Introduction
The eye is a unique sensory organ which exhibits diverse histologic structures. The knowledge of normal ocular anatomy spectrum of pathologic changes that involve these structures is necessary. The rarity at which these lesions occur complicates the recognition of their fine sometimes subtle presentation. Furthermore, clinical signs symptoms of ocular malignancies simulate more commonly occurring benign conditions which pose great difficulties both for treating clinicians experienced pathologists. Also, there exists a variation in pattern frequency on the basis of geographical locations.1
The present study is undertaken at our institute, to evaluate the histomorphological spectrum of lesions of entire eyeball and ocular adnexa, classify tumours tumour-like lesions of eye its adnexa on the guidelines of World Health organization and compare our results with other studies.
Materials and Methods
The present study included the 80 cases of tumours tumour like lesions in the eye its adnexa, in our institute during June 2013 to October 2015.
The surgical specimens were received for histopathological diagnosis, the clinical assessment; nature extent of lesion were studied in each case prospectively. Materials used for the histopathological study were received in 10% formalin. Specimen’s received in the form of 1. Biopsy 2. Resected specimen 3. Enucleated eyeball.
Enucleated eyeball
Fix the intact ocular globe in formalin for 24 hours before sectioning.
Wash in running tap water for 1 or more hour optionally, place in 60% ethyl aclohol for few more hours.
Measure the anteroposterior, horizontal vertical diamensions of the globe, length of the optic nerve horizontal diamensions of the cornea.
Open the eye with sharp razor blade by holding the globe with left h, cornea down against the cutting block blade between the thumb middle finger of the right h. Open the eye with a sawing motion from back to front; the plane of the section should begin adjacent to optic nerve end through periphery of the cornea.
Examine the inferior of the globe.
Place the eye flat on its surface, make a second plane of section, parallel to the first, again passing from back to front.
Examine carefully the ~8mm disc shaped slab thus obtained, which should contain the cornea, pupil, lens optic nerve.31 The sections were examined microscopically, special stain done wherever necessary.32
Observations and Results
The present study includes 80 cases of the tumours tumour like lesions in eye its adnexa from June 2013 to October 2015.
Figure 1
Pie diagram Showing the lesion wise distribution of tumours tumour like lesions of eye its adnexa (n=80).
Maximum number of cases are of malignant tumours 44(55%) followed by tumour like lesions 24 (30%) benign tumour 12 (15%).
Table 1
Showing site wise distribution lesions (n=80).
| Type of lesion | Eyelid | Conjunctiva Cornea | Intraocular | Orbit | Total |
| Tumours like | 21 | 01 | - | 2 | 24 |
| Benign | 06 | 05 | - | 1 | 12 |
| Malignant | 16 | 10 | 17 | 01 | 44 |
| Total | 43(53.75%) | 16(20%) | 17(21.25%) | 04(05%) | 80 (100%) |
Table 1 shows that maximum number of cases were seen in the eyelid 43 (53.75%), followed by intraocular 17(21.25%), conjunctival cornea 16 (20%) minimum number i.e. 04 (05%) cases of orbit. No case of lacrimal gland its drainage system was found.
Table 2
Showing the sex wise distribution lesions (n=80).
| Type of lesion | Male | Female | Total (Percentage) |
| Tumour like lesion | 13 | 11 | 24 (30%) |
| Benign tumour | 08 | 04 | 12 (15%) |
| Malignant tumour | 20 | 24 | 44 (55%) |
| Total | 41 | 39 | 80 (100%) |
Table 2 Shows that males are more affected than female in tumour like benign lesions. While females are more affected than males in malignant tumours. Overall males are affected more than females in tumours tumour like lesions. Male to Female ratio is 1:09.
Table 3
Showing age wise distribution of lesions.
Table 3 shows that tumour like lesions are more frequently observed in 1st - 2nd decade benign lesions were common in 2nd decade (3 cases, 25%) followed by 5th, 6th , 7th decade (2 cases each, 16.6%).
