 So this is a laser pointer and I've juiced this up so if you do fall asleep I will fuse your eyelids together so just keep that in mind. So just a little background for the new residents for our intern. Basically when we do these path lectures I really want you to look at the section in the BCSC book and read it ahead of time. This lecture is kind of hard because it's introduction so there's really not a whole lot to read in there. Next week we're going to just go through the eye a week at a time so next week it's going to be lid and so read the section on lid because I really want you guys to know ahead of time what we're going to talk about. The format we use is we just go around the room and you describe what you see and tell us a little bit about what you know about the topic. Because you are a captive audience you have to see my travel slides and so you are stuck and so wherever I've been that's where you get to go. So since the ESCRS was in Copenhagen you get to go to Copenhagen first and so much like Amsterdam it's famous for its canals it's on the water there's canals everywhere and you see the ambiguous tourist boats and so they cram you know 50 tourists in there they're very low that's really weird. So they cram about 50 tourists at a time in there and the reason that they're low is because the bridges have about five feet of clearance from the water to the bottom of the bridge and so when you're going under the low bridges you literally have to duck your head because they're very very low but this is a nice way to see the city they pile you on tourist boats and this is the famous street they have the rainbow color of all the houses there the people have their boats here there's all kinds of restaurants and bars and things along here so this is kind of the central part of what you think about when you think of Copenhagen and here's a close-up of the other side it goes right up to the end and then it just ends here and this is where you pick up all your tourist boats to go for a ride and then this is the other side again these are these I think are apartments I mean people actually live here which I don't know how fun that would be with with tourists but during that four days we were there it was 72 degrees and sunny which in northern Europe is just unheard of and so as a result people take advantage of it and so everybody all the office workers everybody were outside and they were just they put these little chairs out there and they were just laying there you know worshiping the Sun because you know the Sun as opposed to Salt Lake where it's sunny 300 days of the year it's sunny in Copenhagen about 30 days of the year and so we happen to get four of them so you can see this gorgeous blue sky I mean just unheard of and so all along the water these people are sitting there sunbathing yeah exactly that's what they got and so you know chance to see some of the the older buildings in the museum this is the old central library so this is the main central library a lot of old buildings a lot of old history and we'll go into that as we go so if we're going to talk about the eye you really need to start with the embryology and it's very important that you remember where the different parts of the eye came from because that explains a little bit about some of the diseases that can occur and so you know this is actually a mouse eye which which amazingly enough looks just like a human eye about the same stage of gestation and so really we all look alike when we're at this stage and basically you know the optic vesicle starts as an outpouching from the neural tube and so when you look at the neural tube and it's sitting here you'll start to get an outpouching from the neural tube coming out this occurs very early you know this is just a few weeks in a gestation and so looking at it in the mouse eye down below this is from four weeks to five weeks and I'm looking at it up above very similar in humans and in mice but basically you get this outpouching from the neural tube so this is now neural ectoderm to get this outpouching of neural ectoderm it approaches the surface ectoderm the surface of the skin if you will and then it will induce an infolding so this neural ectoderm will infold and then it will also infold a piece of this surface ectoderm which eventually pinches off and forms the lens so it's important when you look at what part of the eyes come from what this neural ectoderm as it invaginates has got basically two layers so it's like you took a balloon and you put your fist in it it will make two layers and these two layers are very important because these two layers give you what you think of as kind of the neural ectodermal tissue within the eye and so the anterior part of these two layers forms the epithelium of the iris the middle part here forms the epithelium both layers of the ciliary body and then the back forms the retina and the retina pigment epithelium so they all come from those layers now when you look at the retina layers interestingly enough the entire neural retina comes from that single inner layer and so when you look at that little inner layer the outer layer forms the RPE the inner layer of that neural ectoderm