 and just try it that way. Okay, so this is Drs. Crandall and I. We, I've got to tell you the story. We have been going to ESCR's meetings for 20 years and his first wife and my wife just don't like traveling and just don't do it, so we would always travel and you know, you would introduce yourself. I'd say, oh, this is my partner, Alan Crandall. And so after a while, somebody finally came and said, so you guys are partners and they thought we were gay because we were always together. So basically, I had to say, this is my colleague Alan Crandall. So then now, you know, Julie broke us up as a couple. So now that he's married again, you know, Julie broke us up so we're no longer a couple when we travel, but we still go look at, you know, castles and, you know, medieval things. You know, at least I can advance with this. So we'll go ahead and look at that. All right, so here is the, this is one of the national museums of Denmark. And again, you know, in Europe, all the national museums all kind of look the same. But Denmark is kind of an interesting city. It's a Copenhagen, I mean, it's a good mix of old and new. And so you've got a lot of old, you know, towers and all the medieval buildings, but in between, they've got a lot of really ultra-modern glass and interesting buildings on the waterfront. So as we go through our tour, we'll spend some time there. And so this just shows that the sun is going down on the edge. So we're going to talk about kanji taiba today. And so, Ashley, since you're in the first seat and you're yawning there. Stretching. Stretching. Stretching. Stretching. So tell me about the various parts of the kanji taiba. Okay, so there's bulbar for the steel and the tall people. Okay. So bulbar means, you should remember, against the bulb. And so what we think of as kanji, you know, on top of the sclera, is the bulbar kanji taiba. And that blends right in with the cornea at the limbus. And then for the sea, I don't know why am I laser-pointing, for example, but to the right lower corner there, you can see the fornex, where the kanji taiba reflects on itself. And then the part of the kanji that we often forget about that we talked about last week is lining the inside surface of the eye lid, the so-called palpebro kanji taiba. And so that's palpebro kanji taiba. What are these little white spots in there? Goblet cells. Goblet cells. And what do goblet cells produce? Mucin. Mucin, okay. So the further away you get from the limbus, the more goblet cells there are. So you don't usually see goblet cells up near the limbus, but if you get near the fornex on the palpebro kanji or over into the karanko or the lateral campal area, you get a lot more goblet cells. And they make mucin. So why is mucin important? Okay? Chris, how many different layers are there to the tear film? And what are the layers? Three different mucin layers, water to your carbon and oil. Okay? So the reason that the goblet cells are important is if you look at the surface of the corny and the kanji taiba with EM, they're not smooth. They've got little microfilaments to get out all over the place. And if you put water on them, which is what aqueous is, it just runs off. And so basically, if you put some mucin kind of intermix between those interdigits, it allows it to smoothly spread out and not just evaporate or spread out. So it makes the surface of the on more wetable. And then of course the aqueous part of the tears is what we usually think of as tears. And then the final layer that we don't think much about is the oil layer. And that's what the mybomian mines make that we looked at last week when we looked at the islands. So that really keeps the tears from evaporating. The oil kind of coats them and keeps it from evaporating. So any disruption of any one of those three layers can give you dry eyes. All right, Nico, what are we looking at right here? So this is an external photograph of the left eye. And I see the grayish-yellowish white even by the nasal membranes. This could be, my differential is the dermal dermoid. So what if I tell you this patient is five? It'll be a dermoid. OK, so it's good that you said that because there's a term in the literature called limbo-dermoid. It confuses everybody to know it because you have dermoid cysts in your butt. They call this a limbo-dermoid. You say, what does that mean? So the proper terminology for this. And I want to try to get you guys to start doing this because it's going to start showing up on board is this is called a limbo-dermolchorostoma. What does the term chorostoma mean? It means mature tissues, normal mature tissues, growing a different site. Exactly. So chorostoma means it's not tumor tissue. It's normal tissue. It's a growth of normal tissue. But in a site where they shouldn't be there, as opposed to hematoma, which means growth of normal tissue of a site that they could be, but it's just an abnormal growth. So chorostoma means you have... No, let's not install the Apple software. Thank you, since this isn't even an Apple. So what this is, is it's a chorostoma, meaning it's a growth of abnormal tissue. I mean growth of normal tissue in a place where they shouldn't normally be. So when you look at these dermalids under the microscope, let's see, chorostoma, what kind of tissue are we looking at right here? This is exactly that region. What things are we seeing out here? So there's some epithelium up above. There's some... This is not going to let me do anything. It's not going to go back. It's not going to let me do anything. Okay, so we've got some epithelium up above. What is this thing we're looking at in the