Malignant lesions were common in 1st decade (13 cases, 29.5%) followed by 4th, 5th decade (7 cases each, 15.9%).
Our study shows the maximum number of malignant cases occur in the 1st decade followed by 4th decade.
Study shows that, the common clinical presentation of patients in tumours tumour like lesions were the swelling over eyelid in 41 patients (51.25%) followed by swelling over conjunctiva cornea 16 patients (20%) ,diminution of vision in 24 patients (30%) proptosis in 14 patients (17.5%). Patients with malignant tumours show commonest presentation with proptosis diminution of vision in 30 patients (37.50%)).
Retinoblastoma clinically presented with white pupillary reflex, proptosis diminution of vision. The patients of benign tumours of eye its adnexa clinically presented with swelling over eyelid 6 patients (7.5%), diminution of vision in 2 patients (2.5%), swelling over conjunctiva cornea 5 patients (6.25%) proptosis in 1 patient (1.25%). The patients of tumour like lesions clinically presented with swelling over eyelid 22 patients (27.5%), swelling over conjunctiva cornea in 1 patient (1.25%), proptosis in 3 patients (3.75%) diminution of vision in 2 patients.
Figure 2
Tumor Like Lesion: Inflammatory PseudotumorA. Patient photograph showing diffuse swelling & redness of right eye. B: Photomicrograph showing extensive lymphocytic infiltrate forming germinal center like areas along with infiltration by polymorphs & eosinophils. [H & E 400X]
Figure 3
Malignant Tumor: RetinoblastomaA: Patient photograph showing 3 years old male child with gungating growth & proptosis in the left eye. B: Gross photograph of cut section of the eyeball with growth. C: Photomicrograph of section tumor mass showing round to oval cells with hyperchromatic nuclei & scanty cytoplasm forming rosettes. [H & E 400X]
Figure 4
Malignant Tumor: Malignant fibrous histiocytomaA: Patient photograph showing growth in the left eye destroying the eyeball. B: Gross photograph of eyeball showing nodular greywhite tumour mass. C: Photomicrograph of section of tumour mass showing plump spindle cells with pleomorphic nuclei arranged in fascicles & storiform pattern [ H & E 400X]
Figure 5
Malignant Tumor: A: Patient photograph showing pearly grey-black nodule over upper eyelid. B: Photomicrograph of section of nodule showing islands of basaloid cells with peripheral palisading & haphazard arrangement in the center [H & E 400X]
Discussion
The present study of tumours tumour like lesions in eye its adnexa was done in Department of Pathology, Govt Medical College, Auranagabd (M S) India. We encountered 80 cases from June 2013 to October 2015.
Of these 80 cases, malignant tumours are 44(55%) followed by tumour like lesions 24 (30%) benign tumour 12 (15%), including 41 males (51%) 39 females (49%).
Table 4
Shows comparison between types of lesions.
Our study is comparable with of the study of Coroi M. et al (2010).4 While other two studies of Reddy CS.et al2 and Halon A.et al3 show variable range of lesions.
Table 5
Shows sex wise distribution of different lesions
In our study male is more affected than female (1:09). This is comparable with studies of Reddy C.S et al,2 Halon A.et al3 Coroi M. et al.4
We found 13.7% cases of dermoid cyst. This is comparable to studies of Reddy C.et al,2 Chauhan S.et al5 Bastola P. et al6 i.e. 14.60%, 12%, 12% respectively.
We noted 10% cases of epidermal cyst which is similar with studies of Domingo R. et al,7 Chauhan S.et al5 Bastola P.et al6 i.e. 7.47%,7.47% 10% respectively.
We found 2.5% cases of sebaceous cyst where Coroi M. et al4 noted 6.3% cases which is nearer to our study.
