 See that's where now it flips now. I've got that that's okay. That's okay. All right, so today where are we going? We're going to Florence All right, so you guys get get to go to Florence and so This is the main cathedral the Domo in Florence And the architecture is just really amazing. It's got this ornate details right here And the interesting thing here is the dome on the inside It's double layered meaning there's an inside layer with all the mosaics on it and then there's the outside layer But you get to climb up in between So don't do it if you're claustrophobic But if you're not claustrophobic you get to climb up and then you can climb out on here and get a beautiful view of the city So that's a close-up that's the inside dome and again This is back stairway. You can go all the way up to the top But I thought that the you know, the architecture was just beautiful right there Florence is an amazing city This is the front of the of the Cathedral and also you can go to the top here of This spire and again you get a pretty spectacular view of the city but gorgeous gorgeous cathedral This was you know Florence was the height of Renaissance in Italy. So beautiful beautiful architecture There's a close-up of the detail here Some of the stonework and some of the detail in the stained glass windows here on The cathedral. All right, so today we're talking about Conjunctiva All right, so let's talk about the three different areas of the Conjunctava What are the three different areas we talk about your bull bar don't you brawl or still all right? So we've got the bull bar lining the ball Now people lining these inside surface of the island. It's the inner layer of the island And then lastly the area here in the fornix. All right, it really low power These little dots right here You have a bunch of goblet cells goblet cells. What do goblet cells do? Musin and what is musin? Why is musin important helps? So it's the innermost layer of the tear film Describe what it does wet ability So if you look at the surface of the cornea the surface of the Conjunctiva I really high power with electron microscopy. There's a lot of little microvillage on them So if you just put water on that the water tends to just run off and not sit on them So if you put musin on the inside surface it makes it more wettable and allows the tear film to spread More evenly and so if you block off these goblet cells say you've got some adhesions of the Glow so you had Comfort or something even though you're making equities tears. They just Have pretty quick Now I also want you to know the goblet cells are more prevalent the further away you get from the limits So if you're near the limb us Where the congex helium is Cornea there's very few goblet cells Same thing on the Get closer to the fornix, but also closer to the coronical Medially and laterally you start to get more and more about what so that's what gobbled so what is the epithelium of the Okay, so the stratoids queen was non-charitonized epithelium. What is this part underneath it called? It's the substantial propria so the substantial propria is kind of a loose Connective tissue underlying the epithelium and then lastly not really part of the coins, but you get a layer right next to the Metnix of the sclera here anteriorly. What do we call that? Tenons is important because when you are removing a teridium, for example The disease in a teridium is not in the epithelium. It's below the epithelium So you don't want to remove a huge chunk of epithelium when you take off the teridium But you do want to remove some of the underlying tenons capsule and get down all right. Let's talk about some entities What is this thing? We're looking at right here. All right, so this is a picture So the term limbo-dermoid really confuses people so because you have dermoid cysts of the orbit Dermoid and so really the proper term. This is a limbo-dermol Chorostoma now what does Chorostoma mean? Oh me it's perforation I believe of Normal tissue in an abnormal location and how is that different from hematoma. It's the opposite perforation of tissue Yeah, so Chorostoma it's still benign tissue. It's not a tumor, but it's in a location It shouldn't be it. And so this is called a limbo-dermol Chorostoma That way you don't get it confused with the you know, dermoid cysts of the orbit or anything like that If this is indeed a patient who has this limbo-dermol Chorostoma, and it's a young, you know Alice and young child what? Entity can this be associated with systemically? What else would you look for if this is indeed a golden horse? It's like a a regular Facial dysplasia syndrome so you can have like malformations of the external auditory this or the ear globe itself and then kind of a facial Malformations as well body of the job Okay So what you need to know for the boards is that this is often associated with golden heart syndrome So they can get these kind of pre-alicula auricular skin tags They can get these funny teeth anomalies. They get some skeletal anomalies All right, so this is actually the pathology on that lesion what are we looking at right here and what's associated with it? All right, do we normally have hair follicles at the limbus? No, so that's the name Chorostoma So you'll