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Pathology of the Eyelids, Conjunctiva and OrbitPhilippe Labelle, DVM, DACVP
Antech Diagnostics12th Biannual William Magrane Basic
Science Course in Veterinary and Comparative Ophthalmology
Overview
• Non-neoplastic diseases of the eyelid skin
• Non-neoplastic diseases of the eyelid margin
• Non-neoplastic diseases of the conjunctiva
Eyelid/periocular skin
General Considerations
• Any skin disease can affect the eyelid skin (allergic/hypersensitivity disease, zinc-responsive dermatosis, pemphigus foliaceus, demodicosis, dermatophytosis, habronemiasis, etc)
• Eyelid skin reacts similarly to skin elsewhere• Eyelids may be the first or the most severely
affected site• Veterinary Ocular Pathology (Dubielzig et al.),
Veterinary Dermatopathology (Gross, Ihrke, Walder)
Demodicosis
• Demodex sp.• Juvenile and adult forms• Localized and generalized• Perivascular inflammation, periadnexal
inflammation, folliculitis and furunculosis
Demodicosis
Demodicosis
Dermatophytosis
• Microsporum sp., Trichophyton sp.• Fungal hyphae and spores colonize hairs• Folliculitis and furunculosis• Lesions may be more subtle in cats and
pustular disease may predominate
Dermatophytosis
Courtesy of Dr. Marlan Fender
Dermatophytosis
Courtesy of Dr. Marlan Fender
Dermatophytosis
Fungal hyphae invade the hair shaft. Spores surround the hair. Hamster
Habronemiasis
• Draschia megastoma, Habronemamicrostoma/majus, Habronema muscae
• Eosinophilic and granulomatous inflammation• Larvae may be few in numbers• May be diagnosed as “Equine eosinophilic
granuloma” if no larvae are present
Habronemiasis
Courtesy of Dr. Chris Reilly
Habronemiasis
Courtesy of Dr. Chris Reilly
Eyelid Margin
Eyelid Margin
Chalazion
• Meibomian adenitis• Lipogranulomatous inflammation• Secondary to leakage of meibomian
secretions, most often from neoplasia• Macrophages and multinucleated giant cells• Acicular cytoplasmic clefts on HE,
refractile/birefringent material
Chalazion
Chalazion
Chalazion
Courtesy of Dr. Chris Reilly
Chalazion
Courtesy of Dr. Chris Reilly
Idiopathic Marginal Blepharitis
• Dogs• Sterile granuloma syndrome• Granulomatous to pyogranulomatous
inflammation• Typically forms a mass effect, but can be poorly
circumscribed or diffuse• Can be bilateral. • Unknown etiology• No microorganisms (HE or special stains)
Idiopathic Marginal Blepharitis
Idiopathic Marginal Blepharitis
Conjunctiva
General Considerations
• The conjunctiva has limited ways in which it responds to injury
• Conjunctival biopsies rarely identify a specific cause for the conjunctivitis
• Only a few specific entities• Biopsies are taken late in the disease process,
often after treatment
Conjunctival Overgrowth• Rabbits• Pseudopterigium• Unknown cause• Hyperplastic conjunctival tissue• Normal tissue organization• Extends to cover the cornea• Does not invade and is not adhered to the cornea
• Note: true pterygium should have solar/actinic changes (ie solar elastosis +/- actinic keratosis) and will invade the cornea following dissolution of Bowman’s membrane
Conjunctival Overgrowth
Conjunctival Overgrowth
Courtesy of COPLOW
