GROSS DESCRIPTIONS
Templates for cases are complete with history, gross, microscopic and diagnosis. The following are examples of some gross only cases with an explanation of the goals in examination:Rectus Muscle for ID onlyRectus muscles receive a gross description after viewing under the dissecting microscope. The high magnification under the dissecting microscope is of the same order of magnitude (usually greater) than the low magnification at the compound microscope. During the gross examination the resident should try to identify tendon which is white and usually quite abundant with striations that run parallel to the apparent short axis (arrow 1 in the figure).  Muscle appears tan and is usually most abundant at one edge (arrowhead 2 in the figure. The length of the muscle removed needs to be documented accurately. Since the extraocular muscle is quite wide in vivo (about 9 mm) but the length resected quite small (usually 2-4 mm), the axis of the apparent width of the gross specimen corresponds to that of the length in the orbit. This is especially evident when one sees the striations running in the short axis of the specimen. In the figure striations are obvious both in muscle and tendon (arrows 1 and 2) and therefore the muscle length is actually the distance between the arrowheads marked 3. In the body the long axis of the muscle is oriented parallel to arrow 3. Gross description:Specimen 1, in formalin, labeled "right lateral rectus muscle" consists of one rectangular red and white fragment measuring 9 x 2 x 2mm in greatest dimensions. Under the dissecting microscope the external surface has fibrous white strands which are parallel and longitudinally oriented, adipose tissue, and blood vessels.Dx: Muscle and fibrous tissue, "right lateral rectus muscle" (resection) - muscle and tendonFor more detail see this link. Intraocular LensesAn accurate diagram of the IOL should be drawn out. Note the type of lens if you know it; otherwise make your description accurate enough that one could draw a picture from your words. Note any tissue adherent to the lens and process tissue for appropriate histologic sections. Describe the shape, size, and color of optic and note any defects. The flexibility of the lens gives a clue whether it is made of polymethylmethacrylate (PMMA is hard) or silcone (soft). This should be indicated. Note the color, shape, size, and position of haptics (L-shaped, closed loop, etc. for anterior chamber lenses; C-shaped, J-shaped for posterior lenses). Note evidence of broken / amputated haptic or transected optic (often done to get the lens out of the eye). Note positioning holes, their size and position. Intraocular lenses are stored for 6-9 months! Restor Lenses should be saved for possible return to the patient for rebate.Gross Description:Specimen 1, in formalin, labeled "IOL, OS" consists of a clear synthetic hard device measuring 13 mm in overall length with a round clear optic that measures 6 x 5 x 1 mm. There is a positioning hole in the periphery. The lens is a 3 piece style; two blue J-shaped haptics extend from the periphery of the optic 180 degrees apart. The optic shows some pitting on the posterior surface.Diagnosis: Synthetic device, "IOL, OS" (removal) - synthetic intraocular lens, posterior chamber styleLenses (native) Cataractous lenses are carefully examined with a stereomicroscope. It is important to note the color (yellow, yellow-white, or brunescent), the degree of opacification, and the diameter of the lens. You can calibrate the degree of opacification by trying to read newsprint through the lens. The lenses are then shelved for temporary storage (3 months), then discarded. No histologic sections need to be taken unless specifically requested or if there is an interesting finding such as a congenital anomaly, infection (like rubella, fungus, or bacteria) or tissue attached to the lens that would be important to document.