forms all of the layers of the retina when we get to the retina you're going to know those layers and so we have several themes in ocular pathology one of the themes is layers so you'll often hear me talk about what do ogre's onions and ocular pathology have in common layers so lots of layers now when you look at the eye as it's forming interestingly enough you need you need blood you need oxygen you need nutrients to go into that eye and so when the eye is forming what will happen is there'll be a little fissure here a little bit inferior nasally and in this fissure runs the hyalurid artery so the hyalurid artery comes into this fissure and it forms a plexus right behind the lens vesicle and actually gives that blood supply to the anterior segment of the eye as it's forming and so you can look right here here's the hyalurid artery here's the corral fissure coming underneath and going in and forming that that blood supply that goes in now this explains why you can get some congenital anomalies so when that fissure closes it'll start to close at the equator and then it'll run forward and backward. If that fissure does not close properly then you can get a coloboma. What does coloboma mean? Okay what what language does it come from? From the Greek of course so from the Greek so someone someone's gonna look that up and tell me next week what coloboma means. Well actually you guys all have your phones in here. Look it up tell me what coloboma means. Look it up. Coloboma. Defect. From the Greek. Exactly so it just means a defect basically so if you look right here when the anterior fissure doesn't close you get a coloboma of the iris and it's this little inferior area here and you see the keyhole and so you'll see a coloboma you'll see that defect anteriorly. When you go posteriorly inferiorly now here's the optic nerve and you can see this large coloboma it's affecting you know the development of the retina here and you just see bear sclera so it just looks white. Now this coloboma can sometimes involve the entire optic nerve or it can involve parts of the optic nerve. When we get to optic nerve we'll talk about some of the effects of the coloboma. Now the embryonic lens remember we said that that optic vesicle comes out it touches the surface ectoderm. The surface ectoderm invaginates eventually pinches off and you get your early lens vesicle. Now that's initially just a round ball of cells and then eventually those posterior cells will move forward anteriorly and that's really important to remember because as the lens is developing they're normally are not lens epithelial cells along the posterior capsule so that's abnormal. So as the lens develops throughout life these little lens epithelial cells sit at the equator on both sides and eventually send fibers anteriorly and posteriorly so as the lens builds up you get progressive layers like a ball of yarn that you're putting more and more yarn around. So the central fetal nucleus eventually gets surrounded by an adult nucleus and then more adult tissue around it so the center part of the lens gets compacted and the lens fibers continue to go throughout life and so this is normally you do not have cells back here posteriorly. And so when you look at this this is what it looks like anteriorly you do have these lens epithelial cells and they go right around to the equator and then they fan out along the edge of the lens much like along the edge of like a flying saucer and those fibers go both anteriorly and posteriorly. So the part where you know where they meet eventually forms some little sutures and so you get your why sutures when you do that. So here it is again in a mouse embryo invagination and then it forms the circle and then those little cells come forward and fill that in. Again exactly the same in a human. This is an actual human embryo and so this is a human embryo and you can see here is the lens. Here is the invaginated neuroectoderm. This will eventually be iris epithelium, ciliary epithelium, retinone, RPE. Now when you are feeding that anterior segment as it's going that hyalurid artery comes in and it has a plexus of vessels that are around the lens the tunica vasculosulentus basically a tunic you know around the lens. So tunic you think about it remember those old Victorian England pictures where they had that thing around their necks all these people had okay so that's a tunic and so you get this little tunic of vessels around the lens as it's forming and the key thing is that this should eventually regress. Now anytime something can go wrong sometime it will and so eventually if that hyalurid system and this tunica vasculosulentus does not regress then you can get diseases such as this and so here you see here's the stock this is a about a 25 26 week embryo by now this should have regressed you see here's the hyalurid artery coming out of the optic nerve and there's that stock and so you can sometimes get non-regression of this hyalurid system now in the severe forms you get a condition that we used to call phpv persistent primary you know vitreous but now they call it what exactly pv not pfv persistent fetal vasculature so just put letters on everything that you