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BRIEF COMMUNICATIONS
Year : 2016  |  Volume : 4  |  Issue : 3  |  Page : 151-155

Scrape cytology in ophthalmology: Our experience with three cases


1 Department of Oculoplasty, K. B. Haji Bachooali Eye and ENT Charitable Hospital, Parel, Mumbai, Maharashtra, India
2 Department of Cytopathology, Tata Memorial Hospital, Mumbai, Maharashtra, India

Date of Submission19-Sep-2014
Date of Acceptance24-May-2016
Date of Web Publication19-Sep-2016

Correspondence Address:
Sheetal Bakshi
1-Rudraprayag, Bhagwant Nagar, Mumbai Naka, Nashik - 422 011, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2320-3897.190791

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  Abstract 

The aim was to describe the use of scrape cytology as a procedure for the preliminary diagnosis of suspicious lesions in case of three patients. The first patient was diagnosed with sebaceous gland carcinoma of the upper lid, second patient had squamous cell carcinoma (SCC) of the bulbar conjunctiva, and the third patient had SCC of the skin of medial canthus of eye. In this article, we have discussed the history of evolution of cytology briefly. Different types of cytology procedures as well as advantages and disadvantages of each procedure have also been discussed. We have described the procedure of taking scrape specimen and further processing in brief. The article emphasizes the role of scrape cytology in initial diagnosis, treatment plan, prognosis, and subsequent follow-ups in patients of ocular surface tumor.

Keywords: Cytology, diagnosis, neoplasia, scrape


How to cite this article:
Bakshi S, Balasubramaniam V, Kane SV, Oza NS, Dighe SB. Scrape cytology in ophthalmology: Our experience with three cases. J Clin Ophthalmol Res 2016;4:151-5

How to cite this URL:
Bakshi S, Balasubramaniam V, Kane SV, Oza NS, Dighe SB. Scrape cytology in ophthalmology: Our experience with three cases. J Clin Ophthalmol Res [serial online] 2016 [cited 2021 Apr 22];4:151-5. Available from: https://www.jcor.in/text.asp?2016/4/3/151/190791

Cytology is the study of cells, their origin, structure, function, and pathology. Cells, as the units of living beings, were first described by “Robert Hook.” Johannes Muller was the first pathologist to show cancer cells obtained from surgical specimens under microscope in 1838.[1] Lebert and Paget were other giants of 19th century who prepared smears from body fluids, surgical specimens, and aspirates, and hence, added to the immense literature of diagnostic cytology.[1] James Ewing did substantial work on needle aspiration cytology.[1] George Papanicolaou and Aurel Babes popularized the testing of vaginal smears for the diagnosis of uterine cervical cancers. Papanicolaou revolutionized the staining techniques and diagnosis of malignancies.[1],[2]

Cytological studies can unveil characteristics, diseases, dysfunction and malignancies of a living tissue.[2] Cytological techniques are very useful in diagnosis and monitoring of various ocular diseases.[3]

The most common techniques used for collecting cytological samples are tissue swabs, impression cytology, scrape cytology, and fine needle aspirates.[2],[3] Swabs, imprints, and scrapes are the procedures of choice for superficial lesions, whereas fine needle aspiration cytology (FNAC) can be used for superficial as well as deeper lesions.

Swabs are more commonly used for microbiological assessment of conjunctiva and conjunctival cul de sac.[4] Swabs can also be used for cytology, but the tissue yield is much lesser with this technique. The advantage of this procedure is that it is the least invasive of all.

Conjunctival impression cytology is easier to perform, cheap, noninvasive, repeatable, and quick.[5] It has been used to study conditions such as trachoma, avitaminosis A, dry eyes, and other disorders of conjunctival surface.[6] It is also useful in the study of ocular surface malignancies. An important shortcoming of this procedure is that it can deliver only 2–3 layers of tissue. The other drawbacks are lesser information of the background tissue matrix and inability to differentiate between carcinoma in situ and invasive carcinoma. It also requires a special paper called as “cellulose acetate.”[5]

FNAC plays a vital role in deeper orbital lesions, intraocular lesions, or cystic lesions.[2],[3],[7] It can also be used for superficial malignancies, but it is difficult to use it over smaller and flatter lesions, for which scrape cytology is a better procedure.