We found 2.5% cases of inflammatory pseudotumour, while studies of Roh KK. et al,8 Shaikh I.et al9 Domingo R. et al7 shows similar findings i.e. 2.8%,2.31% 2.38% respectively.
Intradermal naevus was found in 1 patient (1.25%) variable incidence reported by other studies, because of less sample size studied.
Squamous cell papilloma was found in 1 patient (1.25%), Similar incidence of 2.8%, 2.77%, 2% 2% reported by Roh KK. et al,8 Shaikh I.et al9 Chauhan S.et al5 Bastola P.et al (2013)6 respectively.
Haemangioma was found in 4 patients (05%), which is nearer to incidence of 2%, 2.24%, 2.94% reported by Roh KK. et al2, Reddy C.et al2 Domingo R. et al7 respectively.
Lipoma was found in 1 patient (1.25%), while similar incidence of 2%, 0.9%, 1% 1% reported by Roh KK. et al,8 Shaikh IY.et al,9 Chauhan S.et al5 Bastola P.et al6 respectively.
So intradermal naevus is more common followed by sqaumous papillom, haemangioma lipoma in our study.
Pterygium was found in 4 patients (25%), while variable incidence of 10% reported by Elshazly L.et al.10
Table 6
Malignant tumours of eye its adnexa.
Basal cell carcinoma was found in 7 patients (8.75%). Similar incidence of 6 cases (10.2%) reported by Kumar R et al.11
Squamous cell carcinoma was found in 13 patients (16.25%). Similar incidence of 29 cases (13.42%) reported by Shaikh I.et al.9
Sebaceous carcinoma was found in 4 patients (05%). Similar incidence of 4.4%, 3.86%, 5% and 5% noted by Roh KK. et al,8 Domingo R. et al,7 Chauhan S.et al13 Bastola P et al6 respectively.
Malignant malanoma was found in 4 patients (05%), Similar incidence of 3 cases (5.1%) 8 cases (3.7%) reported by Kumar R et al,11 Shaikh I.et al.9
Retinoblastoma was found in 13 patients (16.25%), similar incidence of 40 cases (16%) reported by Roh KK et al.8
We found that retinoblastoma is most common malignant tumour followed by Squamous cell carcinoma, sebaceous carcinoma basal cell carcinoma.
The conjunctival corneal lesions were seen in 16 (20%) cases. While similar incidence of 20.37%, 22% 16% reported by Shaikh I.et al,9 Chauhan S.et al5 respectively 16% reported by Domingo R.et al.7
In our study intraocular tumours were having an incidence of 21.25%, which correlates with the study of Shaikh I.et al9 Domingo R.et al7 who noted incidence of 24.53% 25% respectively.
The orbital lesions comprise of 5% of all eye its adnexal tumours. The same finding of 3% reported by Reddy SC et al2 8% reported by Chauhan S.et al.5 While variable incidence by Shaikh I.et al9 Domingo R.et al7 has reported 17.1% 24.07% incidence of primary orbital tumors.
Present study shows age incidence in 2 years to 75 years of age. Maximum number of cases of malignant tumours was observed in first decade of life, because retinoblastoma occurs commonly in first decade of life. Similar findings had been reported by Reddy C.S. et al,2 Das SP12 Duke-Elder S.13
In the present study 41 cases (51.25%) were seen in males 39 cases (48.75%) in females which shows equal male to female ratio i.e. 1:0.9. Reddy C S.et al2 Halon A.et al3 Coroi M. et al4 showing male female ratio 1:0.9, which is similar to present study.
Tumours and tumour like lesions of eyelid:
In the present study, the tumours tumour like lesions of eyelid comprises of 43 cases (53.75%). Similar incidence is recorded by Reddy C.S.et al2 Chauhan S.et al5 who reported the incidence of (51%) (57%) respectively.