have to memorize so and here's a close-up of what it looks like so this is the lens seen in cross-section and look at these little vessels here all over so they form a little spider web of vessels behind the lens and they feed that lens in the anterior segment as they're growing in the embryo but they should regress so again when they don't regress that's when you get disease so we want to talk a little bit about some of the cells you want to look at because when we look at pathology we look at a lot of cells and this is obviously a fake cell nobody gets a blood smear with all these on there and this comes that track this all the way back to the early 60s I don't know where this slide originally came from but I copied it from David Apple who copied it from somebody else and so this is a fake slide from the mid 60s sometime but the nice thing about it is this shows you all of the various blood types and so we're gonna do we're just gonna go around the room so I guess Tara you're sitting in a hot seat first off what kind of cell is that right there PMN so polymorphal neutrophil and you see it's got the multiple nuclei that are there so some PMNs that are sitting here Reese what is that there's another one next to it there what more specific look at the little granules in there what color are they that's yeah well that's more basophilic these are more eosinophilic this is an eosinophilic and the way you can tell an eosinophilic is it's got kind of a heart shape bilode nucleus so you see this heart shape bilode nucleus you've got these little eosinophilic granules that are right there Chris what is this then that's the basophilic I've never seen one of those on a blood smear I don't know there I think they've just made them up I don't think they really exist there is a basophilic that is sitting right there all right what kind of cell is this the interns are still liable so it's a lymphocyte so the way you can tell the lymphocyte as you can see that the nucleus takes up about 90% of the space of the cell in very very thin area of cytoplasm around them so Lee what is this plate that's very good let's finish the round what are these here easy ones red blood cells exactly so that's what you see on a sphere on a smear all right so let's talk a little bit about PMNs I guess we'll come back since you did PMNs here Tara what do PMNs do okay so they're involved in what infections so like bacterial infections they're the cells you kind of think of that are the frontline troops when there's an infection there now the way they fight infections is all of these granules have all kinds of bad humors in them that they try to kill bacteria and fight infections and so the problem is is when these degranulate you know they can eat up bacteria and help to kill the infection but they also kill the tissue around it so if you've got a bunch of PMNs in your skin that really doesn't matter but if you have an infection in your cornea and all those PMNs come in there first of all they can cause the cornea to melt because there's proteases in there there's collagen aces in there's all kinds of bad humors in there and so they can cause real problems which is why treating a bacterial corneal ulcer is truly an emergency because you really want to treat it before the body's own immune system kills that so when you see the PMNs you're thinking of an acute phase infection you think of a bacterial type of infection all right what do we think of in eosinophils yeah so kind of weird parasites and other kind of funny things in there now also eosinophils can show up in what other common thing normally well even no common like even just allergies I mean you know eosinophils can even show up in chronic allergies and things like that but again they've got all these eosinophilic granules that are sitting in here that they dump out in that nice bilo heart-shaped nucleus and so they can be more involved in and you think about them in you know infections with with beasties that are in there you think of parasites and things like that but they can also be part of a severe allergy severe allergic reaction and boy that was supposed to be this has been used so long that was supposed to show so eosinophils doesn't really show very well all right so lymphocytes what are lymphocytes do well they part some lymphocytes can differentiate in the plasma cells not all what kind of infection or what kind of alright so more viral infections you think lymphocytes and viral infections also lymphocytes can be involved in inflammation so they're kind of chronic mononuclear inflammatory cells you think of chronic inflammation you think of viri things like that and since you mentioned plasma cells what are plasma cells what do they do okay so they're basically antibody factories and they're just a type of lymphocyte they're kind of the ultimate B lymphocyte and they become an antibody factor when you look at them the nucleus now becomes eccentric and you've got the cytoplasm here taken up about two-thirds of it oftentimes these nuclei will have this clump chromatin people call this the wagon wheel so you look at like the wheels of a covered wagon with the spokes and the dots on them so they get this wagon