SURGICAL IMPLANTS, METALLIC FOREIGN BODIES, HARDWARE
Unless otherwise ordered, the tissue or material for gross examination (identification) will be stored temporarily (i.e. 3 months) and then discarded. Exercise caution in the following instances:Despite the instructions "ID ONLY" by the surgeon the pathologist must use his own judgment. If a lesion of possible clinical significance is encountered, it must be submitted and processed for microscopic diagnosis.If a piece of tissue, "hardware", or the like has potential medico-legal significance (e.g. intraocular foreign body), the specimen must be marked "store permanent". Hardware of this type are stored indefinitely in either fixative, alcohol, or dry in a plastic bag. ALL NON-METALLIC AND METALLIC FOREIGN BODIES SHOULD BE "STORED". Bullet fragments are routinely requested by the police months to years after their removal from the eye. All metal fragments must be tested with a magnet. The report must indicate whether the fragment is magnetic. While the storage is not “permanent” it should be in keeping with institutional standards compliant with state regulations.A procedure sometimes used by the surgical pathologist is the "block only" category. Such specimens are embedded in paraffin, plastic, etc. and stored as such without microsectioning. This might be used for example when one had a large tumor of possible future teaching value or again, tissue of potential medico-legal significance. When blocked in paraffin or plastic the tissue can be stored virtually "forever".If you choose a gross only work up for a piece of tissue, your description should include the phrase "under the dissecting microscope" and should contain enough information to indicate you accurately described the tissue. For example, "tan tissue with parallel longitudinally oriented fibers that merge with tendinous tissue" describes muscle. If you cannot describe the tissue in this way, it is probably not normal and microscopic sectioning is warranted. Cases with a history of both CPEO (chronic progressive external ophthalmoplegia) and ptosis repair should be brought to the attending pathologist's attention immediately, as the tissue will need to be processed for electron microscopy as well as routine light microscopy.Gross descriptions should be accurate and give enough detail so that the reader could diagram the specimen with measurements from your report. Be sure to detail specific margins that were inked with different colors if appropriate. Document if the specimen was placed in an embedding bag. Clearly indicate when specimens from 2 cassettes, each inked a different color, are combined for embedding in one paraffin block (we do this occasionally in cases such as Mullerectomy specimens for efficiency). SCLERAL BUCKLE: Scleral buckling devices are removed from cases of repaired retinal detachment when they extrude and/or become infected. A complete and accurate description of the size and shape of each piece as well as a description of any bands or grooves should be reported. A microscopic examination is not performed and the specimen is not processed but stored temporarily. See the example below. CLINICAL INFORMATION: retinal detachment repair 2002, exposure
FINAL DIAGNOSIS: Synthetic device "right eye” (removal)- consistent with scleral buckling device
MICROSCOPIC EXAM: Not performed.
GROSS DESCRIPTION: Specimen #1, labeled “scleral buckle from right eye” consists of a translucent soft flexible synthetic bandshaped device measuring 16 mm in length x 2.5 mm in width and x .5 mm in thickness. There is a groove in the center of the band that measures 1 x .5 mm.
BIOPSIES-GENERAL INSTRUCTIONS FOR PROCESSING
ACCESSIONING CASESThe anatomic location for the specimen is given by what is written on the specimen bottle. If the location only appears on the requisition that accompanies the specimen then the gross description should so indicate: "Specimen, in formalin, labeled with the name of the patient and designated diagrammatically on the accompanying requisition as "right upper eyelid" consists of..." Cases are accessioned in our system with a letter S if the biopsy originated from UCLA or JSEI and R if it is outside this facility. The resident must assign the R or S number according to the location. Some cases will be delivered from UCLA Pathology Outreach with R numbers already assigned. These cases have already been accessioned and will keep the R number assigned by outreach. The resident simply needs to log them in the book to complete the accessioning. The basic tenet is that every specimen that is received by the lab is entered in the computer and in the log book by the resident.
BIOPSIESThe work-up of surgical biopsies is only begun when adequate clinical information is available; the work-up contains 3 parts: a narrative gross description, a narrative microscopic description, and a diagnosis. Be sure to obtain adequate clinical information and type everything listed clinically on the requisition form. If the information on the requisition form is incomplete then request history by emailing the assigned physician using your UCLA email account. Alternatively, you can call them or review the patient's chart in the originating physician's suite with their permission. Abbreviations should be typed out as complete words. Mistyped or mis-spelled words can followed by [sic] to indicate the mistake. Some use [sic] to follow the corrected error. Either usage seems to acceptable although most grammar texts use to follow the error left in place. Gross Examination. The examination of the specimen under the stereomicroscope is critical not only for an accurate description but also for correlation to the clinical specimen. This examination permits identification of the abnormal areas and guides further decisions regarding sectioning and processing. Here are some examples: 1. A full thickness wedge resection of the eyelid does not need fiducials placed by the surgeon to be oriented by the pathologist. Under the stereomicroscope the presence of the lid margin will be obvious and orientation simple and margins can be inked. A decision to cut coronally or sagitally will be determined by the location of the tumor, and the gross appearance. Processing. Instructions for Processing are dealt with in other sections. However, the resident should understand that processing will more the specimen from aqueous based solvents to organic solvents and finally to paraffin. Details of fixation and processing are discussed elsewhere.
Microscopic Examination.