have a dense fibers connective tissue, but the weird thing is you can get little hair follicles growing in these What is this stuff here at low power that you can get with these? Exactly, so you can get little Echryngoans growing in here, which normally shouldn't be here And then the other thing you can get that's really interesting is you can get Highland cartilage so these have Interesting proliferation of abnormal tissue. So these are Echryngoans Sitting in the dense connective tissue Highland cartilage Chorostomas. Question. Just I remember like medical school, I remember like teratomas That's different. Is that? Teratomolate is kind of two cellular layers of worth of stuff proliferating Teratomas all three of the embryologic layers proliferating. So teratomas is kind of a Super dermoid And there's a close-up. You see that nice Highland cartilage with the little lacunae that are in there So I just thought it looked cool. It's not normal to have cartilage sitting at the limbus All right, what are we looking at right here? So it seems like a certain photograph of the white, yellowish, black-like lesion that's not growing on to the cornea That's consistent with Probably a pink-like color. All right, so if someone is born and raised in Utah, 100% of them have a pink-white killer Why is that? Yeah, exactly. So it's because the etiology of a pink-white killer Trigium for that matter is UV exposure. So we're at altitude here. We've got very thin air here We've got 300 days of sunshine and so you get a ton of UV exposure and that's the cause you notice It's within the palpebrofisher It's this little triangular shaped area and What is this now? Trigium. So what's the difference between the two of them? I would have asked the limbus. It starts with the cornea. Exactly. So pretty much the same pathology, same etiologic factors, UV exposure And the only difference is a trigium has actually crossed the limbus and grown on to the cornea But still the same findings. And so when we look at the findings, what are the findings? Yeah, so for trigium, you can see much appropriate, you can see Solar elastosis and then you can also see areas of base of billiard degeneration So the solar elastosis, it's a UV induced breakdown of the connective tissue in the substantial property And when you look at it, I think of it as it looks like a frayed rubber bands And so I don't know if you've ever seen a rubber band that was wrapped around something It's been out in the sun for a while and it just frays and curls up. That's what this looks like That's why they call it elastosis. The connective tissue takes on some elastotic properties And we'll have this frayed squiggly elastotic look and then This gray Smudgy look, again as a basophilic degeneration What is this stuff? It could be the calcium like crenicity. Yeah So if you have a long-standing trigium, you can sometimes get calcium in them So when you look at these with the slit lab, you can often see little sparkles kind of underneath them And that's the calcification. So long-term if they're here for a while, these can calcify When it grows over the cornea, does it break through the bowman's? No, usually it stays on top of bowman's And so when you're trying to remove these, be really careful when you're moving the head that you don't dig down into bowman's Try to stay super visual as you can because usually these will grow onto the surface of the bowman's but not penetrate underneath it All right, what are we looking at right here? This is an external photograph of the palpable conch, the right eye It looks a deminus. It almost Looks like cystic and perhaps maybe like it would trans-eliminate if you... All right. So yeah, that's gonna be my next question. So you guys have obviously read it forward. So What you can do, you can take a fan off head and you can just shine it right next to it And if the light goes through and it lights up, then you know that it's cystic as opposed to if it's dull when it goes through, then it would be solid. And so this turned out to be Acistic lesion. What's the most important thing we need to look at on the pathology of a cyst? The epithelial. The lining. All right, so we look at this cyst and sure enough, there's the lining. How would you describe that? So that looks like a stratophyte squamous epithelium with goblet cells. Goblet cells. So what do we call this kind of cyst? So it's just like an epithelial inclusion cyst. Exactly. So you can get epithelial inclusion cysts and the reason that people call them inclusion cysts is for some reason surface epithelium has been implanted underneath the epithelium in the substantial property. So that could be a Previous injury. It could be a previous surgery But something has caused that surface epithelium to go underneath and then it will insist and then it'll slowly grow and Because there are goblet cells normally in the congex epithelium these goblet cells will be in here And they'll actually make mucin. So oftentimes these are mucin film. What do we look at that right here? Here what exactly are we seeing that makes you say that? There are these raised bones. I'm trying to decide if they're follicular or Sounds like So how do you feel the difference between follicles and papillae? Okay