wheel clumping and then right here there's a whole bunch of Golgi apparatuses and they make all kinds of antibodies so plasma cells become antibody factories and the ultimate plasma cell is is it gets so stuffed with antibody that eventually it pushes the nucleus out and you end up getting this bag of just antibodies and so it becomes what's called a Russell body so this is a side of a really chronic inflammation all right I guess we'll go back Ali so eventually this can become a macrophage but remember macrophages start as monocytes and then as they leak out of the blood cell into the tissue then they become macrophages or if you want to sound intelligent you say macrophage you say macrophage and so that is and and if you measure something you say you say sautomies also because it makes you sound intelligent so if you say something with a British accent you sound really intelligent if you say it with an Alabama accent you could be a Nobel Prize winner and you're still not going to sound intelligent so exactly well actually I you can find your own kind so if you say it with a Wyoming accent you know it doesn't matter if you're Nobel Prize winner or not it doesn't sound intelligent so monocytes will eventually leak out into the tissue they become macrophages what kind of inflammation or macrophages associated with so I like to think of macrophages as kind of the scavengers and so you know when they come in there's this kind of you know there's a battle going on the bat body trying to fight off this bacteria and there's all kinds of you know dead horses laying around people and so the scavenger birds come in and scavenge it up and that's what these monocytes do these macrophages and so they kind of help to eat up the you know the the leftover from the battle that's happening when you're fighting an infection and here's a more of a macrophage reaction that's coming in so this is kind of a more chronic phase reaction and kind of the the ultimate macrophage eventually they can become what are called epithelioid cells and they can even form giant cells and so Nico in terms of giant cells there are three different types of giant cells that we need to know about of course we wrote the first one down here first one you get a bonus the Langhans type what are the other two type of giant cells to turn giant cells okay actually the third type is a foreign body giant cells so those are the three types of giant cells it's important there's three types of giant cells there's three types of granulomatous inflammation so we want to keep those straight so what we think of as a giant cell is the Langhans giant cell and that's the one that's kind of shaped like a horseshoe the nuclei line up around the side and then the cytoplasm gets all jumbled up this is what you usually think of in a granulomatous inflammation is these Langhans type giant cells this is what they look like again that horseshoe shape with the central nucleus now they're often not by themselves there's lymphocytes mixed in here there's plasma cells mixed in here there's other inflammatory cells now here's the foreign body giant cell the way you tell the difference between Langhans and foreign body giant cell foreign body giant cell the nuclei get jumbled up so just as the name says it's a reaction against a foreign body so in the eye you will see these around sutures you'll see these if a person got a stick in the orbit you know form body in the orbit they usually don't form around metal that's more of a vegetative material so if you see them you know in the orbit somebody gets a stick in there gets poked with something you'll often see these foreign body giant cells and here is a suture and it's kind of breaking down a little bit an old nylon suture and sure enough there's these giant cells surrounding it so they just kind of tend to surround and try to wall off this foreign material and these are the coolest type of giant cells this is the so-called tuton giant cell so extra bonus points Nico what disease do we see in the eye that are often associated with tuton giant cells good board question young kid comes in with a spontaneous hyphema and something funny on their iris so these are associated with juvenile xanthogranulomas and what these cells have is they have the nuclei around but they have this halo of lipid around them so when we process tissue in the lab it goes through steps where it gets dehydrated and then paraffin gets put in it so we can cut it and stain it and as a result the lipid gets dissolved and so lipid in a normal processed slide will be white because the lipid will dissolve so you get this halo of lipid around them so these are tuton giant cells and the board question you want to remember is these can be associated with juvenile xanthogranulomas on the on the iris all right so there's three types of three types of giant cells of three types of granular modest inflammation so the first type we think of is called diffuse granular modest inflammation and the characteristic of that is is sympathetic ophthalmia so I guess we're back to terror what is sympathetic ophthalmia okay so in the days before steroids people would lose their eyes to this and you know especially