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.