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Sampling of iris tumours
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Sampling techniques
• Broad iridectomy
• FNA
• Small gauge vitrector
• Kelly Descemet’s membrane
• Punch bx
Technically difficult
Requiring corneal sutures
£
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FNA experience
• Hoovering a layer of cells from the surface with a bevelled needle
• 50% equivocal diagnosis-Why?
1. Low cellularity
2. Sampling of Vitamin C modified cells when in contact with aqueous and not deeper cells
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Mudhar HS, Saunders E, Rundle P, Rennie IG, Sisley K.Br J Ophthalmol. 2009 Apr;93(4):535-40
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New method: TC FCA • A clear corneal paracentesis (opposite the iris lesion
being biopsied.
• Viscoelastic introduced into the AC
• A 25-guage Rycroft, or Viscoflow cannula attached to a 2 millilitre syringe and introduced in to the AC.
• Negative pressure within the dry syringe, the cannula bevel passed repeatedly into the substance of the iris tumour.
• This had the effect of creating what looked like a ‘phaco groove’ within the iris lesion
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Method
• The cannula and syringe transferred into a tube containing an alcohol based cytology fixative.
• Repeated flushing of the Rycroft cannula to ensure all lesional tissue was transferred into the fixative
• No corneal sutures required.
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Up to 1.5mm long
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Complications:
• Minor post bx haemorrhage day 1 post-bx.
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Diagnostic outcomes
• 10 MMs
• 1 metastatic lung adenoca
• 1 pigmented adenoma
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Advantage:
Cheap
Quick
Minimal complication
No cornea sutures
Samples deeper melanoma cells (unmodified by aqueous Vitamin C) allowing unequivocal diagnosis in MM cases.
No ‘inadequate’ samples so far.
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Sampling vitreous cells.
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Anecdotal observation
• VR surgeons had noticed quite often that cells in the vitreous tended to concentrate in the cortical vitreous and less in core vitreous.
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WHY?
• Cortical vitreous has different physicochemical properties to core vitreous….cells being trapped.
• Cells near a source of oxygen (retina) and therefore likely to survive.
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Literature
• Documented false negative rate with core vitreous biopsy……often several biopsies needed before a positive diagnosis is made (lymphoma).
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Test the idea of differential distribution of cells.
• 5 patients
• All patients were consented routinely for a core vitreous bx, followed by a PPV (pars plana vitrectomy)
• Cytology-we received 2 specimens-Core bx and vitrectomy.
• Cytopsins prepared.
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Results
• PPV specimen’s, 7.4 to 78 x cellular compared to core bx
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Case number Core vitreous bx-screening
cytopsin cell count/ mm2
PPV specimen- screening
cytospin cell count /mm2
Core vitreous bx cell block final
diagnosis
PPV
cell block
final diagnosis
1 12 89 Granulomatous
inflammation
Granulomatous
vitritis-no infectious agent
detected.
2 1 18 Non-diagnostic-insufficient cells
Primary intraocular
Diffuse large B-cell lymphoma
(PIOL)
3 15 280 Inflammation (NOS)
Paraneoplastic granulomatous
vitritis and retinitis.
4 3 235 Non-diagnostic-insufficient cells
Granulomatous vitritis
-Sarcoid
5 1 33 Non-diagnostic-insufficient cells
Metastatic Diffuse large B-
cell lymphoma of testis
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Experience to date with complications:
One case had peripheral retinal tear, with peripheral retinal fragments ending up in specimen. However, fortuitously, the fragments contained the diagnostic pathology (!).
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Present practice:
• Any vitreous infiltrate suspicious for lymphoma undergoes formal PPV with submission of vitreous cassette or bag to ophthalmic histopathology service.
• Amount of tissue allows immuno and PCR for IgH, TCR, IL-6/IL-10 ratio etc.
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Thank you.