middle here? This thing right here. It's got a sebaceous gland next to it. Yeah, it's a hair follicle. So do we normally have hair follicles in the conch? No, so these lesions often have hairs growing out of them. They've got the sebaceous glands. And then we look right here, a couple of other kinds of tissue in here. Let's just come around the corner here, Tara. Okay, so what is this stuff again? Glans, all right? And then this looks very strange. Let's go to a lighter power. All right, here's the glands. What kind of glands are we looking at right here? Echry glands. Echry glands. So these are like little lacrimal glands or sweat glands. And so again, you shouldn't have glands in the conch you dive. And then to the right, some weird stuff. What is that? Let's go higher. You wouldn't expect to see in the conch. Well, kind of a very dense connective tissue. This is cartilage. And so these are very interesting lesions because you can have glands in them. You can have muscle in them. You can have fat. You can have fat in there, but you can also have things like cartilage. And so these are very much, you know, a growth of normal tissue in an abnormal place. And so these are very interesting lesions. What is an entity that you need to memorize for boards that's associated with limbo dermal horror stones and kids? A syndrome. Again, the iron curtain that you sense across the cerebral cortex. Chris, golden heart syndrome. So you really need to remember that because these kids can have these limbo dermal horror stones, but they can have funny teeth. They get these little pre-oricular skin tags and other things in their bones. And so they love asking about golden heart syndrome. So know that that could be associated with these limbo dermal horror stones. Lee, what are we seeing right here? An overexposed picture. Sorry. So this is the lesion here, ignoring the overexposure. Something you see in every single utop who's native when you look at the stethoscope. Exactly. So this is a ping-wacky line. We see this in everybody. And what's the underlying cause for a ping-wacky line? Exactly. And what causes that? Exactly. So it's UV exposure. Because we're at altitude here, because we have 300 sun days here, people ski and do outdoorsy things, you see ping-wackylla all the time. And then, of course, the ping-wackylla is, you know, cohort, teridium. What's the difference between the two? The steodation and the constellation. Exactly. So they're really pretty much the same entity. It's just a ping-wackylla is technically over the sclerosil in the conjunctiva and a teridium has crossed the lindus and gone up to the cornea. So we look at the path. You mentioned one thing that's common in the fees. An example. So when you look, you get some solar elastosis. The connective tissue starts to undergo almost the metastatic degeneration. You get basophilic degeneration, a smudgy blue-gray degeneration. What is this? Magenta-colored stuff in here. It's actually calcium. And so these can sometimes calcify. So when you look at these with the slit lamp, you can see little specks of white underneath them. So they'll have, you know, this dense connective tissue, but they will also have these little white plexic calcium. So the important thing to differentiate is when you're looking at somebody, especially an old vet who's a rancher out in the sun a lot, the question is, is this a teridium or is this a disease of the epithelium? And you really want to be able to tell that apart. So when you look with the slit lamps very carefully, in these teridia, the epithelium is thin and the pathology is under the epithelium. It's in the substantia propria. Whereas you look at, say, a squamous cell carcinoma or one of the precursors of squamous cell carcinoma, the disease is in the epithelium. So the epithelium looks really thick in gelatinous. So you want to be really careful when you call something a teridium and just look at them real quickly. Look carefully and make sure that it's really a teridium and it doesn't bounce when you see them. All right, what do we see in here, Reese? So it's an inverted upper eyelid and there's a bit of a little bit of a difference to the upper eyelid. If you were to shine a fennel off head next to that, what do you think that would show? That it would probably be cystic. Yeah, it would be cystic, exactly. So what's the most important layer we need to look at if we see a cystic structure? The cystal lining. The lining. What do we see as the lining in this one? There's a stratified swing that's not termed a teridium. What do we have in the middle there? These are the greatest races. Goblet cells. And so what kind of cyst is this? Exactly. So we call it an epithelium inclusion cyst because for some reason, surface epithelium gets underneath the surface and starts to grow. And so by definition, something had to have happened either a trauma or a surgery or something. They get these people and they swear nothing's ever happened to them. So I don't know how it gets there, but if the surface epithelium gets under the epithelium and the substantially appropriate it'll grow into a cyst. And so when you see a cyst, you want to look at the cyst lining to tell what it is. Alright, back to Ashley. What are we looking at right here? So this is an external photograph of the palpable conical. Looks like there's a cobble stone here. Okay. What do we call these things that form the cobble stones? So these don't look like they have a central vessel of follicles. Exactly. So these are follicles, and that's an important differentiating point. Follicles don't have a big vessel in the center, a