SOURCE OF TISSUE: Right eye
CLINICAL HISTORY:
The patient is a 31-year-old man with a history of right eye congenital
cataract with subsequent surgery at few months of age. His vision did not
improve; he had light perception only in the right eye. During late teens he
noted a small bump superiorly, was told this was a staphyloma and that his
right eye intraocular pressure was elevated. He was started on eyedrops
which he took inconsistently due to insurance issues. He described complete
loss of vision in early 2000’s. In 2006 his eye started becoming more
prominent with gradual progression since that time. He has had chronic pain
over past eight years worst at the end of the day. On 2008 he had laser
treatment for glaucoma. He was recently restarted on glaucoma drops:
Alphagan, Travatan and Ketorolac using them only for discomfort. He
underwent right eye enucleation with placement of Medpor sphere implant,
reattachment of muscles and suture tarsorrhaphy closure on June 19, 2015.
GROSS:
The specimen consisted of one right eye globe which measured 30 mm x 25 mm x
30 mm antero-posterior, horizontal and vertical respectively. The optic
nerve measured 10 mm in length. The cornea was opaque and measured 12 mm x
12 mm. The pupil was distorted and measured 5 mm. The iris was green and
irregular with an apparent tear. The eye transilluminated light well,
increased at area where the staphyloma was present. No extrascleral
extention was seen. The sectioning of the globe was done in the vertical
plane. The anterior chamber was deep. The ciliary body was abnormal,
displaced anteriorly. The lens was absent. The vitreous was clear with a
gelatinous consistency. The retina and choroid were unremarkable. The sclera
was thinned in some areas with a staphyloma in the superonasal quadrant. The
optic cup was enlarged. The specimen was received in formalin, two calottes
removed and the pupil-optic nerve section was submitted for histologic
process. All portions were labeled with the patient’s name and medical
record number.
MICROSCOPIC:
Eleven H&E and one PAS stained slides are examined. The slides reveal an
enlarged globe. The corneal epithelium and bowman’s layer are present. There
is subepithelial and superficial stroma neovascularization. The Descemet’s
membrane is intact. The corneal endothelium is attenuated. The anterior
chamber is deep and an entropion uvea is present with a subsequent secondary
angle closure. A Morgagni cataract with mineralization is present. There is
a break present in the lens capsule. The ciliary body is atrophic. The
retina is atrophied with diminished outer nuclei layer, bipolar cell layer
and loss of the ganglion cell layer. There are areas of chorioretinal
scarring consistent with previous laser treatment. The choroid shows
thinning. The sclera is markedly thinned with folding and an atrophic uveal
lining is present. There is marked atrophy of the optic nerve with increased
cupping. PAS stain confirms the above findings.
FINAL DIAGNOSIS:
- Right painful blind eye by history
- Eye with massive staphyloma, atrophy and disorganization
- Interstitial keratitis
- Entropion uvea
- Morgagni cataract
- Secondary angle closure glaucoma
- Retinal and optic atrophy
- Marked scleral thinning with staphyloma
COMMENT:
As the staff pathologist, I have personally examined all slides and relevant
information about this case and have discussed them and arrived at the
diagnosis that is recorded in my report.
Daniel Albert, MD
Staff Pathologist
Electronically signed Jul 02, 2015 12:12 PM
