 The Eiffel Tower is on the Sen and so what they do is they've got all these boats where you can go on a boat. Some of them are really nice. They're enclosed and they have windows around them and you get dinner and then you go up and down the Sen. And so this particular one, this was the night of the, the triple IC is the International Implant Club. It was started by Mr. Ridley who invented IOLs and so it's a club. You have to be asked to join and so I feel like Groucho March. You know, I don't know if I want to be in a club that would take me but in any event, I gave the talk on the boat which was interesting and so people are looking at the Eiffel Tower. I'm trying to tell them about IOLs and so this is trying to get an artsy shot. Believe it or not, that's the Eiffel Tower looking out through the window and that's a reflection of the table where we're sitting. So I don't know if you can quite see that or not. I was trying to be artistic but it's kind of hard to be artistic when you're pathologist. But in any event they light up the Eiffel Tower at night which is really nice and then every hour on the hour the lights just go nuts. It goes completely crazy. They did it for the bicentennial originally and everybody thought it was cool so they're still doing it. So you go up the river and then back down. Unfortunately as you go past Notre Dame, obviously it's all dark. I mean there used to be really beautifully lit up but since the fire it's just totally dark. But it's kind of a cool ride and so again here's the plates and the table shining off. It's got glass. It's all glass and it kind of comes up on the side. So you go right below the Eiffel Tower which is really kind of pretty. There's another close-up. There we are eating. All right there we're coming around the other side now. That was trying to show you how it lights up. It didn't come across too well but that's how it lights up. All right let's let's do some work here. So we've got a young child here and we're looking in and they've got as you look inside they've got a white pupil. So first of all we're going to go backwards now. I'm going to confuse you guys. Okay Brad what is the word for white pupil? The Greek word. Lucchorias. So literally white pupil. So give me one thing that can cause white pupil in a kid. Red noblastoma. Red noblastoma. What's the second thing Marshall? Cataract. Cataract. Chris. R.O.P. Rachel. Okay good yeah we used to call it Ph.P.V. but now it's P.F.V.I. anything. Yeah persistent fetal vascular. All right. Coase disease. Good. Boy we're getting lesser and lesser. Luxucar. Good. Someone already said R.O.P. didn't they or did they? Somebody said that I think. Rental detachment. Good. All right I think that pretty much covers them all. So all right so we're looking right here and we've got a young child and we've dilated them. What do we see in here Allie? Almost like the vasculature seems very anterior. Exactly. So you're seeing it's almost as if that retina is almost behind the crystal lens. It's really pushed forward. So what would you be concerned about in this particular case? Harvey. Okay. What if you looked in and you saw this? Right now Blastoma. I got this yellow mask with calcium. Exactly. How can you tell there's calcium there? It's got these white flecks when you look at it and so you've got these little white flecks as you look at it right here. So you would be very concerned about that and then of course here's a globe where we've actually got a large tumor in here. So what are the two different growth patterns of retina Blastoma? Ethelogy. So there's exophytic and endophytic. All right what does that mean? So exophytic would be underneath the retina. Okay. Exactly. So if you look at this one right here it's hard to tell but this little clear membrane here is the retina. So you can see this is all growing underneath the retina. So this would be exophytic. So growing underneath the retina, pushing the retina forward so that would go along with that first picture we showed. And again all these white chunks here as you cut this open are calcium. And so that's a real tip off because you want to be able to tell if there's calcium in there or not because it really helps you with your differential diagnosis because there's very few things in a child that calcify. And so the presence of calcification is really helpful. So Brad what's the growth pattern here? This is endophytic. Hard to tell but it might still have retina on top of it but in any event if it's growing inside it would be endophytic. If it's going outside it's exophytic. What is all this stuff right here next to that tumor? It's not calcium. Fluid? Yeah it's more specific exudate. And so this can cause a real disruption of the RPE of the blood retinal barrier of the retina itself. And so you get not only a big tumor here but next to it you get all this protein rich lipid rich exudative material. And so it will make it look like the tumors may be bigger than it is. So what's a test you can do in the clinic? Well in the kid maybe not but let's say in the clinic if you get the kid to sleep that would help you with this. To diagnose it. A B scan. B scan and what would happen on the B scan? You'd see like a hyperreflectivity that would be representative of calcium and you'd probably in this particular situation you'd see a large exudative retinal detachment. Yeah so the B scan is very helpful because the ultrasound when it hits calcium it gives you a high reflect bounce. And so what happens is is when you've got that tumor in there you can literally turn the gain down on the ultrasound slowly and the whole eye almost disappears but the calcium stays. So that's really helpful with your differential diagnosis of looking at these lesions. All right so we've got a picture of one right here more pathologically. You