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Sampling of iris tumours

Sampling of iris tumours. Sampling techniques. Broad iridectomy FNA Small gauge vitrector Kelly Descemet’s membrane Punch bx Technically difficult Requiring corneal sutures £. FNA experience. Hoovering a layer of cells from the surface with a bevelled needle

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Sampling of iris tumours

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  1. Sampling of iris tumours

  2. Sampling techniques • Broad iridectomy • FNA • Small gauge vitrector • Kelly Descemet’s membrane • Punch bx Technically difficult Requiring corneal sutures £

  3. FNA experience • Hoovering a layer of cells from the surface with a bevelled needle • 50% equivocal diagnosis-Why? • Low cellularity • Sampling of Vitamin C modified cells when in contact with aqueous and not deeper cells

  4. Mudhar HS, Saunders E, Rundle P, Rennie IG, Sisley K. Br J Ophthalmol. 2009 Apr;93(4):535-40

  5. New method: TC FCA • A clear corneal paracentesis (opposite the iris lesion being biopsied. • Viscoelastic introduced into the AC • A 25-guage Rycroft, or Viscoflow cannula attached to a 2 millilitre syringe and introduced in to the AC. • Negative pressure within the dry syringe, the cannula bevel passed repeatedly into the substance of the iris tumour. • This had the effect of creating what looked like a ‘phaco groove’ within the iris lesion

  6. Method • The cannula and syringe transferred into a tube containing an alcohol based cytology fixative. • Repeated flushing of the Rycroft cannula to ensure all lesional tissue was transferred into the fixative • No corneal sutures required.

  7. Up to 1.5mm long

  8. Complications: • Minor post bx haemorrhage day 1 post-bx.

  9. Diagnostic outcomes • 10 MMs • 1 metastatic lung adenoca • 1 pigmented adenoma

  10. Advantage: Cheap Quick Minimal complication No cornea sutures Samples deeper melanoma cells (unmodified by aqueous Vitamin C) allowing unequivocal diagnosis in MM cases. No ‘inadequate’ samples so far.

  11. Sampling vitreous cells.

  12. Anecdotal observation • VR surgeons had noticed quite often that cells in the vitreous tended to concentrate in the cortical vitreous and less in core vitreous.

  13. WHY? • Cortical vitreous has different physicochemical properties to core vitreous….cells being trapped. • Cells near a source of oxygen (retina) and therefore likely to survive.

  14. Literature • Documented false negative rate with core vitreous biopsy……often several biopsies needed before a positive diagnosis is made (lymphoma).

  15. Test the idea of differential distribution of cells. • 5 patients • All patients were consented routinely for a core vitreous bx, followed by a PPV (pars plana vitrectomy) • Cytology-we received 2 specimens-Core bx and vitrectomy. • Cytopsins prepared.

  16. Results • PPV specimen’s, 7.4 to 78 x cellular compared to core bx

  17. Experience to date with complications: One case had peripheral retinal tear, with peripheral retinal fragments ending up in specimen. However, fortuitously, the fragments contained the diagnostic pathology (!).

  18. Present practice: • Any vitreous infiltrate suspicious for lymphoma undergoes formal PPV with submission of vitreous cassette or bag to ophthalmic histopathology service. • Amount of tissue allows immuno and PCR for IgH, TCR, IL-6/IL-10 ratio etc.

  19. Thank you.

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