Microscopic examination is performed on most surgical specimens (except most gross only cases) and some autopsy eyes. The residents will learn to evaluate microscopic sections of most common ocular disorders during this rotation.
Microscopic descriptions should be written in a concise and systematic manner to include, sequentially, the architecture of the lesion and the cytologic features. Do not begin your description until you have thoroughly read up on your case. 95% of the diagnoses can be found on line at MissionforVision.org or in the books referenced in this manual. Get these references from the Biomedical Library or the bookstore.
For a simple case with one block and one section, begin your description with "Sections show". In this case you do not need to indicate a location or specimen since there is only one. For cases involving more than one specimen or cases in which more elaborate sectioning was done, you may begin by "Sections of the specimen labeled ‘x’ show” or Step sections through the block of the specimen labeled ‘x’show or Step sections of the specimen labeled ‘x’ show. Tailor your report to the way the specimen was sectioned. The term "sections show" is applied to a simple case where a ribbon of more than one section at the same level was taken of the biopsy. "Step sections show" refer to a case where levels were taken at 250 micron intevals to more thoroughly sample the tissue, e.g. deeper every 50th section x 5). "Step sections through the block" is used when sections were taken at 250 micron intervals all the way through the paraffin block exhausting all remaining tissue. This is often used when a neoplasm was strongly suspected and needs to be excluded. Include a description of all special stains that were performed in your report. If a case consists of more than one specimen, each specimen may be described separately. While specimens with the same microscopic findings may be described collectively, diagnoses are listed separately under "FINAL DIAGNOSIS" on our reports for each specimen (see example). Usually the main feature is detailed first (such as focus of cancer, ulceration, or the like), and then the secondary features are described. Occasionally, one may finish the description with pertinent negative statements (e.g. "granulomatous inflammation is lacking") or special features (e.g. "tumor is present in the lateral surgical margin"). In general pertinent negatives are not needed. Each specimen requires its own line and separate heading for "FINAL DIAGNOSIS". There are no exceptions. If a case has 23 specimens that all show the same thing, it may require a single microscopic description but there must be 23 listed separately each beginning with the heading "FINAL DIAGNOSIS" to include the respective anatomic sites. Be sure to comment on margins of all tumors.
Do not expect to be able to write perfect microscopic descriptions in the beginning of your rotation. Please always check your work to eliminate errors of omission, grammar, and orthography. You may use the descriptions in the work file or glossary as a guide for your gross and microscopic descriptions. You should expect that most of your work-ups will be significantly modified. The microscopic work up will reveal areas of ignorance, and is an excellent way for the pathology faculty to plot your progress through the rotation. Expect that you will be asked to rewrite the descriptions if they contain errors.
Format for Final Diagnosis.
In general the procedure for final diagnosis is the same as that for the specimens requiring the gross. The tissue type is that which you see under the microscope. So if there is keratinized stratified squamous epithelium with hair shafts and adnexal structures the tissue is "skin".
Next in quotation one puts either exactly the wording on the specimen label or that which conveys accurately the type of specimen submitted and laterality from the requisition. Next the procedure rendering the speciem is put in parentheses. Finally the diagnoses are given.
FINAL DIAGNOSIS: Tissue type, "specimen label on the bottle" (surgical procedure)-1st diagnosis
-additional diagnoses,from this first specimen
FINAL DIAGNOSIS: Tissue type, "specimen label on the bottle" (surgical procedure)-1st diagnosis
-additional diagnoses,rom this second pecimen
or e.g.:
FINAL DIAGNOSIS: Skin, "left lower eyelid" (biopsy)- seborrheic keratosis
GROSS DESCRIPTIONS, FIXATION
FUNDAMENTAL CONSIDERATIONS IN EYE PATHOLOGY
Clinical History- The importance of adequate clinical information before processing tissue cannot be overemphasized. Collection of clinical history begins as soon as the specimen is scheduled for the operating room. The operative schedule is reviewed 1 day prior to the date of the operation by the resident and history obtained. Specimens, historical information and the approach to fixation are discussed with the attending. In this way, the fixation selection errors are minimized by the operating room staff and surgeon. Common mistakes are formalin for lymphoma when flow cytometry is needed, formalin for conjunctiva suspected of ocular cicatricial pemphigoid, etc. Surgical biopsies must have the relevant clinical information in the appropriate place on the Pathology Consultation Request before the gross work-up begins. Proper biochemical or ultrastructural evaluation often depends upon appropriate treatment of the specimen at the outset - this is especially important in Lymphoproliferative lesions (see Reference 33), in body fluids or "washings," and in lesions that may require electron microscopic analysis (formalin contains methyl alcohol and other ingredients that wreak havoc with the ultrastructure of cells).