Yeah, if you look right here the blood vessels are kind of around the periphery of each of these little bumps They're not in the center. So these bumps would be Follicles, so what's the most common reason for? What are the reasons for them? Okay, so allergy is one of the main reasons. What else can cause follicles to form? Viral infections and so you really want to be concerned when you see these Allergies the first thing you look for but also don't forget that viral infections and no virus Curator-conjunctivitis even herpes virus can sometimes give you follicles. So you look at the follicles What do you see pathologically? So when you look at these exactly it almost has kind of the appearance of a main lymph node and you've got these larger paler paling paler staining lymphocytes in the center and they're surrounded by these Smaller darker staining lymphocytes in the peripheral. We're looking a close-up here. You see kind of the pale Lymphocytes in the center surrounded by the darker smaller lymphocytes around it. And so this is what a follicle looks like pathologically All right, what do we see in here and why is this different? Look at the little dot in the center you can actually see in each of the center of these bumps There are little vessels in the center. So these are Papillae rather than follicles. What can cause papillae? Okay, and even sometimes Allergic can do it too, but but you know, but that's because technically if you think about it contact lens Induce pepular conjunctivitis. It's all it made me do to something in the Solutions rather than the contacts and maybe something absorbed to the contacts So what are the papillae look like pathologically? So There's a fiber possible All right, so here's the epithelium sticking out goblet cells in it still and you see little fiber vascular Tissue coming right up in the middle. So that's forms of papillae And of course the ultimate papillae is this This is what we call Giant papillary conjunctivitis. So we said that this could be due to Contact lens problem. What else can cause this? Anybody Chacoma can vernal vernal So if you have a you know, so you've got an adolescent child and their eyes really get a change in the spring That's the name vernal Conjunctivitis you can even see these giant papillae on the inside of the lid and vernal So key is always make sure to flip that lid when people come in with some, you know, allergic type reactions So for know what that like superior shield also they talk about is that just from like a upper lid? GPC that's coalesce. That's what we think is happening It affects the cornea as it goes over it Are we looking at right here? Why would I be showing you this picture after that one? So this Exactly so there is a subset of vernal conjunctivitis that they call limbo vernal And so you can get again these these kids that have these these adolescents that have these bumps along the limits And the hallmark of the vernal is just intense itchy and these poor guys just gouging their eyes out rubbing them all the time because this is intensely Inducing of the itch and so you can get the giant papillae on the inside of the eyelid But you can get also the bumps the follicles at the limbis I'm sorry the ability at the limbis. And so this is called limbo vernal The same thing is the like horna tetris dots. Yeah What are we looking at right here? Um, let's run to the hormone. All right. I looks like a almost like a pedunculated elevated lesion Maybe translucent to pink looking So this could be a number of things This could be some type of mass lesion All right, so we look at the pathology And we see this at low power. What do we see in here? Yeah, so I got like a pedunculated lesion lined by um non stratified or yes, grandma's done curtainize the epithelium with like Looks like intralesional like radio-spoking vascular channels So I'd be most concerned for like a pageant and granuloma. Okay, pageant and granuloma is one of those Things that it's been in the literature is what we used to describe it. It's it's it's one of two misnomers in ophthalmology. And so Pyogenic granuloma, what does pyogenic mean? Pever so it means that it's infectious. Is this infectious? No, so granuloma Jordan, what's granuloma mean? It's like a collection of Giant cells Exactly you have that in this entity Not that I could see. Yeah, well and not that you not that are any that are in there. So that's why I see it's a double misnomer It's a pyogenic granuloma. It's neither pyogenic nor granuloma It's really a mass of granulation tissue. So think of it as an overabundance of granulation tissue So if you really look at low power all kinds of little blood vessels Little capillaries, of course if they're but you see it's kind of white It's very very loose very white a few little fibroblasts in here a lot of edema in there. So kind of granulation tissue. Yes Good question. What is the second one? End up thomitis is neither end up thomitis You know nor is it is an anaphylactic. So that's the second double misnomer. You have to remember but for conge You remember the pyogenic granuloma neither pyogenic nor granuloma And here's a close-up little budding capillaries Who's connective tissue now a mix of inflammatory cells? You can get