papillae do. So if you look at these, these look like follicles. They're these bumps. They may have blood vessels around it, not popping up in the center. So these are actually follicles. So what are the follicles comprised of? Centers. Exactly. So they've got lymphocytes and you can sometimes even get they almost look like follicles that's going in the body. You get a little bit of larger paler staining lymphocytes in the center, darker lymphocytes surrounding them. So what's the differential diagnosis of follicles on that conjugal inferiority? I mean, classically there's but in reality there's it can be early getting an infectious cause. What kind? Viral. So viral, you know, viral is the most common. If you're going to think it's an acute viral, not bacteria, usually you think viral. So you can think viral. So that's one category, infectious, viral and then other weird viruses. Chris, what's another cause for follicles if you're really one? Allergic reaction. So that's the other big one. When people have these allergies, they get these follicles all over the place. So you want to think infectious, viral or weird things, you want to think allergic reaction can cause these follicles. And here's a close up. You see that paler staining lymphocytes in the center surrounded by the smaller, darker staining lymphocytes around them. It's just a classic follicle. This is a little bit different. We're looking at these, and so what Chris, you looked at, you got the easy one. Niko, what's different about these? So there's blood vessels in the center here. Excuse me. These would be follicles. These would be papilla. Papilla, exactly. Each one of these little bumps has that little blood vessel coming up in the middle of it. And when you look at these pathologically again, you see they have this bump coming out, but you see the little blood vessels coming in the center. So what's the most common cause for papilla? I think of viral arthritis. What else? Yeah, a reaction to something. A reaction to something. And I don't know if you guys ever rotate through contact lens clinic, but this is the bane of contact lens where this is GPC. Giant papillary conjunctivitis. So you look at one, I'm sorry I took this picture, it's bad, but we flipped over the eyelid and they weren't on the use, then we took a picture of it. And so these are these giant papilla and they're usually on the upper lid on the inside surface. And so these are the bane of contact lens wearers. Now come in with these vague symptoms, I wear my contacts and then I start to hurt later in the day and get this stringy mucusy stuff in there. And you see these big cobblestones in here, these giant papilla here. And so this is thought to be a reaction to something on the contact. Be it proteins that are deposited there, be it preservatives and the solutions they use, be it something that's on there. And so the problem is you have to treat these with drops that calm the inflammation. You got to keep people out of their contacts. And so if someone's a minus eight, they're not amused that they're going to be out of their contacts for two months. So this can be really, really no fun. And then you have to have them check out all the solutions, buy solutions that don't have any kind of preservatives in them. You want to buy hypoallergenic solutions. You want to have them change their contacts regularly so they don't get a protein buildup. So this is the GPC giant papillary projectivitis trauma. I see you hiding back there. So what do we see in here? It's all in the lens. So some bumps in the lens. This is a 14 year old male and it's April. Am I giving you enough hints? And it really itches. These are actually follicles, but they're right at the limbus. And so there's a condition called vernal conjunctivitis, vernal meaning spring. And so you see this in especially young adolescent boys and they get this really intense itching with this. And you see these bumps at the limbus. So this is, we just call it limbo-vernal. But it's the same idea. It's these follicles at the limbus. And so this is limbo-vernal. All right. Let's see. Terra. We're pulling this guy's lid out and we're looking at this lesion there. What do we see in there? Yeah, it's kind of got a stock to it. It's a big cauliflower kind of sticking out there. It's a little bit floppy. It's got a stock to it. And then we look at it and we see this in the pathology. So what we see in here is it does have kind of a thin conjugal looking at the helium here on the surface. Okay, so there's some scattered inflammatory cells. What are all those little red spaces? Blood vessels. So this lesion's got a ton of little tiny blood vessels in it. It's got some scattered inflammatory cells. It's got a lot of white space. A lot of just fluid white space. And we're looking at a close up here and you see it's a mixture of inflammatory cells. There's PMNs in there. There's lymphocytes in there. There's lots of blood vessels in there. There's a lot of fluid and really loose connective tissue. What do we call this lesion? That's part of the word. That's half the answer. Well, we're giving you lots of hints. So this is one of those you just have to memorize. This is a what, Chris? A pyogenic manual on that. This is one of those stupid double misnomer that gets into the literature that you have to memorize. A double misnomer. Those two words are correct. So pyogenic means fever inducing. So that means an infectious thing. So it's not pyogenic. It's not infectious. Granuloma means giant cells, epithelial cells. It's not a granuloma. It's actually granulation tissue. So we think of it as