Fixation of Tissue- Proper fixation is of paramount importance in processing tissue for histopathological evaluation. The OR and pathology laboratory in the main hospital (RRMC) leaves tissues unfixed until the pathologist sees them. Keep this in mind for cases that may be delayed when sent to us. They all should be either fixed at the time of surgery or sent to us immediately. For the JSEI OR our current protocol is to provide formalin for most cases with important exceptions. The exceptions are conjunctiva for ocular cicatricial pemphigoid, selected enucleations, orbital tumors and intraocular tumors and corneas from Dr. Casey. In addition any conjunctival specimen from a surgeon that is not familiar with placing the specimen flat on filter paper. Specimens can be assessed for the proper fixative. The resident on service must seek the associated clinical histories on the day the specimen is received. This is generally done by first looking at the OR schedule the day prior to surgery and identifying possible cases that will need special processing. The specimen is then transferred to an appropriate solution or fixative. Here a few common examples for suspected diagnoses:1. Lymphoma- fresh for flow cytometry, touch prep; modified carnoy's for DNA extraction. Orbital and conjunctival cases are generally sent to hematopathology fellows fro processing in main pathology. They are not accessioned at JSEI!2. Ocular Cicatricial Pemphigoid- remain in refrigerated maleimide buffer (Zeus media) and sent immediately to immunohistochemistry for immunofluorescence. Zeus media can be obtained from the immunohistochemistry lab. The composition includes N ethyl maleimide, magnesium sulfate, potassium citrate and ammonium sulfate.3. Sebaceous carcinoma- 4% paraformaldehyde for possible osmication (lipid fixation).4. Pseudoexfoliation- glutaraldehyde for electron microscopy.5. Retinoblastoma- sample fresh frozen or in modified Carnoys for gene sequencing, eye for formalin fixation after material removed for DNA analysis.The following factors are critical: the thickness of the tissue that the fixative must penetrate (tissue blocks should be no greater than 2 mm in thickness and thinner blocks are preferred; the quantity of fixative (tissue should be immersed in a minimum of 10x its volume fixative), and the temperature (refrigerator cooling, will markedly retard autolysis! Freezing disrupts cells). There are special considerations for whole eyes after fixation (see processing of enucleated specimens).
The most common fixatives in use are:
FORMALIN - 10% formalin is a solution containing 40% formaldehyde that is buffered with phosphates (approx. neutral pH) and is an economical fixative with rapid penetration. The rate of fixation is about 1 mm /hour.
Chemical reactions occur between formaldehyde and amino acids as well as with nucleic acids. The DNA is denatured by breaking interchain hydrogen bonds, particularly at the AT-rich regions. Formaldehyde cross links both proteins and DNA by forming methylene bridges between amino groups. Hydrolysis of N-glycosylic bonds can result in release of free pyrimidine and purine residues and a reaction to 2-deoxy-D ribose. Phosphodiester bonds may be hydrolized, (purinic and apyrimidinic). DNA isolated in fomalin fixed tissue exhibits nonreproducible sequence alterations. Formalin is time honored and give excellent standard morphology for paraffin sectioning.GLUTARALDEHYDE and PARAFORMALDEHYDE fixatives are generally used for electron microscopic studies. The size of the blocks (one mm or less) and rapid cooling of tissue are even more critical here. PARAFORMALDEHYDE (4%) is very versatile because it is somewhat reversible. It can be used for paraffin embedded tissues, electron microscopy, and immunoelectronmicroscopy. It is not suitable for lymphoid work ups. Paraformadehyde is simply a polymer of formaldehyde.
ALCOHOL - 95% or absolute must be used for substances that are water soluble (e.g. glycogen). Other substances in use include MERCURIC CHLORIDE (Zenker's fixative), PICRIC ACID (Bouin's Solution), etc. Alcohol based fixatives such as modifications Carnoy's solution (8 parts methanol and 1 part of glacial acetic acid) or (3 parts ethanol 1 part glacial acetic acid) are excellent for DNA preservation. The former, also called modified methacarn, is quite good for RNA preservation and preserves morphology reasonably well (Cox et al. 2006). Alcohol fixation works by precipitating proteins and stopping enzymatic degradation. Although nuclear fixation is quite good, nucleoli are more prominent with alcohol fixation and one must adjust criteria for atypia.