Ligneous Conjunctivitis• Doberman Pinscher, Yorkshire terrier, Golden Retriever,
Scottish terrier• Conjunctivitis, hard consistency, pseudomembranous
exudate• Subepithelial deposition of mostly acellular hyalinized
eosinophilic matrix• PTAH positive, Congo red negative• Fibrin deposition in the conjunctiva, oral cavity,
esophagus and +/- glomeruli and other sites• Plasminogen deficiency in humans and some dogs
– Plasmin is fibrinolytic– PTAH positive (compatible with fibrin)
• Mason et al, JSAP, 2016; Mason et al, JSAP, 2012; Torres et al, VO 2009; McLean et al JAVMA, 2008; Ramsey et al, JAAHA , 1996
Vet Ophthalmol. 2009 12(4):248-5
Ligneous Conjunctivitis
Ligneous Conjunctivitis
Courtesy of Dr. Chris Reilly
Solar Elastosis, Fibrosis and Vasculopathy
• Conjunctiva, not cornea• “Solar conjunctivitis”• Overlaps with solar induced neoplasia• Solar elastosis
– Altered fibers within the superficial substantia propria– New production +/- degradation of collagen and
elastin• Can form plaques in horses• Often seen with conjunctival squamous cell
carcinoma, hemangioma or hemangiosarcoma
Solar Elastosis, Fibrosis and Vasculopathy
• Solar “fibrosis”– Altered collagen, pale, hypocellular (sclerotic)– Forms a band underlying the epithelium– Not true fibrosis
• Solar vasculopathy– Rare, more common in skin– Thickened hyalin vessel walls– May be endothelial swelling
Solar Elastosis, Fibrosis and Vasculopathy
Solar Elastosis, Fibrosis and Vasculopathy
Solar Elastosis, Fibrosis and Vasculopathy
Lymphoplasmacytic conjunctivitis
• Most common inflammatory response• Does not suggest a specific etiology• Infectious and non-infectious causes• Perivascular to diffuse• Non-ulcerative• Can be severe enough to warrant concern for
neoplasia
Lymphoplasmacytic Conjunctivitis
Lymphoplasmacytic Conjunctivitis
Lipogranulomatous Conjunctivitis
• Cats• Nodular inflammation• Macrophages with lipid lakes, multinucleated
giant cells may be present• Can be associated with neoplasia
Lipogranulomatous Conjunctivitis
Lipogranulomatous Conjunctivitis
Courtesy of Dr. Chris Reilly
Lipogranulomatous Conjunctivitis
Courtesy of Dr. Chris Reilly
Triamcinolone Granuloma
• Macrophages and multinucleated giant cells• Rounded rectangular vacuoles• Rarely biopsied
Triamcinolone Granuloma
Triamcinolone Granuloma
Triamcinolone Granuloma
Triamcinolone Granuloma
Nodular Granulomatous Episcleritis
• Episclerokeratitis, episcleritis, NGE• Smooth nodules to diffuse thickening• Most often in the limbal conjunctiva• Also occurs in other conjunctival sites, orbit• Unknown cause• Epithelioid and spindle macrophages admixed
with lymphocytes and plasma cells• Some spindle cells are myofibroblasts
Nodular Granulomatous Episcleritis• The relative proportion of inflammatory cell types is highly
variable• The macrophages do not form distinct granulomas• Some cases may include multinucleated giant cells or
eosinophils• Cases with a predominance of spindle cells have been
called nodular fasciitis• Special stains for infectious organisms are always negative
(and must be) • The proportion of T-cells and B-cells has been said to be
predictive of response to treatment (B-cell predominant were more refractory).