kind of an exuberant healing response. Almost like a keloid of the conger of the lid. It's not pyogenic. It's not a granuloma. But that's what it's called in the literature. So pyogenic granuloma, it's not to be reactive. Granulation tissue. People will often have a history of something getting in their eye or some kind of minor surgery or minor trauma or something. And so that person that we showed you previously that had that lesion grossly, that guy was one of the people who worked in the hospital and he's the guy who holds all those cables through the ceiling that you see on the ladders and something up there dropped into his eye and triggered this reaction. So it's a granulation tissue reaction. Isn't the appearance normally more kind of red or orange? It's kind of red. Exactly. It's kind of red but it can be white because there's just a lot of fluid in there. A lot of loose tissue. So it's not dense. It's not fibrotic. It's very loose in the dividends. Alright Chris, what are we seeing here? So it's a very injected kind of it's like it's elevated with some hemosis with it as well. Yeah, it looks pretty diffused, kind of diffusely elevated. So again, you want to think of like differential diagnoses before you jump right to the path. What could give you kind of a diffuse looking at the viral infection? What else? So you want to look at general categories. Infectious. You know, it could be infectious. What else? Or you could say reactive. I mean maybe it's just like this looks a little bit too vast for positive energy or something. And there's a third category. We could have just a diffuse raised lesion of the conch. Here's the pathology. How about infiltrate data? So sometimes you can get, and these are very rare of the conch. What kind of cells are we seeing right here? Those look like Yeah, a whole sheet of lymphocytes. And so you can get conch lymphomas. Now usually they're associated with the normal lymphoma that's come forward. But rarely you can even just get conch lymphoma. Are they the views of that type? Yeah, usually they're the quote salmon color. And salmon means what? Pinky? Yeah, that looks redder. So usually they're like more pink than red. But they could be diffusely elevated under the conch. You've got to always think of that. And when you look at this, you know, when you look at lymphomas follicle or lymphoma hyperplasia, the way I like to describe it is you just take a handful of lymphocytes and you just smear them on the slide. So they all look the same. There's no follicles forming in there. There's no B cells mixed in with them. It's all just a handful of lymphocytes that's smeared across. So conch lymphomas, you always want to watch for them. They always call them quote salmon color. I think a salmon is pink, but not quite sure what that means. So if you see like a journal centered Do you think more reactive? Exactly. Other than lymphoma. When we get to orbit, we're going to talk about lympho-hypoplasia and reactive lesions versus lymphoma. So we'll talk about that a lot in orbit. And then this is just one of the, you know, peroxidase stains just to show that they virtually all stain, you know, B cell, lambda or whatever. And that's what's most common is low grade B cell lymphoma. All right, Lee, what are we looking at right here? So what would you be worried about here? So you'd be worried about what kind of squamous cell or maybe a pre-cancer type. Now what's the first thing you want to do with this patient? You want to get that cataract out. I'll wipe that out. You can take out that cataract with a corneum. Sign them up quick. So for getting the cataract, but you see this just as you said, it gelatinous. And so as opposed to a teridium that if the feeling isn't thin and there's not any tissue under it, this looks gelatinous and the epithelium looks thick. So you're really worried about some kind of a carcinoma going on. Here's another way these can look. Again, you see that kind of gelatinous look to it. You see that the epithelium is thick and it starts at the limbus and then it can grow onto the cornea or it can grow out away from the limbus. So we do a surgery to remove it and we get this picture. What do we see in here? So it's like characterised There's a little character on the surface. That's abnormal. Okay, so What do we call this? CIN CIN, that stands for Conductible Inter-Infrared Irreducible Reputation Exactly. So the key thing here is this is a carcinoma in situ. Meaning it has not gone beyond the base of membrane strictly within the epithelium so the key thing here is that the epithelium base of membrane is still intact so these changes are all in the epithelium and there's nucleolide there's loss of normal maturation there can be mitotic figures that can be characterisation both on the surface and even deeper so you see these little pink areas in here those are all dyskeridosis character down deep where they shouldn't be any. But it's all in the epithelium and so when we describe these CINs what are the three different classifications we do? Exactly. So simple. Mile, moderate, severe. What do you note is mild? Exactly. So we look at the degree of epithelium that's involved with the atypical cell starting with the basilar layer so mild is the lower third moderate is up to two thirds severe is more than two thirds so this would definitely be severe you've got these changes going all the way up to the surface and here you can see this is the basilar membrane here it's still completely intact look here's your nucleolide all over the place here's a weird mitotic figure starting to split in half and so you see that the