Decalcification- is accomplished with acid solutions in combination with EDTA. For dense bone a rapid decalcification solution is used. Decalcification is required for tumors containing bone and phthisis bulbi specimens and occasional other specimens. The decalcification solution is generally kept beneath the sink. Decalcification is always done prior to processing but after fixation.Freezing Tissue- is indicated for lymphoid work ups when PCR of infectious material is contemplated at a later date and for evaluation of research type specimens. Each procedure requires a slight variation of the freezing procedure and the pathology attending should always be consulted.
Handling of Tissue- After fixation an important aspect of processing tissue is to handle the tissue with care,  being careful not to crush with forceps, not allowing the tissue to dry during blocking, and permitting adequate space in cassettes to allow free access of dehydrating and infiltrating fluid during processing. Specimens that have been properly fixed in formalin are examined in water in a deep petri dish under the dissecting stereomicroscope. The water dilutes the formalin to a level where the concentration of formalin in the air above the water is undetectable (hence providing safety) as well as rinses out the formalin for the next step which will be 50% ethanol. Forceps are chosen for examination which are appropriate for each sample in handling the tissue. In general eye pathologists use forceps that much smaller (as the 3 on the left in the photo) than those forceps used by general pathologist, on the right. Forceps without teeth are generally preferable for delicate conjunctiva; curved blunt end forceps are best for scooping up corneas without damaging endothelium or epithelium; very fine forceps are necessary for epiretinal membranes. The specimens will be examined under a stereomicroscope with external illumination from a movable focusable light source that permits a range of lighting techniques.
Inking tissue samples- It is important to understand the orientation of each sample if that is discernible. In order to process the specimen one needs to know if it is possible that it contains a neoplastic lesion. Adequate history, thorough knowledge of diseases, location, and the gross appearance are all used in making the decision that a specimen in inked. If uncertain then ink the specimen (ink don't think!). The usual reasons for inking the specimens include identifying surgical margins in the case of neoplasms, providing orientation for the technician and orienting a lesion on microscopic examination. See also embedding instructions to understand how ink place on the cut face will be translated to a slide and the example of a skin ellipse with orientation to understand the principles of inking to preserve margins.
Suspected Neoplasms: Surgeons in general would like to know what margins are involved if they were not cleared. To do this the pathologist needs to ink the margins at the gross bench appropriately. In general, if no orientation is discernible (e.g. a eyelid biopsy without lashes, grey line, margin or conjunctiva) and was not provided by the surgeon with a marking suture or diagram then the undersurface is inked green and the specimen is submitted for appropriate cutting after processing and then embedding and microtomy. If orientation for the specimen is provided then it is critical to identify and ink the margins with different colors so that the proper orientation can be discerned once the specimen is cut. In other words to which margin did the tumor extend? In general the under surface is inked green and 2 adjacent sides of the specimen are inked with black and yellow marking inks. In this way each margin is able to analyzed under the microscope.