can see this one is sometimes a combination. It looks like this is more endophytic but there's even little pieces growing underneath the retina so you can sometimes have both. Now when you look at this let's see Marshall what are we seeing right here? What's some of the characteristics that you can see that tells you this is a retinoblastoma? You can see these round rosette looking structures kind of like foamy cells within them. There there are some mitotic figures also. Well if you can see mitotic figures at this power you've got really good eyes. I can't see them. Okay. This is still pretty low power. What's going on in here? You look like a lot of blue cells a lot but very disorganized. Why is that disorganized? It's necrotic. Exactly and so that's the important thing is when you look at these at low power gross the term pseudo rosettes are really bad term and it's a confusing term but when you look at these in really low power what you'll see is you'll see a central blood vessel and you'll see all of these viable tumor cells around the blood vessel but then these things grow so fast they outgrow their blood supply the blood supply can't keep up with them and they die off and this is necrotic dead tissue in between and then eventually they calcify so it's called dystrophic calcification so these tumors grow really fast they outgrow their blood supply they die off and then they become calcified and so seeing these round areas that surround the blood vessels the viable tumor cells surrounded by necrotic calcified tissue is the classic growth pattern that you see with the oblastoma. Here's a close-up all of this magenta material is calcium so here's viable cells viable cells necrosis calcification and so that's the classic growth pattern that you see and that's why they calcify. Chris what are we looking at here? Two things. So these are the rosettes of the flexor and wintersteiner rosettes? All right so these are the classic rosettes that these that these tumors form that call flexor wintersteiner rosettes what's the second thing we see? Something that Marshall had really good eyes to see. Mytotic figure there we go there you go that's mytotic figure I'll buy that one that's a nice high power and so that's a mytotic figure and so the pathologists I didn't know this we've got a pathologist rotating with it they call them mites so I picked that up that's a mite so we've got a mite there but you see this classic rosette formation for some reason when you get tumors derived from neural tissue they have a tendency to form rosettes and we had another kind of rosette at orbit conference what kind of rosette was that just this last week okay and what do they call it? Pummelrite. Yeah we had some nice Pummelrite rosettes and so for some reason neural tissue as it goes bad tends to form rosettes around structures and so here's that nice flexor wintersteiner rosette it's even almost trying to form little outer retinal segments and so Rachel what what cell does this tumor derive from? It's exactly it's from a primitive retinal blast and so it's from a really primitive retinal cell not a mature retinal cell so it does attempt to make outer retina here and you'll even see sometimes little rods and cone segments not really complete but in the center of these rosettes you'll sometimes see those. Now what kind of stain is this? It's recent boy the extra credit if you get this one. Alcien blue. Alcien blue what is it stain? Mucopolysaccharide. Why would I show this? Exactly so remember the mucopolysaccharide is in the outer retina between the outer retina and the RPE. Oh man you got what I got? I hope not. No you better hope not. Let me tell you operating without an alpha you know without an alpha blocker and and having your nose drip for a whole day in surgery is really a pleasant sensation so very very pleasant so as as you know we don't take alpha blockers before surgery because what does it do? Causes a tremor. Causes a tremor so don't do that so you just have to have stuff your nose with Kleenex. All right so we've got that Alcien blue stain staining the mucopolysaccharide out here in this attempt to make primitive retina. All right what is this thing Sean? Yeah it's almost laying out like retina would be what do we call that? A floret. Why is that important? Exactly so it means that the tumor if anything is even more differentiated so here's some classic rosettes down here but this one is almost laying out it's almost C shaped here and so that's a sign that this tumor is even more differentiated so if you see lots and lots of rosettes and especially you see florets it's a sign that the tumors are relatively well differentiated. If you don't then that's a little bit of a worse prognosis because the tumor is not well differentiated. What am I trying to show here Sneha? Well there is calcium in between here but what's going on in these blood vessels here? Yeah they're almost dark it's almost got the kind of a dark black purple around it what is all that extra material? Yeah exactly so this is like nuclear material from these cells that became really necrotic they'll diffuse to the vessels and they'll deposit in the vessel walls and it's got DNA and it's got a lot more nuclear material in it and so you'll often see a little dark staining around the blood vessels here in the center when you see these tumors. There it is all this deposition of stuff from these necrotic cells now if you look around here this tumor is poorly differentiated there aren't a lot of rosettes. Now pay attention to these pictures because to be honest have we seen a retinoblastoma since you guys have been here? Yeah so we're treating these now with intra arterial chemotherapy and so we're not seeing these in the laboratory and so this is almost historical for you guys we haven't seen a specimen now in