Scrape cytology of conjunctiva has been used to diagnose and score dry eye conditions. However, the most important role of scrape cytology is for the diagnosis and follow-up of ocular surface malignancies.[8] Though considered as traumatic, it is done easily as an outpatient department procedure. The tissue yield is better, and it saves an invasive incisional biopsy surgical procedure. The procedure is very safe, and complications are rare. When done with proper techniques and under aseptic precautions, pain is negligible and the chances of infection are almost none.

We report three patients who underwent scrape cytology examination of different lesions, and hence correct presumptive diagnosis were made.


  Case Report Top


The first case was a 35-year-old female presenting with a right upper lid nodular mass [Figure 1]. The clinical appearance of the mass favored the diagnosis of sebaceous gland carcinoma (SGC) [Figure 2]a and [Figure 2]b. However, patient's age did not correspond with the diagnosis. The mean age for diagnosis of SGC is mid-sixties, although exceptions are possible. Scrape cytology procedure was performed with samples taken from over the palpebral conjunctiva under the nodule. The report was SGC [Figure 3]. Wide local excision of the mass with frozen section was done. The lid was reconstructed with Cutler beard surgery after the margins were confirmed negative on frozen section [Figure 4]. Punch biopsies were also taken and reported negative subsequently. Patient is doing well on subsequent follow-ups for the last 2 years.
Figure 1: Nodular mass on right upper lid embedded in tarsus

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Figure 2: (a) Some surface vessels as well as loss of lashes seen. (b) Conjunctival surface of lesion showing yellowish material. Scrape taken from conjunctival surface

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Figure 3: Papanicolaou stained smear with ×200. Smears show singly occurring and sheets of benign metaplastic cells and columnar cells. Pagetoid spread is present. Also seen are sheets and clusters of atypical cells with enlarged hyperchromatic pleomorphic nuclei with intranuclear and cytoplasmic vacuoles. Squamous differentiation and necrosis is not seen

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Figure 4: Mass excision with frozen section and Cutler beard surgery

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Second case is a 22-year-old male, a known case of xeroderma pigmentosum [Figure 5]. Patient had a history of left eye conjunctival mass excision, which was reported squamous cell carcinoma (SCC) in histopathology.[9] He had received strontium plaque brachytherapy. When the patient presented to us, on examination, the conjunctiva was dry and lusterless. There were suspicious looking dilated vessels over conjunctiva [Figure 6]a and [Figure 6]b. Whole body had hypo- or hyper-pigmented spots. Though there was no obvious mass lesion in the eyes, bulbar conjunctival scrape cytology was performed to rule out microscopic or precursor lesions. Cytology was reported as “severe dysplasia” (corneo-conjunctival intraepithelial neoplasia Grade 3 [CCIN III]) [Figure 7]. Patient was given mitomycin C 0.04% eye drops four times a day as treatment. Scrape cytology was repeated after 3 months and which showed “moderate dysplasia” (CCIN II) [Figure 8]. Patient had been advised mitomycin C eye drops for another 6 months. After 6 months, repeat scrape was performed which was reported negative.
Figure 5: Case two is a known case of xeroderma pigmentosum

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Figure 6: (a) Dilated conjunctival vessels (b) dry, lusterless conjunctiva. Pigmented eye lids

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Figure 7: Papanicolaou stained smear with ×200. Smears show clusters and singly occurring squamous metaplastic cells, few polymorphs and red blood cells. Occasional group of cells with enlarged hyperchromatic nuclei, raised nuclear cytoplasmic ratio, nucleoli seen

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Figure 8: Papanicolaou-stained smears with ×40 and ×200, respectively. Smear show groups of squamous cells with hyperchromatic nuclei and scanty cytoplasm. Mild pleomorphism is noted. Few loose aggregates of regenerative squamous cells are also seen