Out of 43 cases, tumour like lesions were 21 (26.25%) cases, benign tumours were 6 cases (7.55%) the malignant tumours were common having 16 cases (20%). Reddy C S.et al2 studied 89 cases found 8(8.9%) of benign, 5 (5.6%) caese of malignant 32 (35.9%) cases of non neoplastic tumour like lesions in which tumour like lesions is more commom than malignant benign lesions. Chauhan S. et al5 observed that benign lesions were more common than malignant lesions.
We found 25.58% cases of dermoid cyst, same is observed by Reddy C S.et al,2 Bastola P.et al6 who also found dermoid cyst in range i.e. 28.8% 21%, Roh KK.et al8 shows variable finding i.e. 10(13.69%).
Similarly we found 18.6% cases of epidermal cyst which is comparable with studies of Bastola P.et al6 who found 14%. Roh KK.et al8 Reddy CS.et al2 shows variable finding i.e. 2(3.8%) 4(8.8%) respectively.
We noted 4.6% cases of sebaceous cyst, similarly Coroi M. et al4 who found 6.3% cases
Intradermal naevus was found in 1 patient (2.3%) of all lesions of eyelid. Variable incidence reported by above given studies.
Squamous cell papilloma was found in 1 patient (2.3%) of all lesions of eyelid. Similar incidence of 2.3% reported by Ramya BS. et al.14
Haemangioma was found in 4 patients (9.3%) of all lesions of eyelid. This is variable with the studies incidence of 3.8%, 4.4%, 18.6% 1.3% reported by Roh KK. et al,8 Reddy CS.et al,2 Ramya BS. et al14 Domingo R. et al7 respectively.
A case of haemangioma was reported in 2nd to 8th decade of life, similarly Aurora Boldi,15 showing incidence of haemangioma in 1st decade to 6th decade of life. Among the eyelid benign tumours age incidence was more in 6th 8th decade of life.
Table 7
Shows malignant lesions among total eyelid lesions.
Now tha Basal cell carcinoma was found in 7 patients (16.27%), Similar incidence of 772 cases (15.49%) reported by Drepez et al.16
Squamous Cell Carcinoma was found in 3 patients (6.97%), Similar incidence of 10 cases (6.45%) 29 cases (6.97%) reported by Kumar R.et al11 Domingo et al7 respectively.
Sebaceous carcinoma was found in 4 patients (9.30%), Similar incidence of 5 (8.7%), 15(9.67%), 4(9.30%) 5(8.7%) reported by Chauhan S.et al5, Kumar R.et al,11 Domingo R. et al,7 Bastola P. et al6 respectively.
Table 8
Shows malignant lesions among malignant eyelid lesions
It is noted that the commonest malignant tumour of eyelid is basal cell carcinoma, accounting for 75% Reddy C et al,2 21% Halon et al,3 69%Font et al,17 86% Deprez et al16 (43.75%) in the present study.
The basal cell carcinoma to squamous cell carcinoma ratio in present study is 2.3:1. Similarly observed by Reddy C.S., et al2 , Halon et al3 , Font et al,17 Deprez et al.16
The incidence of sebaceous carcinoma is (25%) which is variable finding of 14% of Font et al (1978).17
Tumours and tumours like lesions of conjunctival cornea
16 cases of conjunctival corneal tumours tumour like lesions were found, comprising 20% of all eye tumours. Similar incidence of 20.37% 22.7% of eye tumours as reported by Shaikh I.et al,9 Chauhan s.et al5 Domingo et al7 got 16%.
Out of 16 cases there was 01(1.25%) case of tumour like lesions, benign tumours were 05(6.25%) the malignant tumours were 10 (12.5%). Reddy C.et al2 studied 45 cases of eyelid lesion found 2 (2.24%) of benign, 2(2.24%) cases of malignant 24(26.9%) cases of non neoplastic tumour like lesions in which tumour like lesions is more commom than malignant benign lesions. Where as in our study malignant lesions more commom than benign tumour like lesions. Chauhan S.et al5 observed that benign lesions were more common than malignant lesions.