• Breaux et al. VO, 2007 (T vs B); Barnes et al, VO 2010 (orbit)
Nodular Granulomatous Episcleritis
Courtesy of Dr. Chris Reilly
Nodular Granulomatous Episcleritis
Nodular Granulomatous Episcleritis
Nodular Granulomatous Episcleritis
Nodular Granulomatous Episcleritis
Eosinophilic conjunctivitis
• Eosinophils are a component of the inflammation
• Eosinophils may not be the predominant cell type (lymphoplasmacytic)
• Perivascular to diffuse• Allergic/ hypersensitivity disease• Cannot exclude (or confirm) Herpesvirus
infection in cats
Eosinophilic Conjunctivitis
Eosinophilic Conjunctivitis
Eosinophilic Conjunctivitis
Herpes Keratoconjunctivitis
• Cats, primarily kittens• Unlikely to be biopsied• Window for inclusions is narrow• May include eosinophils
• Role of Herpervirus in adult cats is controversial• Clinical lesions suspected to be, diagnosed as, and treated for
herpesviral infection lack any histologic evidence to specifically support a viral cause
• The presence of eosinophils is not a helpful feature as many hypersensitivity disease has eosinophils as a hallmark of the lesion
Feline Herpes Keratoconjunctivitis
Courtesy of Dr. Chris ReillyTongue from a shelter cat
Inclusions
Syncytial cell
Feline Herpes Keratoconjunctivitis
Skin from the face of a cat
Inclusions
Conjunctival Histoplasmosis
• Histoplasma capsulatum• Cats• Subconjunctival nodules• Pyogranulomatous inflammation• Special stains (GMS) often needed to best
visualize the organisms
Conjunctival Histoplasmosis
Conjunctival Histoplasmosis
Conjunctival Histoplasmosis
Conjunctival Histoplasmosis
ORBIT
Conjunctival/Orbital Onchocerciasis
• Onchocerca lupi• Dogs and cats• 205 canine, 2 feline and 18 human infections in
Europe, Tunisia, Turkey, Iran and the USA (2015).• Subconjunctival or periscleral/orbital nodules• Granulomatous inflammation• Eosinophils may be present in large numbers,
there may be fibrosis• Parasites may not elicit severe inflammation
Conjunctival/Orbital Onchocerciasis
• Must be differentiated from other nematodes with microfilariae
• Annular/circumferential ridges distinguish from Dirofilaria immitis
• Association with onchocerciasis and glaucoma in humans, unclear in dogs and cats
• Endosymbiotic bacteria Wolbachia• Larval development in blackflies
Conjunctival/Orbital Onchocerciasis
• Canine• Tudor et et al Parasitol Res 2016• Otranto D et al. Emerg Infect Dis
2015• Otranto D et al Parasit Vectors
2015• Otranto D et al. Emerg Infect Dis
2013• Labelle AL et al. Vet Parasitol, 2013• Fascia P et al VO 2010• Zarfoss et al. Vet Pathol 2007• Komnenou A et al. VO 2002• Egyed Z et al. Vet Parasitol, 2001
• Intraocular k9• Komnenou AT et al. VO 2016
• Feline• Labelle AL et al. VO 2011
• Review• Gracio AJ et al. Parasitol Res 2015
Conjunctival/Orbital Onchocerciasis
Modified from : Am J Trop Med Hyg. 2013 Mar;88(3):601-5
Conjunctival/Orbital Onchocerciasis
Modified from : Parasit Vectors 2015
Feline cases
Conjunctival/Orbital Onchocerciasis
Vet Ophthalmol.
2002 5(4):119-26
Vet Ophthalmol. 2016 May;19(3):245-249Emerg Infect Dis. 2015 21(5):868-871
Conjunctival/Orbital Onchocerciasis
Courtesy of COPLOW
Conjunctival/Orbital Onchocerciasis
Courtesy of Dr. Chris Reilly
Conjunctival/Orbital Onchocerciasis
Courtesy of COPLOW
Conjunctival/Orbital Onchocerciasis
Feline
Conjunctival/Orbital Onchocerciasis
Feline
Annular ridges
Striae
Orbital extraocular polymyositis• Affects all the extraocular muscles except the retractor
bulbi muscle• Rare disease, typically young dogs• Bilateral and variably symmetric exophthalmos,
retraction of the upper eyelid, and mild chemosis• Chronic: enophthalmos and strabismus• CD3+ predominant lymphocytic myositis with
myonecrosis• Attempts at regeneration with muscle atrophy and
fibrosis• Immune-mediated attack directed specifically against
the extraocular muscles is suspected• Unlikely to be biopsied
Orbital extraocular polymyositis
Courtesy of COPLOW