some PMNs You can get some lymphocytes You know a lot of capillaries a lot of swelling and so again, this is kind of an exuberant Reaction a granulation tissue reaction So patients will often have something get in there or have some previous surgery It's almost like a a cheloid of the conjunctiva if you will All right, let's see. I guess we're back to Abby. What is this right here? What do we see in here? Injected rays, what would your differential be here? Um All right, so people call this a salmon Patch or salmon look because salmon's Pink red and so these lesions are pink or red. It's elevated. It's smooth. There's no discharge. There's no sign of infection And you do the biopsy. What do we see here? All right, so this is very much concerning of a lymphoma and we do some special stains and we see that they All stain this little brown Amino peroxidase stain outlining the Nuclear there. So this indeed turned out to be a lymphoma Um, what kind of lymphoma are the classic conch lymphomas? B cell. Yeah, so they're usually a small B cell lymphoma. A lot of people will will further call these Eucosal associated lymphoid tumors, malt, MALT. And so these tend to be malt type low-grade mantle zones small cell B cell Lymphomas and so very similar to the B cell lymphomas you give to the orbit. In fact Oftentimes when you look real carefully if you've got the conch lymphomas, you know, there's there's often an orbital component to it So you want to look real carefully when you see that What are we looking at right here? What would your concern be? So when you look, you know, people will say well, how do you tell the difference between say a teridium and something And then you So basically when you look at it when you look at a teridium the disease is under the epithelium. So the epithelium is very thin You can see through it real easily. This one looks gelatinous and you can actually see that the epithelium itself is thickened when you look here So your concern is that this is an epithelial lesion. So what's the first thing you want to do? Actually, you want to take out that cataract first. Look at that Yeah, I just tumor-laden Get that intermessant cataract out of there. Yeah, so you don't want to get a tissue diagnosis if you can And here's another one you can see again, you've got a lot of vascular cheer here, but look it's it's gelatinous Kind of starts at the limbis, which is where often these lesions start We'll go somewhat under the cornea. We'll go somewhere not here. So again a concern that this is an epithelial proliferation epithelial type Now we do the pathology and this is what it looks like. So Ashley, what do we see in here? So we see a stratified spleen. It's not geratinized. Very thick. And then there's also dysplastic cells within that epithelium. The basement The basement membrane appears to be intact. Is that important? Yes So if the cells are still kind of CIN And if it's broken through the basement membrane, it would be considered a squamous cell carcinoma All right, so that's an important differentiating point if the basement membrane is completely intact The lesion is strictly intrepithelial. We call it CIN, conjunctival, intrepithelial neoplasm, or you know, it's part of oss, you know And our ocular surface neoplasm. Now, you know, people are lumpers or people are splitters I like to be a splitter. I like to put things in its own little individual mailbox, you know, like upstairs where you get your mail I don't like the mail all being chucked into one sack. I like it in little individual boxes And so I remember it more easily if I do this rather than lumping them all together and just say it's surface neoplasm So I still like to split it up In whether or not it's strictly intrepithelial or it's gone beyond the empathelial So we can see here once again basement membrane completely intact, but look at the nucleoli in here Very active And the nucleoli go clear the heck up here. So how do we subdivide CIN? Usually in the thirds If it's one third up from the basement membrane, mild two-thirds moderate And full would be severe. All right. So we do mild moderate severe in terms of the degree of dysplasia of the CIN And here it's more than two-thirds. And so this would be considered severe dysplasia But the key is the epithelial basement membrane is still intact. None of those dysplastic cells have gone beyond the basement membrane And here we see another one basement membrane. But look at that. I mean you can see look at the pleomorphism huge cells here Smaller cells here nucleoli Clumping of chromatin all the way to the surface. So CIN with marked dysplasia What do we see in right here, Jordan? So again external photograph of the right eye And on the boulder conch, there's large thickened epithelium there Potentially Deposits within it So I'd be really worried about like a squamous I I agree with everything you said except calcified. I don't see any white But you definitely see this gelatinous whitish appearance in the epithelium Growing up the limbus onto the cornea on the backside. So your differential again would be CIN versus actually Superficially invasive squamous cell And when you look at the pathology, what do we see here? So now you have Epithelium that looks I mean