nine months of an enucleation from retinoblastoma because of the intra arterial chemotherapy that they're using to treat these kids. There's the close-up there's all this material deposited in the vessel wall so that's a classic path finding. What are we looking at right here Allie? There's kind of silly processes up here. Why would I be showing you this picture? All right so there's tumor kind of up here behind the iris even between the silly processes kind of in the area the zonules and the lens why is this important? Okay so if it's got anterior seeding you've got little bits of tumor that've kind of broken off from it can go into the anterior vitreous it can even go more anterior almost in the area of the ciliary body and the zonules that again is a poor prognostic sign because it's really tough to get that part of the tumor treated even with intra arterial chemo it doesn't get up that well up there so that makes it tough to treat when you've got anterior seeding of the tumor separate from the main tumor. Now what are we looking at right now? I'm so bad now I know in turn your name again is Cole. Cole? God it's going to take me three times it takes me three times to remember everybody's name so if I like look at you funny I'm like trying to find your name tag and say we're gonna have to do the old football coaches first day of practice they used to put your name and tape on the helmet you know and so they could like you Cole you know so we're gonna have to put names on the forehead so that we you know who you guys are. All right what are we looking at here? It looks like cornea starts at the bottom so what's wrong with this picture? Exactly it's upside down so every once in a while I'll put one in just to see if you're paying attention so cornea kind of on the bottom here it's upside down and then let's go back and then iris here what's going on with the tumor here exactly so is this prognostically important? Yeah it's bad so if you have tumor in the anterior chamber that's even worse and you could even see these advanced tumor cases these kids get what are called pseudohypopions so you know hypopyon like you get an end up the mitis a little layering of white blood cells in the anterior chamber you can get layering of tumor cells in the anterior chamber and that's that's again a prognosis there's tumor cells even going up into the angle and in the anterior chamber so that's a poor prognosis. Why am I showing this picture here back to Brad? Probably because you can see that tumor is in there. Is that important? Yes. How do these tumors spread when they get out of the eye via the optic nerve and that's an important distinction between this and other kinds of tumors and so retinoblastomas spread directly through the optic nerve and so when we enucleate these again which isn't common anymore but the plastic does want to get a long piece of nerve if they can. In fact you want to get that nerve all the way back to the you know close to the apex as you can without disturbing the tissue otherwise so you're going to get a long piece of nerve because when these spread they spread via direct extension into the optic nerve and this is an old old slide from the AFIP that I copied but before we had chemotherapy to treat these this is the percentage of kids who died from these tumors and so you know eight percent at that time if they were inside the eye died if it goes to the laminar fibrosis it was 15 percent if it's in the nerve but not at the cut edge it was 44 percent don't don't memorize these numbers but just give you an idea of what would happen if you still had tumor at that posterior surface of the nerve where it was cut off they had a 65 chance of dying so this is even with the systemic chemo and all the things they had in the 1970s and so this was a bad actor now it's it's much much better treated at the moment but if you've got tumor still at the cut surface of the posterior nerve that's a very bad prognostic factor and this is what can happen this is a young kid from from Nigeria and so if you don't treat it these tumors are extremely aggressive and so this child by the time they brought him in from the bush you can see a massive tumor here and and this child succumbed to that tumor very rapidly the metastatic disease from that so you want to catch these well you can still save the eye if possible all right what are we looking at here partial looks like I got in the Victoria um looks to be like the retina is raised up you can see some a few loaves of the retina almost like there's there's you know retina's kind of coming forward and kissing itself from the inside okay what's the color when you look at that that's yellowish so what could this be coach disease so what is coach disease um it's where you have a lot of meaty vasculature causing like with excitation of lipids and other cellular material like others and uh an excidative potassium okay now um what's the age average on coats as opposed to retinal blastoma um around eight yeah it's a little bit older retinal blastoma is maybe 18 months two years roughly coats is maybe eight to 10 years old males or females males males and we're not quite sure why unilateral or bilateral uh it's usually going to be uh unilateral right so it could really rarely be bilateral but usually unilateral so again we're not quite sure what happens but you get these telangiectatic vessels and they leak like crazy so they leak exudate that's got a lot of lipid in it and you can see here's a close-up we're looking inside you see these telangiectatic vessels look at that yellow because that sub-retinal exudative fluid it's yellow because there's a lot of lipid in it and here you can see it when you cut these open in the lab that exudative material is almost like jello and the fellows have seen that just in chronic rds and so when