma. Barry Collin, Peter C. Donshik, S. Arthur Boruchoff, et al. The fine structure of nuclear changes in superior limbic keratoconjunctivitis. Invest. Ophthalmol. Visual Sci 17(1):79, 1978

IMPRESSION CYTOLOGIC ANALYSIS OF SUPERIOR LIMBIC KERATOCONJUNCTIVITIS:

NEW DIAGNOSTIC AID

To conclude, impression cytology is a simple, noninvasive

method of demonstrating the underlying pathological changes

and thereby becomes an important tool in diagnosing SLK.