PLEASE CONSULT THE ATTENDING PATHOLOGIST BEFORE PROCESSING SPECIMENS WITH WHICH YOU ARE UNFAMILIAR. IF YOU FAIL TO INK THE SPECIMEN APPROPRIATELY AND IT IS PROCESSED THAN INFORMATION MAY BE PERMANENTLY LOST. BIOPSY EMBEDDING BAGSUSE BIOPSY BAGS FOR SMALL SPECIMENS LESS THAN 3 MM IN ANY DIMENSION AND MAKE SURE BIOPSY BAGS ARE FOLDED ON ALL EDGES SO THE SPECIMEN DOES NOT FLOAT FROM THE CASSETTE DURING PROCESSING. THERE ARE TWO TYPES OF EMBEDDING BAGS. THE NYLON BAGS DO NOT FOLD EASILY AND DO NOT STAY FOLDED. THE PAPER (TEA) BAGS FOLD AND RETAIN THEIR FOLD WHEN WET. SO WET THEM SLIGHTLY BEFORE YOU PLACE THE TISSUE IN AND THE AGAIN AFTER YOU HAVE FOLDED ALL SIDES. DOUBLE BAG ANY CRITICAL SPECIMENS THAT ARE SMALL. IF TEA BAGS ARE USED, THEY SHOULD BE QUARTERED WITH SCISSORS FIRST FOR SMALL SPECIMENS BECAUSE IF THE VOLUME IS TOO LARGE, FINDING THE SPECIMEN WILL BE COMPLICATED FOR THE TECHNICIAN. CAREFUL FOLDING AND WETTING OF THE QUARTERED BAG IS IMPERATIVE.To saveguard cassettes from losing specimens that slip through the cassette slats, we employ a system of transfer containers. Each day cassettes with tissue are placed in a yellow topped container, with the current date. 50% ethanol is filled just to cover the casettes. The specimens are taken to the main lab in these containers but the solution is not thrown out. The containers are returned to us the next day with the 50% ethanol for our inspection in case a specimen has slipped out. The resident is obliged to make sure these containers are clean before use, and to write the correct date with a marking pen. Labeling Cassettes: At the current time we use a color coded system in surgical pathology for cassettes. Eye pathology cassettes are red in color and are labeled in a very specific way. The name of the patient is written in pencil on the side of the cassette. The surgical number beginning with a J for Jules Stein precedes the S number of the surgical case. Each cassette must bear the suffix of a single letter starting with A and proceeding in sucession in the alphabet (A,B,C...) This cassette letter does not necessarily correspond to the specimen number or letter assignment. LABEL THE CASSETTES IN PENCIL OR WITH A SPECIAL PERMANENT MARKING INK MADE SPECIFICALLY FOR CASSETTE MARKING (e.g. STATMARK PEN) AS MOST INK WASHES OFF IN THE ORGANIC SOLVENTS USED IN PROCESSING. PUT THE NAME OF THE PATIENT ON THE SIDE OF THE CASSETTE IN CASE THE PENCIL IS ACCIDENTALLY SMEARED AND WRITE CLEARLY.
GROSS ONLY (IDENTIFICATION) CASES - general instructions
Certain categories of surgical specimens only require a careful gross description. In general, you should be confident that you can identify the tissue in the gross and that it is normal. If you cannot, microscopy should be performed. Specimens in which only a gross exam is usually performed include:
- eyelid tissues from blepharoplasty that are clearly completely normal
- most extraocular muscles from strabismus surgery (provided striations are seen)
- crystalline lenses
- intraocular lenses
- hardware from retinal detachment repair
- Ahmed valve
Use the templates in the computer available for each of the above specimens. After a careful stereo microscope examination and description, the case is signed out as indicated in the following examples:
FINAL DIAGNOSIS: Tissue type, "specimen label" (surgical procedure),
-1st diagnosis
-2nd diagnosis
FINAL DIAGNOSIS: Muscle and fibrous tissue , "right lateral rectus muscle" (resection) –muscle and tendon
RESIDENT SYLLABUS
INTRODUCTION
The ophthalmology residents at the Jules Stein Eye Institute, UCLA medical school are an integral part of the daily functioning of the pathology lab. While this manual is written for the Jules Stein resident, the guidelines here are also helpful for ophthalmology at other training programs. Responsibilities include accessioning, obtaining adequate history, writing a thorough gross description, preparation for embedding, microscopic descriptions, and editing final changes in the typed gross and microscopic descriptions. The residents are also an integral part of the medical student teaching process that gives them an opportunity to teach ocular anatomy to the medical students.
In general, surgical pathology material comes in a number of general categories: 1. gross only (identification) 2. biopsies 3. cytologic samples such as conjunctival smears, fine needle aspirations, vitrectomy specimens 4. whole eyes 5. eviscerations 6. exenterations.
Another important function of the ophthalmology residents is the processing and study of autopsy eyes.
SPECIFIC RESIDENT RESPONSIBILITIES
Surgical Pathology Service: Residents are responsible for obtaining the surgical specimens from the operating theater, accessioning specimens, obtaining a complete and adequate history, describing the gross appearance, properly labeling cassettes and providing adequate orientation for processing. The residents will also perform the microscopic examination and provide a diagnosis. The attending pathologist supervises all work.
OR Schedule: The OR schedule should be reviewed the day before the operation to prepare for special cases such as intraocular tumors, fine needle aspirations, lymphoid lesions and other specimens that require urgent handling. Notify the pathology staff of such cases.