like World War one you know these poor guys are in the trenches and things are blowing up and one eye would get really severely damaged and then a couple weeks later the other eye would start to get inflammation they could go bilaterally blind fortunately in the era of steroids I mean I think I've seen one case of sympathetic ophthalmia in the last 20 years and so you just don't see this anymore but it is an autoimmune reaction people will argue about what's what it's the reaction to but it's an autoimmune reaction well that's what we find is that if you have a severely damaged traumatized eye if you remove it within 10 to 14 days you can prevent sympathetic ophthalmia from developing so if you have an eye that's been severely traumatized you know somebody gets shot in the eye or they have a severe accident there's no way you're ever gonna save that you can remove it but you have to do it within 10 to 14 days to prevent sympathetic ophthalmia because it's not an immediate reaction I think it's just been people have observed enough cases and they saw when it when it occurred when it didn't but we have found if you nucleate early you can prevent it but you know that's always a tough thing that you'll talk about when you talk with boopy and those guys so if a young person especially comes over the severely traumatized eye you don't just take it out right away I mean psychologically people that just devastates them and so I always tell the resident especially when you're on call you do everything you can in the or you stay in there for three hours you put that eye back together you tell the person you know we did everything we possibly could to save that eye but it's severely damaged and then you go on talk to the family you make sure you leave some beads of sweat on your forehead you know okay we tried for hours to put that eye together but it's severely damaged and then you give the patient a week or 10 days to get used to the fact that that eye is blind it's not coming back it hurts then you broach the issue of a nucleation because if you do a primary nucleation they really it really devastates people so you give them time to realize that the eye is not going to be saved and then you take it out but as long as you do within 10 to 14 days you will prevent sympathetic ophthalmia so sympathetic ophthalmia it's this diffuse granulomus inflammation it just affects the whole quarry exactly so vkh does not and sympathetic does and if you look very real carefully and they show you the path the coreo capillaries is spared all right and you start to see and you know some some other kinds of inflammation that you can see in these and now this is a little bit different this is now not a diffuse granulomus inflammation but this is a kind of a multifocal granulomus inflammation and what is this characteristic of well no there's a specific type of granulomus inflammation where you see multiple multifocal areas of inflammation it's called sarcoidal and so sarcoidal inflammation you see multiple nodules of inflammation that's another type of granulomus they call it sarcoidal so when you look at sarcoid you see these multiple lobules of inflammation you see these really bizarre giant cells and it's really cool they get these asteroid bodies in them which are kind of cool and I don't know I guess that looks like an asteroid I don't know looks kind of like a big spider to me but they call these asteroid bodies and so this is the second type of granulomus inflammation it is called sarcoidal it's these nodular granulomus multifocal granulomus inflammation and then the third type is more of a focal or zonal type of granulomus inflammation and the ones that kind of characterize this is where you have a traumatic rupture of the lens capsule and you get this granulomus inflammation around the ruptured lens capsule and so the three types the diffuse type which is sympathetic ophthalmia the nodular type which is the sarcoidal and then lastly the focal type and this is a patient the horse kicked him in the head cowboy from Wyoming that believe it or not is the cornea there's what's left of the iris there's the remnant lens ruptured lens capsule raging inflammation around the ruptured lens capsule all right so there's no place else to put this so I'm gonna go ahead and just describe it a little bit here so this is the beginning of an end stage eye so when an eye has a severe insult of any kind infection traumatic chronic disease eventually the eye begins to shut down and so this happens to be an eye that had just chronic vitreous hemorrhage it just shut down and you can see it's just full of blood little cholesterol you know sparkles coming in there and so eventually when an eye shuts down chris what do we call the end stage of an eye that shut down it's actually but it's pronounced tices tices ball by so ticycle but it's weird because it's ph th so it's like but just tices and what language does that come from exactly it's the Latin it's not the Greek but but remember the Romans they took everything the Greeks invented it first the Romans they took from the Greek so even though it's Latin the Greeks invented it first but so this is called tices ball by and so when