it's still very like a cathodic and thick Looks like it's actually Violating basement. Yeah, look here's that kind of pink squamous looking epithelium here Underneath the basement membrane And when we look at this at low power You have these nests of these malignant squamous cells beneath the basement membrane So this is now superficially invasive squamous cell carcinoma What is this thing I'm I'm showing you? Tissue with um malignant appearing cells What is this stuff? Very similar to lid malignancies of this kind That's actually a little keratin world And so as these cells become malignant they can start making keratin And so just like a squamous cell carcinoma of the lid you can get these keratin worlds in here Again, look at these cells. This one's got two nuclei in it big nucleus clump chromatin and so this invasive Squamous cell carcinoma can often have these keratin worlds Keratin pearls and here you can see this is actually the underlying Sclera right here and you can see that this invasive Squamous cell carcinoma has gone all the way to the epi sclera and even to the surface sclera And so you can take a you can see that so so pretty much a really invasive Squamous cell carcinoma of the conjunctiva What is this structure lidium? Why would I be showing you this? Why would I show you a nerve? I just showed you squamous cell of the conch Exactly. So when you have these superficially invasive squamous cell carcinomas They can invade back into the orbit then sometimes they actually go into the nerves And so you can get them along the inferior orbital nerve You get them in the nerves and they can gain access Behind behind the orbit They can either be painful initially and then it can really kill off the nerve and then you can have some focal areas of numbness So you want to check for both? So here again Are these tumor cells here along the nerves? You really want to remember That these invasive malignant invasive squamous cell carcinomas can spread by the nerves Is there a particular reason you're characteristically with a squamous cell carcinoma that costs it to have that preference for? I do not know the answer to that question. That's a good question I'm sorry. I don't know what exactly it is about that tumor that doesn't but it's interesting It's that particular tumor. So Don't have the answer for you So now I can do whatever lectures usually do. Well, dr. Look that up and report back to us next week I I'm sorry. I don't know the answer to that question But just remember that when the squamous cells do spread they do spread by nerves All right, look at that right here. So Here's some scrupulomal pigmentation You're going to live this almost 360 And had more importantly Seems like some pigmentation that's deeper potentially into the sclera itself Okay, so why would I be showing you this picture? What is it that's important about this picture? You actually described what's important about this picture In case you know the pigments. Yeah, some of it is deep and some of it is superficial So that's why I wanted to show you so it's not uncommon that you'll have pigment Especially at the limbus and in people who are darker People who are darker pigmented you can often get in fact Limbo pigmentation here. You could even get superficial pigmentation here, but look at that That instead of being brown instead of being tan that looks almost kind of grayish And so that's a sign of a deeper pigmentation. That's why I like this picture It kind of differentiates the two. So what if you have a patient ignore this And they've got this deeper pigmentation here. What does that mean? Yes Exactly. So you can get oculocutaneous melanosis and what's interesting is the pigmentation is deep It's not on the surface of the eye. So you don't get melanoma of the conge in in oculocutaneous melanosis Rarely you can get melanoma of the sclera Very uncommon, but it can occur and so oculocutaneous melanosis. It's a deeper pigment It's a pigment underneath the sclera and that's why it looks gray rather than brown So I just wanted to show you that that's what the oculocutaneous melanosis looks like. All right now What the heck is this? It kind of looks Maybe it's a little bit tan a little bit pigmented. What would you be concerned about here? What if I tell you this this person is 12 I'm more likely anivis. All right, so more likely anivis now. What's interesting is if you take the history From the parents and again, I'll say the mom. I'm being sexist here. Do dads bring kids in? Virtually never. It's always mom, you know For a dad to bring them in this growth has to be coming out of the orbit Mom will usually say, you know what this has been there for a while. It was pink, but now it's changing And so now it's more tan in color Maybe it's even growing a little bit. And so it's not uncommon In these nevi that they'll look pink initially and then as the kids hit adolescence, you know, they'll hit beginning of puberty These will start to pigment more and they may even grow more and then they'll be more concerned about it Now we look at the pathology here. Let's see. Yeah question Is that the same responsive? Exactly. It's a hormonal response and now we're seeing that earlier and earlier and earlier And so you're seeing