you poke up forceps into this it's like jello it sets up like gelatin so you get that that lipid rich exudate underneath the retina here shows you some telangiectatic vessels all of this lipid material within the retina itself what am showing here chris cholesterol class and so when you see a banana or a slit like space in there these are what cholesterol does i'm not sure why cholesterol makes banana claps but it does and you see big banana in there you think cholesterol what are these things down here exactly so the poor macrophages they're being overwhelmed they're trying to come in and clean up all this exudate that's leaked out but they just can't keep up so they're like a little pac men in here they're going out or they're trying to gobble up that stuff they're all choked full of this lipid in this exudate but they can't keep up with it so all these foamy swollen macrophages they just can't keep up how do you pronounce it if you want to sound smart macrophages so if you say anything with a british accent you sound smart and so i don't mean to to really deride people from where they're from but i was listening to npr and they're interviewing someone in north carolina and i'm sorry i don't care if you're a phd in astrophysics when you talk really slow with the drawl you just maybe don't sound so smart to other people but if you say macrophages they go oh wow that guy must be smart you know because he talks british and so something about that so dr patel even though you may not know what he's saying he sounds really smart when he says it so if you want to sound smart say it with a british accent all right this is kind of a bad picture i copied this um rachel it's really anterior and you can even see there's almost a clear area behind it here and then this stuff kind of white with the vessel so maybe it would be the lens what would this be okay how would you tell on this picture and you could tell i can't tell size from this eye do you get blood vessels in congenital cataracts no exactly so the real tip-off is you see a little blood vessel here and you see a few little fine vessels there and so when you see this white lesion it's almost like it's going into the lens kind of trying to take over the lens and so this will be um with the blood vessels in it this could be what we call persistent fetal vascular we used to call phpv persistent primary hyperplastic vitreous or persistent fetal vascular mature and so when you look at these what they're characterized by is this white area of the lens but look at the ciliary processes it's like as the steamer shrinks it grabs some of the ciliary processes and pulls them centrally you get these really elongated ciliary processes what do we see uh in here so here you see this high load artery coming up and then you see this mass beginning to take over the lens or some hematurin look how it's pulling these ciliary processes in so it's like it's shrinking and grabbing and pulling them in so this is a classic appearance of persistent fetal vascular mature and here of course you can see that stock going all the way back to the optic nerve that remnant high load artery and then this mass of this you know lenticular fibrous vascular material that are in there sorry all right so here we have a picture of an actual lens of which we'll move they tried to save the eye to remove the lens and here's that stock of that high load artery and here's all this material invading the lens a lot of exudate a lot of vessels and some fibrosis and it's kind of taking over the lens if you will so forming a focal cataract here's another close-up look at this look at the retina here the retina that's the aura serata clear up here and there's a ciliary process pulled way up here so it's almost like that masses it shrinks is again pulling those elongating those ciliary processes to the center and then it's invading the remnants of a lot of exudate this kid out of pseudo hypopia on and a lot of exudate here's the aura serata clear up here behind the iris with that ciliary process pulled in all right what is this thing John what would that signify yeah so this is the remnant posterior part of the high load systems and if the anterior part of the high load system proliferating could eventually lead to that persistent fetal vasculature the posterior part is this high load regresses doesn't regress completely and you'll get this funny corkscrew vessel now these kids as opposed to the persistent fetal vasculature where they get rental detachments and other issues these kids can have normal retinas so they just have this curiosity that's on you and then they could sometimes get a little fibrous membrane around it the so-called burgmeisters papillae so it's kind of the posterior remnant of this persistent fetal vasculature and there you see a nice one on an autopsy eye just coming all the way down and then inserting in and here's a little bit of some dilated vessels around it so that posterior remnant of the high load artery system here we see it there's normal retina there's the optic nerve hand and there's that corkscrew vessel coming up out of it what do we see in here snake huh now by the way back to let's see shun i guess we'll go back um persistent fetal vasculature unilateral or bilateral 5050 chance unilateral ah good guess okay 5050 you got it all right so what do we see in here that's different stay out bilateral so you've got bilateral leukocorrhea that puts us into a little bit of a different differential so what would we think of if we see bilateral leukocorrhea exactly so you think of severe retinopathy of prematurity now you could sometimes get bilateral cataracts too and so you can do that but you want to start thinking of of possibility of rop retinopathy of prematurity and what is this um alley what is this sign here the drag disc and