you look at an eye it's an end stage eye that's just shutting down and so there's several characteristics when you look at it pathologically so name one a characteristic that you would see when you look at a ticycle pathologically okay so it's disorganized you look at all of the intraocular contents completely disorganized name a second one exactly it shrinks third one exactly so it's hypotenuse it's very soft fourth one did you hate when you get down to the fourth one oh I knew those I knew those you can get set you can get calcification exactly and what is eventually calcification lead to exactly so you get bone inside the eyes even get bone another thing when you're looking at this look how thick the sclera is so you get thick sclera so the eye becomes hypotenuse it gets really low pressure then it shrinks and as the pressure is low it's almost like there's nothing to push out against the sclera so the sclera thickens as it becomes more edematous the core rate is almost like a sponge and so the core rate is like a sponge in water it will even thicken and get more edematous you get disruption of intraocular contents and the shape it's almost square rather than round as it gets hypotenuse and this is the thickened sclera really thickened edematous sclera and this is the core rate very out like a sponge with water in it so it becomes very spongy very edematous because the eyes hypotenuse and lastly here is bone so you literally get bony formation now the cells that really lead to this are the RPE so the retinal pigment epithelium is a pluripotential cell if stimulated in the right way it can form gliosis it can form bone I mean it's really a pluripotential cell and so if you look this is bone so my technician hates these when she cuts them because bone really chews up your blade when you're cutting it up and so this is indeed bony formation that you can see in tisus bulbine here's woven bone here's the disrupted RPE next to it and so that's the end stage tisus bulbine all right so I want to talk just a little bit about pathology because I want to get you guys while you're young before you spend a lot of time in the OR because I know the seniors never come to these lectures they're always either off operating out of the country or somewhere except right before the final O caps and then they're going like oh gee maybe I better start looking at this because I have to take O caps next month so you know you guys I want to get you when you're young so the key is when you want a pathology analysis done of a specimen communicate with me or when you're out in practice communicate with a pathologist let them know ahead of time because there may be something special they want done and it's better to just send an email or give a call ahead of time say hey listen I'm looking for this entity what do I do and so spend a lot of time communicating now when you guys are in the OR working with Crandall and he's doing 14 cases he's not going to worry about pathology or filling out forms or anything you guys are so so please do it and that helps me a lot now the key thing is is the pathology requisition slip and so when we get this requisition slip it'll often say blind eye lid lesion that does nothing for me so I don't know are you worried about cancer are you worried about an infection do you want special stains do you want the tissue treated especially so if you say you know superficial lid with ulceration rule out squamous cell all right that gives me information and tells me how we need to treat that specimen and so just two sentences on the form really help me to know what it is you're looking for so you know fill out that requisition form and let us know you know drawings help a lot and on booby does these all the time he'll put a little drawing on it and it's okay Nick suspicious lesion and he'll draw exactly where it is and he'll put on there where it is okay this is temporal this is nasal and then we can orient that in the lab and we know what to do with it so that's very very helpful now there are some special things you want to do with tissue when you're removing tissue if you grab it really hard with the forceps it causes crush artifact so you want to be pretty gentle with that tissue you don't want to crush it if you're concerned about a tumor or something abnormal you want to get normal edges around it so that we can first of all make sure that the lesion is removed completely but secondly that there's good normal tissue around it to compare it to and put it in the fixation right away tell the nurse okay put it in fixation now don't let it sit around now what do we normally use 10% neutral buffered formalin is our standard solution and that fixes the vast majority of them rarely if you want to do for example electron microscopy that's pretty uncommon unless you're looking for some weird storage disease or who knows and so you have to have some gluteraldehyde mixed in there in order to get the tissue fixed for em now if you want lipid or you want fresh tissue then we have to freeze that and cut it without fixating it so if you want tissue that's fresh again you got to call us right away because we're gonna have to go pick it up immediately and