now kids are starting puberty younger and younger age. It's all nutritional And so as as you know nutrition is getting better and better and better kids are going into into Puberty a lot sooner. My other theory if you're a conspiratist is it's the growth hormones that they give to the cattle You know to make them grow somehow they get in there and make kids grow more to them But I love there's conspiracies all over the place that they use hormones on cattle that that's affected people so But in any event puberty is coming on earlier and earlier and so these lesions are starting to grow earlier And If you look right here, you can you know in a pinguachina turidium You know, it's a sub epithelial lesion and you see a lot of connective tissue. So it's white. It's dense. It's thick These tend to be more translucent And you can actually see through them more almost like you would see in a in a c i n And so this is definitely Um, you can differentiate that that pretty easily from a turidium Now we're looking at this at low power. This is actually that that um, that young ladies. So what do we see in here? If you look right here, what do you think those cysts can be? Exactly so you can get not uncommonly in these nevi that are there long standing maybe even congenital And then they start to grow you'll often get little epithelial lines just within them. So here's how you remember it Which embryologic layer do melanocytes come from crests? So these melanocytes, they migrate up from the neurocrest They go to the junction between the epithelium and the substantial propria. They start to grow And then as they're dropping down into the sub epithelial little substantial propria They grab epithelium and yank them down with them Now don't tell the examiner when you do oral boards that story But that's how you remember them. And so this is how you remember Those melanocytes grab that epithelium and yank it down with them And so basically if you see one of these that are congenital in nature or are very young young in age They will often have epithelial lines cysts between the nest of melanocytes All right. So we're looking right here random. What do we see in right here? um so looks like the Nest are kind of confined to the epithelium. Maybe there's a little bit of a junctional component about not super convinced So I would say this is I mean I come from component. So I say this is a junctional Exactly. So the melanocytes will start to grow at the junction between the epithelium and the propria So you'll see these nest of melanocytes here at the junction. So we call this a junctional Nevis And Jordan, what do we see in here? Is this different? So now you see Nevis cells both above All right. So again, here's those epithelial cysts. You see melanocytes here at the junction and down below in the substantial propria What do we call this lesion? It's a compound. So compound means both junctional and sub epithelial Now it's important because if there's junctional um, you know still activity at the junction, there's still technically A risk for this going on to melanoma. So both the junctional nevis and a compound these could Technically still go on and form melanoma once you lose that connection with the junction. You lose the malignant potential All right. So Abby, what would we call this? Exactly. So this is strictly sub epithelial. There's really no dermis in the conch. So your home nevis is not proper But sub epithelial nevis. So you can get nevis cells under the epithelium once they've lost that junctional connection They've lost their malignant potential All right, Lydia. We're looking at this lesion right here. What do we see in here? All right. So you'd be concerned here, you know, this person is a Caucasian so you wouldn't have the racial pigmentation But you do see this little focal area. It's not thick and it's this dusting of pigment now I tell you this story every year, but I love this story. So this was a woman in her 40s very very nervous about this lesion And in fact on a scale anxiety of one to ten She was a 12 and I said man, we're going to photograph this We're going to have you come back again in six months if it's growing if it's changed then we'll just go ahead and we'll just remove it And but let us know if it grows. So she said, okay, so I'm sitting home It's like, you know, eight at night And this is when we had pagers and the resident on call pagers me and said, did you see mrs So-and-so today? I said, yeah, I did. Well, she called tonight. It's growing And so she was totally convinced that that was growing and it was a tumor. So we took it off And the good news is I got to see this lesion Pathologically. All right. So what are we seeing right here? What would we call this This is the second three word turn you have to know for Conch path Ham primary acquired melanosis And this is primary acquired melanosis. We further subdivided into With or without a tip you see what would this one without without a tip you so if you look at this These benign melanocytes are right along the basilar layer. They're not extending into the epithelium There's no um dysplastic features to them. So this is Pam without atypia now racial melanosis limbo melanosis Looks exactly the same. So this is