what causes that not even so much end stage but just just you know later rop so why does that happen okay so remember when rop happens um you know it's a combination of oxygenation and the child being premature but in any event the retina especially out temporarily doesn't really completely grow its normal vasculature and grow all the way out to the orserot until at least birth sometimes maybe even after birth and so if you've got a child that's really premature then you blast them with oxygen what happens is is that far peripheral retina if anything the little blood vessels constrict and become very hypoxic but at the air at the edge between where you've got vascular retina non-vascular retina you actually get neovascularization so you can eventually get scarring and then eventually you get that disc dragging over so the so-called drag disc and you'll often see kids as they grow up i mean i've i've got a couple of patients now who are in their 40s who had rop but didn't get a total retinal detachment and have discs that look like this years later now if you don't treat it what can happen call see third time huh exactly so this is what we call a closed funnel shaped retinal detachment remember the retina inserts at the optic nerve head and then at the orserot on both sides when you get a total retinal detachment it's like a funnel that closes off and so this is kind of the end stage they used to call this retrolental fibroplasia because when you looked in there it would almost look like a massive fibroplasia behind the lens but it was really just that part of that totally detached retina so you want to actually do everything you possibly can to keep it from getting to this stage once it's at this stage no matter how heroic you do your surgery and steve charles is uh as a just crazily um aggressive retina surgeon in tennessee and he actually takes these kids and he tries to open up that detachment with silicon oil in and everything and he still can't get these kids to see well so prevention is the key you recognize them early and you guys when you do your peds rotation you know we do everything we can now now you know one time we used to cryotherapy in the unprofused retina to prevent any of escarization now they'll do laser which is a little bit easier on the child and now people even talking about anti-veg gas but but doctor part that will talk to you about possible systemic issues and other things with them but in any event we do everything we can with threaten up the agreement sure to prevent that total retinal detachment that retrolental fibroplasia and here we see it in a pathological specimen um brad what kind of surgery has this kid had sclerobuckle sclerobuckle there it is there's the outline of the buckle there on him so they tried to put a sclerobuckle on to keep this kid from detaching but still funnel shaped retinal detachment all right weird-looking specimen here um marshal big white thing here kind of in the anterior vitreous maybe behind the lens a little bit what could that be i'm not sure i might be concerned like an infection all right what kind of infection gives you a picture like that that's a car box of cara and so how do kids get tux of cara um usually from cats or dogs uh could be from feces cat or dog what's the dog usually dog yeah because it's tux of cara canine that's actually the real name of the bug so canine means dog so usually from dogs and so dogs if you see little puppies especially what do they do they eat their stool you know and then what do little kids do they get down there with a puppy the puppy ricks them all on the face and then you get this this bug into the kid's system it goes through their gi system it can actually go through the wall of the gut and then go to end organs and so it just happens unfortunately the eye is an end organ from this tux of cara so you get a bug going here into the eye and it can cause a raging vitritis raging inflammation and here we actually have a past specimen here's the bug in the tux of cara bug now the problem with these is if you treat them with an anti-parasitic medicine and you kill that thing the um inflammation can cause a lot of problems you got to be really careful you want to get rid of the bug but you want to calm the inflammation that it can cause so tough tough things to treat chris why am i showing you this picture first of all where are we here's the angle here's the iris what tissue is this down here sorry body what am i looking at here let's go back one sorry what kind of what kind of tissues that trying to form yeah exactly and so remember i said that calcification is really rare you know right no blastomas one but you can get in these kids actually calcification in the ciliary body and it can form cartilage and bone even and so what entity is this good what's what's the one on boards even more than major ophthalmomas okay what's unlucky yeah try to be 13 so unlucky on board so try to be 13 can give you highland cartilage in the ciliary body and so that'll show up as calcification also so try to be 13 the other thing tries to be 13 i'll do is you'll get retinal dysplasia so you get these rosettes they almost look like weird looking flexor winter steiner rosette so try to be 13 highland cartilage in the ciliary body but also retinal dysplasia so that's one thing they love asking that stuff on boards all right switching gears now so we finished with kids and local koria any questions all right great show what are we looking at here is that worrisome at all so when you see pigmented irish lesions you want to check a couple things first of all you see does it distort the pupil change the pupil shape give it a tear drop over here secondly you want to look really carefully in the angle because if these are approaching the angle or going into the angle then the differential