In malignant tumours age incidence ranged from 3rd decade to 7th decade. Sundarraj P. et al16 reported an age incidence ranging from 4th to 8th decade. Male to female ratio reported by Das12 is 2.3:1, while Sundarraj P. et al18 reported 1.1:2 showing higher incidence in male, while in the present study the male to female ratio is 1:1.6.
Conjuctival cyst was found in 1 patient (6.25%) of all lesions of conjuctiva. Similarly reported by Roh KK.et al8 , Chauhan s.et al5 Bastola p.et al6 .i.e. 2(4.6%), 1(4.5%) 1(4.5%) respectively.
In the present study age incidence of conjuctival cyst is in 1st decade, same is seen with Reese19 Das,12 with male predominance, similar to that of Sunderraj P. et al,18 and Ash.20
Lipoma was found in 1 patient (6.25%) of all lesions of conjuctiva. Similar incidence of reported by Roh KK.et al8 Ramya BS.et al14 Shaikh I et al9 i.e. 5(6.9%), 4(4.65%) 2(4.5%) respectively.
Pterygium was found in 4 patients (25%) of all lesions with variable incidence of 10% reported by Elshazly L.et al.10
Squamous cell carcinoma was malignant tumour found in 10 patients (62.5%) of all lesions of conjunctiva, Similarly 29 cases (65.90%) reported by Shaikh I et al9 31(52.54%) reported by Kumar R.et al.11
Squamous cell carcinoma is the single most common entity found in malignant tumours of conjunctiva cornea comprising 100% of conjunctival corneal malignancies. A similar incidence has been reported by Kumar R.et al,11 Das12 Sunderraj P. et al.18
The age incidence ranged from 3rd to 7th decade with an average age of 45 years, in the present study, similarly 44.3 years reported by Das.12
Male to female ratio reported by Ash Wilder20 was 5.2:1 Das12 reported male to female ratio being 17:1 but in the present study it is 0.2:1.
All patients presented with a small painless nodular swelling over conjunctiva, similarly it is reported by Reese,19 Duke-Elder13 Nath K and Gogi.21
In the present study 5 tumours were situated over the limbus it is the most frequently encountered site of carcinoma due to transition of epithelium as reported by Reese,19 Duke-Elder13Nath K and Gogi.21
In the present study the intraocular extension was seen in a single case same is noted by Nath K and Gogi21 Yanoff and Zimmerman.22
No tumour tumour like lesions of lacrimal gl its drainage system was found in the present study, same nas been reported by Das12 Ryan Font.23
Intraocular tumours and tumour like lesions
17 cases of intraocular lesions comprising of 21.25% of all eye its adnexal tumours, similar to the incidence of 24.53% 25% reported by shaikh I et al9 Domingo R.et al7 respectively.
Among all lesions of intraocular, the malignant tumours were 17(21.25%), Roh KK. et al8 noted 49 cases found (19.6%) cases which is similar to our finding. Chauhan S.et al5 observed 8(8%).
In the present study age ranges from 1 to 70 years, similar to age incidence reported by Das.12 Males were more affected than females showing male to female ratio 1.4:1 which is similar to 1.5:1 reported by Das.12
In the present study retinoblastoma is the commonest malignant intraocular tumour having incidence of 76.47% of all intraocular tumours. Roh KK et al8 reported 81% of retinoblastoma which is nearer to our study. Nath K and Gogi21 reported 97.06% in his study, which did not match with our study.
The retinoblastoma comprises 23.5% of all eye adnexa tumours, which is nearer to 25% as reported by Belagavi.24 Out of 17 intraocular tumours, 13 cases (76.47%) were of retinoblastoma, which indicate that it was the most common intra ocular tumour in the present study.