maturation is disordered it doesn't normally lay out nicely this goes all the way up you know 90% thickness so this is a CIN with marked dysplasia and here again is another one look at the multiple nucleolide in that little center cell and so you can see it could be very dysplastic looking but it's still intrepithelium so we want to look at that basilar membrane very carefully when we look at these all right what do we see in here Rhys it's an elevated nucleopathy of the type of estates and so again Appalimbus Whiteish you know Leucoplechia White plaque working lesion Ficcant Gelatinus epithelium probably some keratin on there look at this and what's the difference between this and the previous one exactly so you see the base of membrane is up there look here's these abnormal cells down here so these cells are now broken through the base of membrane so this has gone from being a CIN to actually being a superficially invasive swamish cell exactly so this is now a superficially invasive swamish cell sometimes these could be very extensive what are these things down here exactly so just like the swamish cell carcinoma on the eyelid you can get keratin worlds, keratin pearls so you see these growing under epithelium in this substantial propria and so this is a more extensive swamish cell carcinoma and here you can see on the close up there's that keratin world, keratin pearl you see the nucleoli the conch chromatin the bizarre sizes and shapes so this is a swamish cell carcinoma and sometimes they can even invade down into the what is this tissue here sclera so you can even go into the episclera the superficial sclera so these can be you just think of them as surface neoplasia but they can actually go into the orbit they can spread along the nerves back into the brain and so you leave them alone and you miss them so they can go all the way to the episclera and they can even go back into the orbit so squamous cell carcinoma and here we have boy this is a good one here actually what kind of tissue is this thing I'm showing you here it's a big rattle thing in the middle believe it or not that's a big nerve and so the reason I'm showing this this is one of whoopie's favorite topics we talk about this at orbit conference at least once a year when these squamous cells spread for some reason they can go along the nerves and so you can get people with the superficial squamous cell either lead or conge and then they can also get them going back through the orbit along the nerves and they can go back even into the brain and so these for some reason have a tendency to go along the nerves which means they can have pain associated with them and then eventually if they can invade or if you can get numbness associated with them so when these spread they can often spread along the nerves and back into the head so you want to get these before they get to this point there's a close up again of these tumor cells you're going along the nerve here so you want to remember that because they can actually go back into the orbit and go back into the brain all right Chris what do we see in here there's a photograph of the left eye with the hyperpigmented spots throughout some smaller ones, nasally some bigger ones, laterally with a few blood vessels feeding though very laterally so what could this be part of the orders of those hyperpigments are actually areas that are excromalaceous and dimmy that's the RT coming through that could look like this now let's say this person is 30 instead of 80 so what if I say there's lots of funny pigmented things in there later on this side too so do you think poor wine stain anything like that no, not reddish looking more tangy and melanoma not sure this is actually a picture of what we call a nevus of ODAP a piece in the nevus of ocular cutaneous melanosis and so the reason I really love this picture this is a really good picture because if you look they've got this superficial pigment at the nevus which is tan around very common but if you look at this it's kind of grayish almost and the reason that it's grayish is that it's actually not on the surface of the conjunctiva that's actually below the sclera and so you can get this ocular cutaneous melanosis where you get these lesions actually in the sclera so they are below the sclera in the corollae so what's interesting is these lesions don't go on and form melanoma of the conge they can't have melanoma of the corollae because remember this isn't the conge because the superficial that's a total totally separate lesion so this is where you get these lesions that are underneath the sclera but can also be in the lid and the skin and they're usually on one side and so that's the ocular cutaneous melanosis alright, Nico so this is an external photograph we have the right eye and what I see is the temporal limb this is a brown brownish flat patch there seems to be some that's feeder vessels or just prominent vessels ok, so what would you think what would your differential here be my differential would be a ping-pong versus a nevis a nevis ok, so what if I tell you this patient is 13 and this could be a congenital nevis exactly, so the usual history here is that you know, you ask the mom how long has this been here well, it's been here for a few years but it's getting worse or it's getting bigger or it's getting darker and that's usually the history so these can even be some people speculate they're congenital but these start very, very young and then as the kids hit adolescence in the beginning of puberty these can grow and they can darken so when they're younger they'll often look almost pink and then as