becomes a little bit more you know more more skewed toward the worrisome side than the non worrisome side so if you're really worried about these guys and you worry about gosh could this be thicker could there be tumor behind there what would you do ultrasound so dr. harry's got a nice i think it's a 50 hertz probe he can put on he puts a water bath on then he can look at these but even with that high frequency ultrasound probe these if there's going to be tumor behind there it's got to be at least a couple millimeters thick for an ultrasound to pick it out but you know you may want to have him just look and say okay is there any pigmented cells behind there that you worry about is this more worrisome threesome okay so why would this be worrisome it's going to get look how big that is look here's the slit lap beam on the cornea here's the beam on that too is that tumor is almost behind the cornea there so you'd be much more concerned about this one than the previous one all right so we spent some time in the path lab and for those of you who haven't rotated through the path lab i'm sorry but eventually you will see these when we talk about iris melanomas you know they used to talk about iris melanomas they had a really good prognosis you know because you can see them you get them out early well frichocobiac it's been now mid 80s went to the old AFIP where all the past specimens were and he got all the iris melanomas and he looked at them and it turns out the reason why the prognosis is so good is that you know three quarters of them were actually nevi not melanomas and so that's why and so he actually put together a classification of iris pigmented lesion so i want to try to go through that and we've done that in the path lab so i'm shan what is this first one right here so we would call this a spindle nevus so this is the equivalent of the so-called spindle acels in the core right now that the classification of iris is a little bit different than core and cellular body so see the spindly nuclei in distinct cytoplasm no nuclei no activity this is called a spindle nevus of the iris now this is low power why would i be showing you this neon yeah so sometimes you can get a surface plaque and so you see these pigmented cells kind of on the surface of the of the iris stroma this is a spindle nevus with a plaque now looking at these alley what do we see in here yeah there's little spindly ones some rounded ones maybe a little bit of clump chromatin and rare nucleolus what would you call this one exactly this is a borderline spindle nevus still looks spindly but is showing you know some some atypical features that you want to worry about so borderline spindle nevus what is this thing called all right so this is the so-called spindle melanoma this would be the equivalent of a spindle b melanoma of the quarry so you can see these cells are rounder they're more oval they've got this single necliolus like a little eyeball looking out at you still indistinct cellular borders in between so this is now truly a spindle melanoma brad what are we seeing here so these look more like epithelioid or spindle b now they're pretty big for spindle b so these are more epithelioid looking is this concerning or no why they're less differentiated than spindle b well look right here though look closely look at that nucleus there and there and there and in here even though it's heavily pigmented if you look those nuclei are still pretty darn benign even though that cell is really big and there is a very rare entity called an epithelioid cell nevus of the iris this is exceedingly rare this is the only one i've ever seen in in you know 35 years so you can still get an epithelioid cell nevus exceedingly rare um Marshall what do we see in here all this pleomorphic cells there might be there's two men also interspersed throughout and the cells are more oval shaped as opposed to oval or red as opposed to spindle shaped and look at that look at that big necliolus clump chromatin distinct cellular borders so what would this be exactly so you get epithelioid melanomas now they're not really pure but you sometimes can get what we call a mixed melanoma where you'll have some spindle b cells down here and they don't have these big epithelioid cells up here so you can get a mixed melanoma then you can get an epithelioid melanoma very uncommon now we're looking at this picture right here chris what do we see in here okay now very other subtle finding what can you see on this picture i took this myself as a resident i love i keep this in here because i love this picture look at this subtle thing right there there's a subtle mask kind of behind the iris poking out here at the angle and poking out here so this guy was interesting he was a die hard university of Illinois football fan and when he went to the first game of the season he could see the scoreboard from his seats by about the third home game the scoreboard started getting blurry and by the last home game in this side the scoreboard was blurry so then he finally came into the VA and we saw this so we've got this lesion coming out here poking out here what would you be worried about here ciliary body melanoma now and this just shows a different patient but similar idea poking out here but then coming up and encroaching on the crystalline lens so you can get a focal cataract with these guys now ciliary body melanomas are classified the same as melanomas of the coroids so they're both exactly the same since it's a ciliary body melanoma why are ciliary body melanomas more worrisome in terms of prognosis than coroidal melanomas exactly so first of all they can grow for a while just behind the iris because patients don't have symptoms you don't see them but secondly especially if they go into the angle they get into the mesh work there's a lot of