Accessioning Specimens: All specimens are to be accessioned by the residents on the computer. This is a simple and easy but important process. Eye Pathology Staff or the resident departing from the service will teach the incoming resident. It is critical that for consultations received from referring pathologists, laboratories and ophthalmologists, all packing material be saved until the case has been signed out. Immediately upon receiving and opening the packages all slides and blocks should be recorded in the login book. The envelopes and packages should be carefully checked for paraffin blocks or stray slides that may have separated during transport. The paperwork that comes with case should be compared to what was recieved to verify its correct identity and to be sure that the number of slides and blocks as well as their labels are accurate. Any discrepancy should be clarified immediately with the referring hospital, laboratory or physician.
Preparing Reports: All reports will be prepared for sign out. Included will be a detailed and accurate clinical history, a detailed gross description and a microscopic description. Each report should be reviewed for accuracy of description, diagnosis, content, spelling and grammatical errors. All errors should be corrected directly on the computer. There is a specific format for preparing these reports that will be discussed in following sections. In our system we value the contribution made from residents evaluating cases de novo and attempting to make a diagnosis free of bias. We implore you to write the report without the attending input at first. You will see that this will force you to consider histology and induce a great deal of reading around cases. Reading Assignments:
The Resident Manual for Ophthalmic Pathology (this site) should be carefully studied prior to the rotation and be used as a reference during the rotation. This will replace the methods sections in the textbook.
In the past, reading from the pathology section of the Academy series was assigned to the residents as the only reading source. However, in an effort to emphasize specialty reading around your cases, we have provided a number of textbooks for your use on the rotation. It is expected that the resident will read these basic texts and current articles pertaining to their caseload. In general, the pathology section of the Academy manual will be covered adequately in your first year during the Wednesday evening sessions and again in Basic Science sessions prior to Grand Rounds. The resident should be amply prepared to discuss the literature on any of their important cases. It is the philosophy of this service that we provide not only histologic diagnoses but also investigate information that would be useful to patients and our clinical colleagues. You should read widely around each case.
Recommended reading and references:
1. Section 4 Ophthalmic Pathology and Intraocular Tumors- this is currently a good starting point.
2. http://www.missionforvision.com and follow the links to the ocular pathology tutuorial. This is a very well illustrated site with current information about eye pathology diseases. It is actively being constructed and will soon replace the textbook. Abundant clinical information is provided. Currently, the conjunctival section essentially complete. 3. Ocular Cytopathology , 1993 Excellent for analysis of cytology specimens. A new edition is planned and will be free on http://www.medrounds.org/ soon!
4. Online Resourse: http://www.medrounds.org/: see review of anatomy and ocular pathology study guide. 5. Board Review on http://www.medrounds.org/ is a very good review of the most commonly asked board questions. Although not sufficient for this course it is an excellent self testing review and contains unique information and excellent photos with provided links for more information.
Evaluations: All residents are carefully evaluated during the rotation. Evaluations are based on performance of service duties (including preparation for sign out) and fund of knowledge. Fund of knowledge is tested orally in daily activities. Formal testing is performed each week over assigned reading and current cases. Each test is cumulative. At the end of the rotation the test scores are compared to residents in your class, all previous residents and residents at your level who took similar examinations. The examinations are rigorous and are generally a series of open ended questions to allow the resident to express both the breadth and depth of their knowledge. In addition there are numerous pictures for which simple diagnostic identification is necessary or an answer to a question about the disease. The residents are evaluated on their teaching ability, their thoroughness and care in following cases, their interactions with staff, students and referring physicians, and their puntuality. All evaluations will be reviewed with and reported to the resident, department chairman, and the clinical committee. If you wish an interim evaluation, simply ask. If you are not doing well the attending pathologist will undoubtedly let you know.
Residents are encouraged to make constructive remarks during and after the Pathology rotation. Changes in the program have been initiated as a result of previous comments. This manual is the compilation of work by attendings, residents and fellows. Resident should understand that since the implementation of this curriculum scores on standardized tests specifically, OKAPs, have risen dramatically attesting to the effectiveness of the resident studying regimen. Most of the residents find the course rigorous but well within their reach. Inadequate performance is rare and is dealt with on an individual basis in consultation with the Chair and Clinical Committee.
Teaching Medical Students: Residents are assigned teaching duties each Monday morning for 3rd and 4th year UCLA Medical Students. This is to be performed in a prescribed manner. Please study this link.