they hit adolescence they'll be younger and younger and so some people theorize it's the diet now, you know kids are really well fed now so they start puberty early my conspiracy theory that I'm sure President Trump believes in is that it's the hormones that are in the beef in the McDonald's burgers and so they give all these animals hormones so that they grow faster so I think the hormones are having kids hit puberty earlier so that's the conspiracy theory side of it so memorize that for boards, okay but in any event kids, it's probably due to nutrition kids are just eating puberty earlier and as a result you're seeing these lesions change in size and change in pigment and so it starts to bother them and then they bring them in so I made another sexist comment there against guys you can do your own kind of stuff so mom gives you the history okay, does dad ever bring these kids in? no, it's always mom now, would dad even notice this? no, I mean the eyeball would have to be coming out of the head for dad to be like oh yeah, there's something wrong with the kid here mom, it's like if this gets like a single platypia on it oh my god, it's changed from yesterday we better get him seen the triage right away and so you'll see this and so mom will usually bring them in but the problem is when kids start to hit middle school other kids start to notice things and so if you've got a little thing on your eye kids are brutal, they'll notice something and so dad has reasons to remove them aside from you know, mom being nervous is that the kids are starting to notice them and so we look right here and here's the pathology, what are we seeing here? I see like a kind of like cystic spaces large cystic spaces alright, so large cystic spaces and what's the lining of the cystic spaces here? that's epithelial exactly, it's a surface epithelial there's all these epithelial lines cysts, now gosh I wish I had this laser pointer working I've got a three in my desk but I'm not going to run up and grab it because I thought this would work but if you look way at the top you see little nests of melanocytes where are they located? I think it's in the sub-epithelial well if you look at the ones especially right in the middle there they're not only sub-epithelial but they're right at the basal layer of the epithelium so what area do we call that? melanocytes at the junction and then you see melanocytes down in the substantial propias, what do we call this? compound nevis so nevi, you can get melanocytes initially at the junction but then when they start to grow down into the substantial propias they'll be in both places, we call that compound eventually they will lose their connection with the junction and just become sub-epithelial so they'll be kind of the equivalent of a dermal nevis in the skin we call the sub-epithelial nevis and those are important because once the melanocytes lose their connection to the junction they really lose their malignant potential and so it's important seeing the cysts because in kids, especially when they've been there a long time you will see these little epithelial line cysts and the way I remember it is the melanocytes come from which embryologic layer? almost neurocrests so the melanocytes migrate out from the neurocrest they go to the junction they start growing and they grab epithelium and yank it down with them when they grow down so you get these epithelial line cysts now is that what happens? No! so don't remember that for portraits but that's a good way to remember it neurocrests, melanocytes, they start to grow at the junction and they sort of drop it down they grab epithelium while they go down so when you often see these epithelial line cysts that's the tip-off this has been there a long time, maybe even congenital so that's really reassuring in kids because when general pathologists look at these sometimes these melanocytes are just a little bit active and so we'll often get a referral that says you know, I'm uncomfortable about this if you see these cysts it kind of gives you a little bit of confidence that these have been there for a while here's the lining of the cyst it's surface epithelium, you can even have goblets help it which is very interesting and then here are the melanocytes at the junction now the thing that folds you in these especially in younger kids is they often aren't pigmented and so they won't look brown or tan, they'll often just look pink and so there's the melanocytes growing at the junction and then here you have at the junction and then down into the substantial proprioces so compound on the nevus and then last but not least oh man, I can't consult my fellows here so I don't know who took this one but again, we've got to get there PRK, are you done? so you can see right here the melanocytes are now down deep so they're just in the substantial proprioces almost like the dermal nevus and so these do not lead to melanoma all right Tron, what are we seeing here? does that work alarming at all? yeah, you can see it's kind of superficial it's not thick and it's uniformly brown it doesn't have different sizes, shapes, colors and so this is, I tell this story every year because I get sick of it but I love this story, so this lady's about 40 and on an anxiety scale of 1 to 10 she's about a 15 and so I talk to her, I said, no, this is not anything related, we don't have to worry about this what we're going to do, we're going to take a picture of it and when I come back again in six months and we'll compare, but in the meantime if it changes, let me know and she's very nervous in a half hour we'll have the questions I'm sitting