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The third case was an 18-year-old male presenting with an ulcerated lesion on the right lower lid since 2 months [Figure 9]. The patient was a known case of acute lymphoblastic leukemia. He was undergoing chemotherapy and regular follow-up at tertiary cancer center.[10] Patient was advised for scrape cytologic examination and subsequent management. However, the patient defaulted and returned with a larger ulcerated lesion involving both lids medially and medial canthus after 1 year [Figure 10]. Scrape cytological smears were taken from the skin lesion and sent for examination. Report was positive for SCC [Figure 11].
Figure 9: Nodulo-ulcerative lesion on lower lid

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Figure 10: Lesion increased in size as patient defaulted

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Figure 11: Papanicolaou-stained smear with ×200. Smears show few singly occurring and groups of squamous cells with dense orangeophilic cytoplasm and enlarged hyperchromatic nuclei. Some show irregular nuclear borders and nuclear pleomorphism. Degenerating changes are noted

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The procedure of scrape cytology is described here. The patient was explained in detail about the procedure, and a written informed consent is obtained. The patient was made to sit comfortably on a slit lamp, and topical anesthesia was administered by use of proparacaine hydrochloride 0.5% eye drops.

Under aseptic precautions, 15 number blade was used to scrape the lesion. This is done with at least three different blades; in three different areas of the lesion. The tissue scrape on the blades was applied on albuminized labeled slides in gentle circular motion to make a smear [Figure 12]. Slides were immediately fixed in 95% ethanol for Papanicolaou staining and transported in a Coplin jar to the cytology department [Figure 13]. Antibiotic eye ointment was applied and eye patched. Patient was instructed to remove the patch after reaching home and use antibiotic eye drops for 5 days. Subsequent staining and reporting was done by the cytopathologist.
Figure 12: (a) 15 no. blade for scrapping lesion (b) diamond pencil for marking slides (c) Coplin jar for carrying fixative and slides

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Figure 13: (a) Slides (b) labeling of a slide with diamond pencil (c) making of a smear

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In centers lacking adequate facilities, smears can be air dried and later stained with Giemsa stain. Apart from surgical blades, spatulas, and cytobrushes can also be used.


  Discussion Top


Scrape cytological assessment is a powerful tool in the hands of an ophthalmologist to differentiate, diagnose, and monitor diseases, especially malignancies. It is quick, easy, and cheap. It is comparatively less invasive and allows better assessment of tissue.

It has a distinct advantage in cases of malignancies as a presumptive diagnosis is readily possible. Along with clinical judgement, a presumptive diagnosis is very helpful in formulating an effective surgical plan.

In our first case, the upper lid nodule was diagnosed as sebaceous carcinoma. Sebaceous cell carcinoma is an aggressive tumor which is known for pagetoid spread and multicenter appearance. It can masquerade as other conditions as chalazion, chronic blepharitis, keratoconjunctivitis, basal cell carcinoma, and SCC.[7],[8] As a result, it can go undiagnosed for a long time. Hence, it can lead to local recurrences and distant metastasis. With the preliminary diagnosis of sebaceous carcinoma in hand, treatment could be planned more efficiently. Conjunctival punch biopsies were taken from different quadrants, which turned out negative. We could also communicate better with the pathology department. This patient shall be followed up regularly with scrape cytology, as sebaceous cell carcinoma is known for recurrences.[8]

The second patient did not have an easily obvious lesion, and hence it could have been easily overlooked. Scrape cytology has the advantage to help screen invisible precursor lesions. Xeroderma pigmentosum patients are predisposed to recurrent malignancies of sun exposed parts such as basal cell carcinomas, SCCs, and less frequently malignant melanomas of the ocular surface.[9] Scrape cytology is preferable to multiple punch biopsies in xeroderma pigmentosum as scarring can be minimized. We believe that scrape cytology can be a boon for patients who are predisposed to recurrent ocular surface malignancies.

