ABSTRACT
Setae refer to stiff structures resembling a hair or a bristle, especially in an invertebrate. The caterpillar hairs are also referred to as caterpillar setae. These can have devastating effects on the eyes especially if they embedded themselves in the deep cornea tissues.
At Kitwe Teaching Hospital Eye Annex, a very rare case of caterpillar setae embedded in deep corneal layers was encountered. An 8-year-old female patient presented with painful/pricky sensation, lacrimation, red eye, photophobia and failure to open the right eye. Poor vision was noted in the Right Eye (RE). Slit Lamp examination revealed RE chemosis, hazy cornea and a lot of corneal foreign bodies (FB). Multistaged surgical FB removal was performed and medical management was instituted afterwards. Patient recovered well after treatment.
INTRODUCTION
Multiple Deep Corneal FBs refer to more than 8 FBs on or in the cornea. Among the rare corneal FBs that can injure the cornea, are caterpillar hairs (setae) which can get embedded deep in the corneal layers [1]. The caterpillar setae can cause severe ocular tissue reactions that can lead to significant visual disturbance if intervention is delayed [2]. The major treatment approach is surgical FB removal [3].
The prevalence of FB corneal injury due to caterpillar setae in Zambia is not known for there is nothing documented. Few cases have been reported on from African countries, but literature shows that there are many cases in the Eastern Mediterranean countries where there are farms that breed caterpillars [4]. Corneal FB due to caterpillar setae was known to be an occupational disease for being common among caterpillar farm workers, but currently it can occur in even non-caterpillar farming communities and in any age group. The caterpillars in the Eastern Mediterranean region are found on red pine trees on which they feed. These caterpillars are put in farms in order to limit their infestation in the red pine trees and to be destroyed by a trained bug that eats them (the so called Calasoma sycopanta).
Literature revealed that workers lacked protective wear as they were exposed to caterpillar setae in caterpillar breeding farms resulting in setae ocular trauma. The only well-known risk factor for intraocular penetration was found to be intracorneal caterpillar setae.
The first report of reactions caused by caterpillar setae was published by Schon in 1861 [5]. In 1904, Saemisch was the first to describe the granulomatous nodules found on the iris and conjunctiva caused by vegetation or insect hairs as ophthalmia nodosa [6]. Caterpillar setae ocular toxicity resulted from setae presence in the eye tissues which retain toxins [7,8]. The development of classification of ophthalmia nodosa was initiated by Cadera et al., (1984) [9]. There are five classifications which include:
Type 1. An acute toxin reaction to hair (chemosis and inflammation)
Type 2. Chronic mechanical keratoconjunctivitis caused by hair found in the bulbar or palpebral conjunctiva with foreign body sensation and corneal abrasions
Type 3. Formation of conjunctival granulomas due to subconjunctival or intracorneal setae
Type 4. Iritis secondary to hair penetration of the anterior segment
Type 5. Early or late vitreoretinal involvement due to penetration of the hair through the cornea, iris and lens or via transscleral route, vitritis, cystoid macular oedema, papillitis or endophthalmitis may occur.
The progression of such complications could be prevented by using protective wear to people exposed to such caterpillars. Avoidance of rubbing the affected eye could be considered to prevent further penetration. Then seeking early medical attention to be considered immediately eyes were exposed.
CASE SUMMARY
An 8-year-old female from the outskirts of Mpongwe District on the Copperbelt Province of Zambia came to Kitwe Teaching Hospital Eye Annex (KTHEA) with complaints of reduced vision, painful, pricky sensation, redness, photophobia and lacrimation in the RE for a day. The patient further complained of having developed eye problem while sleeping the night before she came to KTHEA. She was referred to KTHEA as a case of Conjunctivitis of unknown cause.
On examination, general condition of the patient was satisfactory apart from reduced vision in the RE of 6/36, while LE vision was 6/6. The RE was tearing, photophobic, had conjunctival injection, chemosis, caterpillar setae and corneal clouding noted during examination. Other findings were corneal abrasions, caterpillar setae on the tarsal conjunctiva and in the deep cornea. The LE was normal.