home watching the weather news at 10.15 and the phone rings and some of the residents on call and say, did you see so and so today and I said, oh yeah, I did well, she's here in the ER it's changed and so she wandered it off so for her mental health we took it off and it was good that we took it off because we usually don't remove these and in fact, when we looked at the path what are we seeing here is the basilar layer so you see these little anisides along the basilar layer coming along the basilar layer but they're just in the basilar layer they're not atypical they're not extending up into the epithelium so what do we call this entity three letters, three letters, girl's name so this is Pam which stands for primary acquired and so these are even more commonly seen than what we see in terms of nevine so this is Pam, girl's name and when we subdivide Pam we divide it into Pam without atypia Pam with atypia so this is what we call Pam without atypia and this is what it would look like if you see someone who has racial pigmentation at the limb this and that looks exactly this way too so it's not anything atypical that doesn't extend into the epithelium it's just along the basilar layer without atypical and these are not pre-religionate and then you see the close-up the nine melanocytes along the basilar layer it's the only way to tell the difference between the racial pigmentation and the pain with the clonal history exactly but they look the same so if you see the Pam a nervous 40-year-old Caucasian woman obviously that's different than a 60-year-old African-American guy and then Hispanics and Asians you can see pigment around the limb yeah, I guess technically purists would say no but I would still call the same you can often see some secondary melanocytes with a long-standing tumor so it's not uncommon and racial melanocytes that's also we also call that back exactly the same thing pathologically it looks like Pam without atypia Tara this is a little different looking what do we see in now so is this more concerning okay so we look at the pathology here and here we have these melanocytes except the difference here is they've taken over the whole epithelium and not only that look at the cells here what's going on right here, what is this exactly so there's nucleolide, there's pleomorphism some are big, some are smaller all epithelium so this is now Pam with atypia and we can some divide the atypia into how extensive it is but the reason that this is important is this can be premalignant so if you look at 100 cases of conge melanoma 80 of them will have preexisting Pam and probably 10 of them would maybe have a preexisting nevis and the rest, who knows what causes them to come on but this doesn't mean that 80% of Pam with atypia cause melanomas but if you see a melanoma of the conge, if you look carefully you'll see about 80% of them will have some preexisting Pam with atypia so it's important to recognize this because this is premalignant and especially here if you look at this guy he's right here he's right here yeah, so what do we call that it's a symboliferon and so symboliferon so what that tells you is this is a vat and he's had multiple surgeries for Pam that keeps popping up and so there's scarring there but the key thing here is you see those atypical areas up there but then when you look down here and this is one thing I really want you to remember if you see Pam in the fornix it's melanoma until proven otherwise so once it's in the fornix you can't mess around with it I'm going to get that out of there because it's melanoma unless it's proven otherwise the other stuff on the vulvar you can see that the patient's had multiple surgeries before and some scarring and the problem is is you have this Pam with atypia up here in the epithelium but then it comes down here and then it's breaking through the basement membrane down here and so this is preexisting Pam with atypia leading to malignant melanoma and you can see how I'm close up some of these cells can be really bizarre looking look at those cells in the middle huge nucleus, clumped chromatin big body there and so very aggressive looking cells and these can't be aggressive so you want to make sure to not let them spread into the orbit or out of the eye so if you have melanoma again 80% have a preexisting Pam with atypia 10% arise from the need and so this is malignant melanoma this is one of the conjunctiva that arose from preexisting Pam with atypia and of course just for fun we did a stain this is called HMB45 this is just an immunoproxidized stain that stains from melanocytes and so just to show you that these are all melanocytes and if you don't treat these this is what can happen so we love showing gross pictures of 8 in the morning isn't it fun? this is what can happen a person who ignored it and at this point you see that it's on the lid it's all through the orbit and so this patient had to have an exenteration which is not a very nice surgery so melanoma can be aggressive so you really go and be careful and get on top of it and remove any suspicious tissue alright so it's interesting for some reason this looks like the winged horses on top of the Brandenburg gate in Berlin but this is in Copenhagen so Christmas I don't know who scheduled the lecture on the 27th but they did so I apologize for that but next Tuesday 7am day after official holiday Christmas is cornea so again I apologize but just to make things easier I will bring whatever sweets we have left over from Christmas for you guys to munch on so don't eat breakfast bring your appetite and we'll do that next Tuesday morning ok