COURSE OBJECTIVES EYE PATHOLOGY ROTATION
COURSE OBJECTIVES- EYE PATHOLOGY ROTATION FOR OPHTHALMOLOGY RESIDENTS
1. Learn the methods in preparation of surgical specimens.
a. proper operative technique in preparing specimens
b. providing adequate clinical history
c. preparation of specimens so margins of resections are informative
d. proper orientation of surgical specimen for processing
e. limitations inherent in methods of preparation
2. Learn the process by which a pathologic diagnosis is made.
a. careful gross and microscopic examinations
b. establishing a differential diagnosis
c. evaluation of literature and textbooks to sift through differential diagnoses
d. rapid communication with clinicians responsible
3. Acquire a basic fund of knowledge of Ophthalmic Pathology.
a. successfully complete a core curriculum of basic Ophthalmic Pathology
b. improve ability to interpret pathologic material
c. provide adequate training for passing ophthalmic pathology on Board Examinations
4. Acquire a framework for future practice in Ophthalmology.
a. Examine autopsy eyes and become intimately familiar with normal anatomy.
b. Be able to teach ocular anatomy to medical students and non-specialists.
c. Understand the developmental variations in normal eyes that can lead to clinical misdiagnoses and improper treatment.
d. Evaluate many of the common lesions that are surgically removed.
SPECIMEN PROCESSING MANUAL FOR EYE PATHOLOGY
EYE PATHOLOGY SPECIMEN PROCESSING MANUAL FOR RESIDENTSThis manual is used by residents rotating in Ophthalmic Pathology to aid in specimen processing.Here are some tips on navigating this site. For all figures, click to enlarge, for topics and references many of the terms and topics are highlighted so click if indicated to link for more details. For your convenience buttons move to the next page or you can use the table of contents to search specific topics.
Routing Form for Eye Pathology
A variety of routing forms are supplied for your convenience. Instructions for processing, demographic information, clinical history and your personal notes about each case should be kept on the routing forms. Name:________________ ROUTING FORM Accession Date:___________Date / Pending Hospital #: _______________Notes: _______________________________________________________________ Specimen Container label for:#1 ________________________ #2 _____________________ #3 _________________: x x mm x x mm x x mmInk color ______ Ink color ______ Ink color ______Cassette _____ Cassette _____ Cassette _____Embedding Instructions: block(s)______( ) On Edge ( ) Flat Face ( ) As Shown Sectioning Instructions: Face block; Take ribbons/ sections at the following intervals ( )1 stained, 1 unstained block(s)______( ) Deeper q 30th section x ____ or (through block) block(s)______ ( ) Deeper q 50 x ____ or (through block) block(s)______ ( ) Deeper every 20th section x ____ (through block)( ) Cornea –face, 1 section stained / 1unstained / 1 PAS( ) Pterygium – 1 H&E – deeper q50x5 stained w/PAS( ) ____________ unstained slides ( ) Routine Infectious Package Gram (+/-) Brown-Hopps GMST, PAS, AFB,( ) Corneal Dystrophy Package Alcian Blue pH 0.4; PAS; Congo Red; Masson's Trichrome ( ) PAS all corneas and eyes ( )Jones ( )GMST ( ) Verhoff Van Gieson( ) Oil Red O ( )AFB ( )Silver ( )Steiner-Steiner ( ) Gram Stain ( )Giemsa ( )Fite's Stain ( )Warthin-Starry ( )Alcian Blue pH 0.4 ( )Von Kossa ( ) Masson's Trichrome ( )Congo Red ( )Crystal Violet( ) Thioflavin T ( )Prussian Blue ( )Gordon-Sweet( ) Heidenhain Hematoxylin ( )PTAH ( )Sudan Black ( ) Mucicarmine
|
|
|
Muscle appears tan and is usually most abundant at one edge (arrowhead 2 in the figure. The length of the muscle removed needs to be documented accurately. Since the extraocular muscle is quite wide in vivo (about 9 mm) but the length resected quite small (usually 2-4 mm), the axis of the apparent width of the gross specimen corresponds to that of the length in the orbit. This is especially evident when one sees the striations running in the short axis of the specimen. In the figure striations are obvious both in muscle and tendon (arrows 1 and 2) and therefore the muscle length is actually the distance between the arrowheads marked 3. In the body the long axis of the muscle is oriented parallel to arrow 3. 