Pam primary acquired melanosis without atypia. You see these benign Melanocytes along the basilar layer of the epithelium. So Pam without atypia What are you seeing right here? So we you know, you'd be concerned here because this is not just flat like a little dusting pigment This has got some thickness to it. It's got some irregularity of the borders. It's right here at the limbo So you'd be a little more concerned about this lesion And then we do the biopsy of this lesion. And what do we see here? Let's pretend that this picture is strictly in the epithelium Okay So Exactly. So this is Pam with atypia. So you look at the melanocytes in there. They have atypical features. There's nucleoli in them There's pleomorphism in them. They're spreading throughout the epithelium, but if they're still within the epithelium This becomes Pam with atypia All right. Now we're seeing a lesion here. What's our concern here? Can I ask you a question about the last one? That's okay. So I know pathologically Pam without atypia looks similar to racial melanosis, but Isn't there a, I mean a distinction between like Pam without atypia is typically Caucasians, you know, lateral Versus racial melanosis is typically biopsy Exactly. They're different entities, but they look the same. But they're not, yeah They're not different pathologically All right. So what do we see in here? I mean Sorry, what do we see in here? Yes, so you have um external photograph of the right eye. It looks like you have some pigment lesions You can see on the oval or and help you roll and formacil conge You can see some formacil shortening and starting just in blood frond Which is your concern for like melanoma prior resection probably So this patient's probably had previous surgery You can see these areas likely Pam and some some blepharine starting to form But when you see pigment like that in the fornix and Dr. Patel really stresses this He pounds that into you that that when you see this lesion in the fornix melanoma until proven otherwise So you really want to make sure that that's not melanoma. So Let's say you went ahead and you did the biopsy here And if you look right here, here's that Pam. Here's that Pam. Here's that Pam So now the melanocytes have gone below the basement memory. So this has gone from Pam with atypia to melanoma Yes Well, you can get you can get pigment lesions in the car, but they're very distinct. They're very round. They're nevine But if you've got a diffuse lesion, especially deep, it's almost like the phonics You want to be concerned for melanoma until proven otherwise, but deep So if you look right here, here is primary cord melanosis primary cord Lignant melanoma when you look at it. This could be pretty nasty. Look at that cell That's a nasty looking cell big nucleus clump chromatin big Cellular body these huge cells are so this is malignant melanoma. All right. That's really important because Let's say jordan. You've got a hundred malignant melanomas of the conjunctile. What's the most Common cause of that most common underlying melanoma With Yeah, okay, so remember there's only three percentages you have to learn in medicine 15 45 and 80 So if you think it's rare you say 15 if you think it's in the middle you say 45 if you think it's a lot you say 80 This actually turns out to be 80 And so about 80 percent of malignant melanomas of the conjunctiva arise from pre-existing pam with atypia 10 to 15 percent arise from pre-existing needles And the other five we often we sometimes don't find it But it doesn't mean 80 percent of pam with atypia goes on the melanoma It's 80 percent of melanomas arise from previous pam with atypia And here's one of the special stains you can do to confirm that those are indeed melanocytes And there's some I mean a peroxidase stains that tell you that they are melanocytic In origin if there's a question And this is what can happen if you don't Take care of these. This was a patient at the va And you can see this huge pigmented lesion growing here and this patient did have documented pam with atypia previously and then just You know refused to come back for follow-up. So you see this huge lesion at this point Um, you know this required an exeneration and he had metastatic All right questions on melanomas just like externally on exam. Can you Tell the difference between like pam with versus without atypia? So let's look down right here Here's our pam without atypia. It's a dusty There's no thickening to it. There's no irregularity to it. It's also like somebody took some pigment and just dusted Thelio Whereas if you see a pam right here with atypia, you see the irregularity the thickness the feathering of the borders And so this is really suspicious for pam with atypia Those are the things that you look for We're congenial. I'll hit melanoma once it's biopsy proven Do you still do like the liver and lung workup? Although they spread by like length to a headed neck Yeah, you still want it. You still want to go ahead and get get some scanning of especially the liver And this is one of the stained glass windows at the Duel of the cathedral in florida All right, any other questions congen general You guys know it all All right, have a good Thanksgiving. We'll see you next Tuesday