freeze it so that we can cut it without processing it so when you're looking at the fresh tissue don't let it sit around because the tissue if it's not preserved will rot and so what you want to do is you want to go ahead and you want to keep it cold if you can so say you're practicing when you're done here you're gonna go out to Price Utah and practice you want to send me a specimen you can put it in a container and put ice around the container and it'll keep for 24 hours then FedEx it to me now the key thing is if you're going to get a tissue that you want fresh you can't just put it in an empty jar that'll you know gum up the tissue if you put a piece of wet tissue onto a 4x4 the 4x4 will suck the moisture out of it and that'll ruin it also so what you want to do is put it on a moistened 4x4 or moistened gauze don't put it in a container full of saline and we've seen that before they say oh saline okay so they you know fill a thing with saline and plop it in that that just macerates the tissue too so you take a saline soaked gauze or BSS or saline or whatever moisten the gauze put the specimen on there close the container and then if you call us we'll come get it right away if you're on the outside you can put ice around it and it'll keep for 24 hours but the key is saline soaked gauze not all the way in saline now conjunctiva is its own different tissue if you take off a piece of conge it rolls up in a ball and so if we want to look for pathology if you're worried about a tumor and we get this rolled up ball that doesn't do us any good so what I tell you to do is take a little piece of cardboard and what's ideal is you know the little cardboard that you spin your gowns with that's perfect and so you cut about a 2 by 2 centimeter piece of that take the non shiny side lay the specimen on it and let it sit there for about a minute and then just tell the technician to put it into formal and the whole thing and it'll stay stuck on there and then when my technician in the lab takes it she'll literally leave it on the cardboard while she fixes it and then once the specimen is fixed it'll come off like a little piece of you know pants that you put too much starch on that's really stiff and then she can align it and cut it and so that allows us to do that now if you want to mark the margins it's the non shiny side of the cardboard oh you want to definitely put the the substantial propria down and the epithelium up and so the other thing people say is well how do you know which is superior which is inferior how do you market people put stitches in there and you know sometimes that just comes up the tissue don't write on anything because ink will dissolve from our processing so the ink will dissolve and so what I find the best is to cut notches into the cardboard and if you cut notches that can do it because sutures are okay but if people have tried to pin it they've tried to write on there that just doesn't work and so here's a little piece of cardboard and we laid out the conch so it fixates on then then we said okay this notch is temporal then if you want to mark superior maybe put two notches and then on the form you draw a picture say it you know notches temporal two notches are superior and then we can align it when my tech cuts it she'll put it on the slide okay superiors here temporal is there and then we cut all the way through the specimen and we can make sure if there is a tumor where the margins are and if you got them all or not so that's conch lids you don't necessarily have to do that because lid skin holds its shape better you maybe put a little stitch in one edge or something like that all right one last little thing here and then we'll quit this one this is just the intro so I said we start real path next week so this is the standard stain we use I can't remember Reese what's our most standard stain what's when we do 99% of the time okay so he metoxylen eosin so he metoxylen stains the blue eosin stains the pink or the red so that's our standard stain when you think of it so here's a cornea you can see that the eosinophilic stains stains the red the hematoxylen stains the blue and so this is our standard pathology state but there are several specialized stains that we do when you we're looking for specific things Chris what do you think this stain is staining here's the hint what here's what is this right here first of all that's a basement membrane okay what stains stains for basement membrane okay so it's called PAS periodic acid shift that's what we call it PAS because it's easier to say so we occasionally will do a stain looking for basement membrane and that's called PAS this is a really nice nice example here because here's the epithelium of the cornea here's the basement membrane right here this layer right here is not staining so Chris chance to save yourself is that layer right there more specific part of the anterior stroma that stroma that's Bowman's layer and the reason I'm showing this is Bowman's layer is not a basement membrane so it does not stain positive for PAS decimase membrane on the posterior part of the cornea is a basement membrane so it does stain positive so if you look right here here's the basement