Table 9
Showing the comparison of age distribution of retinoblastoma in different studies.
| Age in years | Devesa SS25 | Dhir et al26 | Present study(2015) |
| 0-1 | 18 | 01 | 01 |
| 1-2 | 22 | 05 | - |
| 2-3 | 10 | 09 | 06 |
| 3-4 | 06 | 11 | - |
| 4-5 | 03 | 12 | 06 |
| 5-6 | 01 | 04 | - |
| 6-7 | - | 05 | - |
| 7-10 | 01 | - | - |
In the present study the age of youngest patient was 10 months eldest was 5 year. Maximum cases of retinoblastoma were observed in 2-3 4-5 years of age group in the present study. These findings are comparable with Dhir et al.26
Average age 3.3 years as observed in the present study is similar to 3.3 year reported by Belagavi,24 3.5 reported by Das.12
The present study showed male to female ratio 1.6:1. It is similar to that of Shrikande SS,27 Dhir and Jain.26
In the present study proptosis was seen in 60.6%, same is noted by Dhir and Jain.26 White pupillary reflex 65.6% was seen, which is similar to Howard et al,28 impaired vision in 40%.
Table 10
Showing the comparison of site distribution in retinoblastoma
| Authors | Right eye | Left eye | Bilateral |
| Das12 | 37.85% | 35% | 27.15% |
| Munier F L et al29 | 40.5% | 52.2% | 7.3% |
| Present study (2015) | 53.84% | 38.46% | 7.6% |
In the present study the right eye involvement was seen in 53.84% which is higher than the findings of other authors. Left eye involvement was seen in 38.46% of cases which is nearer to 35% as observed by Das12 bilateral involvement was seen in 7.6% cases, same is noted by Munier F L et al.29
In our study we found 23.52% cases of malignant melanoma. This is comparable to studies of Shaikh I et al,9 Chauhan S et al5 who also found 15% and 15.38% respectively. Where as Domingo R et al7 who also found 9.6% cases which is less than our finding.
In the present study the incidence ranges from 3rd to 7th decade. The average age of patients was 48 years as recorded by Duke-Elder.30 Yanoff Zimmerman22 recorded the average patient's age 56.3 years with a range from 27-84 years.
Tumours and tumour like lesions of orbit
In our study 4 cases (05%) of orbital tumours and tumour like lesions were found. Out of which 2 (2.5%) cases, we found benign malignant cases 1(1.25%) for each. As compared with Chauhan S.et al (2009)5 who shows similar finding.
The age incidence ranges from 11 to 50 years maximum lesions were seen in the first four decades of life. This is similar with Yanoff Zimmerman.20 Higher numbers of cases were found in males, similarly Das12 Nath and Gogi21 reported male predominance.
We found 50% cases of inflammatory pseudotumour. This is comparable to studies of Nath K.et al21, Roh KK. et al8 , Shaikh I.et al9 who also found variable percentage of cases of Inflammatory pseudotumour.
It constitutes 10-50% of all orbital lesions seen in 2nd 4th decade of life, presented with exophthalmos pain. Similar findings were reported by Narla L.D et al.31
In present study fibroma is benign tumour constituting 1.25% of all eye lesions appears in 10 year old chlild, similar finding was reported by Mortada A.et al.32
Our study shows that NHL was found in 1 patient (25%), similar incidence of 21.6%, 25.4% reported by Shaikh I.et al9Domingo R.et al7 respectively.
In the present study the case was found in 4th decade of life with rapid unilateral proptosis. Showing female predominance, similar findings were observed by Essadi I et al.33
Conclusions
The histopathological examination is absolutely mandatory for definitive diagnosis and management. The early diagnosis proper treatment of these tumours may predict favorable prognosis.
In general, early diagnosis prompt surgical intervention followed by radiotherapy chemotherapy can result in either cure or good survival rates in ocular malignancies.
As the eye is the delicate important vital organ in the body, the special attention should be given in any form of functional or symptomatic abnormality with expert opinion which will preserve eye and its adnexa. Most of the patients came from rural area which are illiterate take home remedies, which may result in complications loss of eyesight.
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