Our third patient had a skin lesion at medial canthus. With the use of scrape cytology, a tissue biopsy could be avoided, thereby saving costs and morbidity. A tissue biopsy requires anesthesia, leads to more ulceration, scarring, and an increased risk of spread of malignancy. Hence, for superficial skin lesions, scrape cytology can be of great help. It is speedy, safe, fairly accurate, and less expensive.

Occasionally, the biopsy reports obtained after surgical excision may not match the previous cytology report. False positives and false negatives can be minimized by using proper techniques. Proper procurement of tissue sample, correct technique for making smears, quick transfer of slides, and proper staining is essential. There should be excellent communication between the pathologist and the clinician. Presence of both the cytopathologist and the clinician at the time of procedure is desirable.

Limitations of the procedure are the presence of “air drying artifacts,” which interfere with the evaluation.[2] This happens when the smears are not immediately fixed in alcohol and transferred to the lab. Another reason is the presence of too many inflammatory cells in the collected sample, obscuring actual findings. Hence, proper history and meticulous examination are vital for correct reporting. Moreover, the lesion might bleed at the time of scraping, which can lead to red blood cells flooding the sample and obscuring the abnormal cells. In such cases, scrape procedure can be repeated.

Certain conditions such as keratinizing lesions pose diagnostic challenge to the cytopathologist. Too much keratin can obscure malignant cells. Reactive hyperplasia due to infection or inflammation can also mimic malignancy. Topical chemotherapy and radiotherapy can also induce changes in the tissue resembling malignant changes.[2] A cytopathologist has to be very methodical, meticulous, and observant to look for signs of malignancy.

In short, scrape cytology is evolving as an important investigative modality for all kinds of ocular surface lesions.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Hajdu SI, Ehya H. Foundation of diagnostic cytology. Ann Clin Lab Sci 2008;38:296-9.  Back to cited text no. 1
    
2.
Al-Abbadi MA. Basics of cytology. Avicenna J Med 2011;1:18-28.  Back to cited text no. 2
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3.
Sanderson TL, Pustai W, Shelley L, Gelender H, Ng AB. Cytologic evaluation of ocular lesions. Acta Cytol 1980;24:391-400.  Back to cited text no. 3
    
4.
Everts RJ, Barnett T, Lahood BR. The utility of routine conjunctival swabs in management of conjunctivitis. N Z Med J 2011;124:64-71.  Back to cited text no. 4
    
5.
Sen S, Lyngdoh AD, Pushker N, Meel R, Bajaj MS, Chawla B. Impression cytology diagnosis of ulcerative eyelid malignancy. Cytopathology 2015;26:26-30.  Back to cited text no. 5
    
6.
Shrestha E, Shrestha JK, Shayami G, Chaudhary M. The conjunctival impression cytology between the diagnosed cases of dry eye and normal individuals. Nepal J Ophthalmol 2011;3:39-44.  Back to cited text no. 6
    
7.
Maheshwari R, Maheshwari S, Shekde S. Role of fine needle aspiration cytology in diagnosis of eyelid sebaceous carcinoma. Indian J Ophthalmol 2007;55:217-9.  Back to cited text no. 7
[PUBMED]  Medknow Journal  
8.
Arathi C, Vijaya C. Scrape cytology in the early diagnosis of eyelid sebaceous carcinoma. J Cytol 2010;27:140-2.  Back to cited text no. 8
[PUBMED]  Medknow Journal  
9.
Halkud R, Shenoy AM, Naik SM, Chavan P, Sidappa KT, Biswas S. Xeroderma pigmentosum: Clinicopathological review of the multiple oculocutaneous malignancies and complications. Indian J Surg Oncol 2014;5:120-4.  Back to cited text no. 9
    
10.
Maule M, Scélo G, Pastore G, Brennan P, Hemminki K, Tracey E, et al. Risk of second malignant neoplasms after childhood leukemia and lymphoma: An international study. J Natl Cancer Inst 2007;99:790-800.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13]



 

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