membrane staining PAS positive there's Bowman's not staining all right now you will memorize eventually when we get to cornea the various corneal stromal dystrophies and these are a good example of some special stains we use and there's a special mnemonic we're going to do but this is one of the corneal stromal dystrophies and this is one of the stains that we use and again since we haven't covered this you get a buy now just because you're an intern but this is called Alchin blue and so this is Alchin blue stain and say what is Alchin blue stain stain anybody okay so what's the mnemonic okay that's not a singer exactly so you're going to memorize that when we get to cornea so that's a couple more lectures but in any event Marilyn macular dystrophy Monroe muco polysaccharide really recessive always Alchin blue so this is muco polysaccharide on Alchin blue staining and then gets granular her Hyland man mason trichrome don't worry about it now you'll learn it in cornea so this is the mason's trichrome stain it's a three-type stain and it it stains the mucopoly saccharides red it stains the stroma blue and then the epithelium more of a red and then finally the third one that Chris was trying to get to before which is exactly and what is that material is it amyloid and so L lattice a amyloid county or California see what's the stain Congo red things I hear that whisper there Congo red and so it's not really red it's kind of orange but Congo red stains stains the amyloid so it's a stain you need to know about and what's cool about it is if you cut the stain thick enough and you put cross polarized filters on there it lights up so that's one of the most exciting things that you'll see in the ipath lab which tells you how unexciting ocular pathology is yes no those are angioid streaks different those are breaks in Brooks membrane and so those are different not amyloid streaks angioid streaks different things so you can see amyloid in the cornea you can rarely see it in the conch or in the skin but cornea is where we see it in the dystrophies okay there's some other stains we can do what is this stuff all the interns can get this what is this stuff we're looking at yeah look at these little beasties what kind of our what are these those are fungi to remember bacteria are very tiny little round clusters a little rod these are big you know high-fee here this is fungi and so there is a special stain we use for fungi it's a silver stain it's called GMS Gamori methenamine silver so GMS stains for fungi and it'll stain them silvery black and so that's a fungus stain now there's even a specialized stain we use for these guys this is a stain for amoebas so you believe it or not get acanthamoeba in the cornea and so this is called a gridly stain and this stains for acanthamoeba so you can see it stains the stroma green but these are these big cysts acanthamoeba cysts and so the gridly stain will stain for those and we'll talk about these when we get to cornea but I just wanted to show you there are various different stains we can do for various different situations now this is an interesting stain this is a stain where this is the cornea and there's all this blue right along the base of the epithelium anyone care to venture a guess here it's an iron stain and what's the iron stain called okay it's Prussian blue how do we remember that who were the Prussians the Prussians were the militarists and in what the eastern part of Germany they're the ones who really well I don't want to again be culturally insensitive the ones who like basically started the basic part of like three different wars but okay so Prussians guns tanks iron so Prussian blue stains for iron so that's how you remember it so Prussian blue stains for iron and you get all kinds of little iron lines depositing in the cornea and it's characterized by that iron in the epithelium so anywhere you get a pooling of tears you can get deposition of iron so at the base of the keratoconus the head of a teridium even where your eyelids sit you can get a little tiny iron line in there so Prussian irons Prussian blue iron stain all right this is an even more interesting stain this I'll give you guys a hint this is a piece of fresh tissue was taken out fresh and then frozen so what what did I say we have to do fresh to see lipid so this is a stain it's really I like it because it's very descriptive so when you want to stain for lipid you use the oil red oh so it's interesting it stains oil these little rados and so look there's oil and it forms these little red ohs so oil red oh is the name of the stain it stains for lipid but you have to have fresh tissue because our processing will cause the the lipid to dissolve away and then it'll just be empty so if you want to do a lipid stain you have to have fresh tissue so lipid is stained it makes these oil red ohs so it stains oil these little red ohs oil red oh all right so we'll say goodbye here here's one of the museums in Copenhagen so next Tuesday morning we're going to do lid so know all your lead lesions your lead tumors and everything and and so I'm going to talk a lot less and you guys are going to talk a lot more questions all right great thanks