vessels that you know aqueous veins drain that mesh work and a lot of vessels there so these tumor cells can get out of the eye more so when they're in the ciliary body just because of their location and here you see now this is agonio look at this lesion behind the iris in the ciliary body but again coming up actually into the angle and so ciliary body melanoma is spreading anteriorly what is this thing Rachel what do we call that it's called or people call this a sentinel vein and so if you see one focal vein there's really nothing else dilated around there and you see one thing sometimes that acts like an arrow it's pointing and saying hey look here and so you really want to dilate these guys really widely put on a you know a nice three mirror and then try to look behind that iris have them look toward that area because this is pointing you to the fact that there's probably going to be a lesion in the ciliary body behind there so it's a sentinel vein it's pointing you to a problem and sure enough here we have a tumor it's growing from the ciliary body kind of extends a little bit almost to the equator and then you see it pushing the lens next to it so it'll displace the lens it can cause a focal cataract now why is this concerning excuse me exactly so look here's the ciliary body this tumor is growing behind it into the trabecular mesh work and here you've got there's the mesh work right there you know you've got these aqueous veins the drain that so you really worry about those guys and here's a bigger one tumor arising from the ciliary body here's the peripheral iris right into the angle here and we look right here sure enough here's one of those aqueous veins here's aqueous vein on the surface oops those tumor cells have actually gotten out of the eye and spread via those aqueous veins so that's what we really worry about in these ciliary body tumors what do we see in here Sean are there signs there that would point you one way or another yeah so it's flat you don't see any edema around it any exudated fluid you don't see any lipofusin orange pigment on the surface anything like that now for anybody what's the shields as acronym for you know telling these nevi from melanomas you can have no specs all right so here's your this is your assignment look up no specs it's the shields and you should know that okay I can't teach you everything so no specs look that up NO and then SPE CS no specs so look that up so that's a way you can help differentiate nevi from melanomas in the core right say huh this more worrisome now look at how blurry that optic nerve is that's blurry because you're not in focus so if you're focusing on the surface of this this is growing under the retina it's pushing the retina forward so this is a bigger lesion this would be more concerning and now this is that lipofusin that orange pigment we talked about here there's some exudative detachment here and this is definitely elevated so this is more concerning for melanoma rather than an evis and alley what's the classic shape if these melanomas grow long enough from the core right mushroom shape why is it mushroom shape so remember brooks membrane and had all those layers in it but two of the layers were collagenous so one was elastic so once that tumor grows in the core right it'll break through brooks and then it'll mushroom out underneath the retina but brooks will still almost act like a little lasso it'll still have some elastic and some collagen features so kind of restricted there so it's almost like the base of a mushroom here and then it mushrooms out underneath the retina here so that's the classic growth pattern that you see with these here's a small one now it's not all tumor that's actually exudate here and there's tumor now this one was posterior so patient had symptoms really early so they could tell now col who's the pathologist who described the way we classify caroyal and silver body melanomas the way you remember it is is what do you look at when you want to see what the date is today yeah exactly so I should say you guys probably say phone phone so so calendar is his name and he's a pathologist and he classified this into different types we kind of touched on this a little bit with with some of the iris tumors but what do we see here what is this pretty similar to like the iris spindle shape all right so spindle nuclei no nuclear lie in distinct cytoplasm this is what we call a spindle a melanoma now spindle a's really aren't melanomas they're really nevi but that was kind of the first classification that the calendar called it so spindle a that's not quite so good this is better um brad what is this spindle b spindle b and how can you tell that cigar shape it's kind of cigar shaped and what else what what's in that nucleus to tell dark like pulling teeth what is this thing right here the nucleus nucleus all right so these often will have a single nucleolus so they'll be cigar shaped round to oval single nucleolus indistinct cytoplasm these are the so-called spindle b melanoma cells what are these marshal epithelioids so how are they different a lot of chromatine multiple nucleolide distinct cellular borders some of these are even multi-nuclear so distinct cell of course this is called epithelioid the other classification that the calendar had is so called mixed so mixture spindle b and epithelioid that's the most common so if you have more than 10 epithelioid cells they call it mixed now he also had one called fascicular which is just spindle b cells tend to form fascicles and he had one called necrotic and that's just where the you know the eye gets enucleated and the cells are broken down by then so the main ones you need to know spindle a spindle b mixed epithelioid and they're very important prognostically so all the other factors you look at size you look at vasculature you look at other things it's the cellularity it's how advanced the the play more how advanced the changes are in the cells that are critical so if you have a pure epithelioid tumor those are really nasty mixed less so spindle b even less so spindle a probably just an evus why am i showing you this here chris so what are we holding on to here yeah so that's a vortex vein and sure enough look at that little dark pigment so again as we're putting radioactive plaques on these guys we're treating them with external beam we're not seeing as many gobs with tumors anymore though we just saw one recently and so you look real carefully on the outside because these spread via channels through the eye we call them emissarial channels and so Rachel what's an emissary yeah or someone who goes from one line of battle to the other so an emissary from one to another you kind of cross the border so you're an emissary so emissarial channels now the vortex veins are the most common way these tumors get out of the eye but they can also spread along channels where arteries come in or nerves come in so it's not so much that they go down the middle of the vein they go along the vein and that's where they gain access remember sclera is really tough tumors don't just eat through sclera they really can't do that and so where the veins go out where the arteries and nerves come in the tumor cells go along that weak spot there and eventually get out here we have here's the vortex vein here's the sclera and look at that tumor going right along that channel so that's where it kind of probes for a weak spot and then goes out that way and here we have now this is actually here's the vein right here here's the tumor next to the vein going out through the sclera and where does it go Teresa when it goes out the liver and how do we remember that exactly beware the yellow man with the glass eye and after that you say arg so if you've got someone who's been enucleated and they're yellow you really worry because when these metastasized they go to the liver so here's a liver and there's all these dark pigmented tumors on here you know this is three times a normal liver size the weird thing about these tumors is they can have liver meds years after the eye was removed so I don't know what happens if these cells metastasize and your body's immune system keeps them under control and then something happens down the road and they start to grow so there have actually been case reports of liver meds even 20 25 years after any nucleation so somehow they must hide in there and then and then be sequestered but not be killed off completely and then eventually they grow so melanomas go from the chloride or from the ciliary body to the liver whereas as Brad had said the retinoblastomas invade directly through the optic nerve now a couple of other things here john 70 year old female vague blurred vision okay breast cancer so you can get meds to the chloride and in fact you're going to be very careful when you do boards if they ask a question they say what's the most common tumor of the chloride the answer is metastatic but hopefully they'll be more specific they'll say what's the most common primary tumor and then you'll say melanoma but if they don't say primary be really careful they'll sometimes throw trick questions in them which I think is cheating but they do that all the time so you know you want to make sure that you think about it and so really most common tumor if you just looked at a bunch of autopsy eyes would be metastatic so in a woman most common is the most common tumor and breast breast carcinomas are the most common tumors in women and so in women you get you know metastatic breast carcinoma number one but rapidly catching up now is lung cancer and so the reason why lung cancer was more rare in females is men smoke women didn't but in the 60s and 70s they had these really classic tv you know believe it or not they advertise cigarettes on tv they're sure these swabs sophisticated women smoking and so you know you can be swabbing sophisticated if you smoke and there was one called virginia slims and and the idea was the catch line was you've come a long way baby that was the line i mean different era and the idea was you'd see these women in business suits and they were really powerful and they were smoking and so yeah so women have come a long way baby you could now die of lung cancer just like men can now hopefully what's countering that is the smoking rate among young people is going down down down down and so hopefully within another generation we'll see that you know go down even more but remember so carcinoma metastatic women breast men lung but women lung getting really close so here we see this is a classic adenocarcinoma of the breast and we've got here's the viable tumor cells we've got this mucinous material around them it's a mucin stain and so metastatic breast carcinoma this is a man again lesion white a lot of white in here irregular they can even be multiple and this turned out to be metastatic lung now rarely you can get prostate you can get other tumors but they're much much less common and so remember breast lung and then lung coming up in women those are the most common metastatic tumors all right so we say goodbye from the deck of the ship as we leave the Eiffel Tower on the other side questions on tumors all right so next week we're going to do an OCAP review and basically what we're going to do is we're going to show a whole bunch of past slides and so you guys can we'll show you everybody gets about 10 seconds to describe what they see and it's going to be like flashcards so I'm going to just show lots of pictures just to try to put this fresh in your mind when you're I'm going to go what's OCAPs two weeks now all right well good luck all right so next week review