A diagnosis of deep corneal caterpillar setae was made, and patient was admitted for corneal FB removal under general anaesthesia through a multistaged surgical corneal FBs removal process. All the setae were successfully removed, and patient was commenced on topical steroid and antibiotic treatment.
DISCUSSION
Classically, patients with caterpillar setae corneal FB present with failure to open the eye, painful, red eye, pricky sensation, lacrimation, photophobia and FB sensation. The severity of these ocular manifestations is mainly based on the number of caterpillar setae embedded in the cornea worsen due to rubbing the affected eye. This action facilitates intraocular penetration and the eye happened to be increasingly traumatised [1].
Caterpillar setae on the cornea is a rare case but can occur anywhere in the world and in any age group. The complications that arose from caterpillar setae in this case were inflammation, chemosis, mechanical conjunctivitis as it has been reported in literature [9].
It is important that a careful history is taken from patients presenting with such signs to avoid misdiagnosis.
Health personnel should be aware of such manifestations of caterpillar setae trauma as there is no typical way of clinical presentation. Intracorneal caterpillar setae are very difficult to remove and a good number of them can remain unremoved [10]. Though caterpillar setae are difficult to remove, in this case the surgical removal was successful in two sittings and all the caterpillar setae were removed.
CONCLUSION
Caterpillar setae ocular trauma can occur in Zambia. It is possible to remove all the caterpillar setae through a thorough and well-planned surgical approach.
ABSTRACT
A female patient aged 30 years was brought to the University Teaching Hospitals – Eye Hospital (UTH-EH) complaining of poor vision in both eyes after suffering from Steven Johnson syndrome (SJS). On examination, visual acuity was hand movement (HM) in both eyes. The right eye (RE) had adhesions (symblepharon) of both upper and lower eyelids, haziness and cornea opacification, while left eye (LE) had a total permanent tarsorrhaphy with Osteo-Odonto-Keratoprosthesis (OOKP) at the centre.
INTRODUCTION
Corneal opacification is the second most common cause of blindness in the world affecting an estimated 10 million people [1]. Corneal blindness is far more prevalent as a result of ocular surface disease leading to corneal neo-vascularization and scarring. The blindness due to corneal scarring can be managed in various ways depending on the density of the scar [2]. The Osteo-Odonto-Keratoprosthesis (OOKP) is indicated for corneal lesions resulting from Steven Johnson Syndrome, trachoma, pemphigoid, trauma limited to the cornea and chemical burns [3].
Benedetto Strampelli described the original technique of OOKP nearly fifty years ago using the patient’s own tooth root and alveolar bone as a vital support to an optical cylinder. The OOKP also known as tooth in eye surgery is an auto graft used for the treatment of severe corneal opacities not suitable for corneal transplant [4,5]. A Kerato-prosthesis is used to replace damaged cornea [4,5].
Falcinelli et al., 1986, modified this technique in a stepwise fashion [6-9]. OOKP is a 2-stage operation. Stage 1 of the surgery involves 5 separate procedures. First the eye is opened up and the entire inner surface of the eyelids, corneal surface and all scar tissue is removed. Then the inner mucosal lining of the cheek is transplanted onto a new surface of the eye [10]. A canine or premolar tooth and part of the adjacent bone and ligaments are harvested. A bolt shaped structure is fashioned from the tooth-bone complex which is fitted with a plastic optical cylinder [11].
Stage 2 (about 4 months later) involves two separate procedures. The cheek mucosal lining over the eye is opened and the inner contents of the eye are removed. The tooth-bone-cylinder complex is harvested from the cheek and inserted into the eye; the mucosal cheek lining is placed over the implant. At the end of the procedure, light can now enter through the plastic cylinder and the patient is able to see through this cylinder with good vision [12-14].
The cornea is replaced by a polymethyl methacrylate (PMMA) optical cylinder glued to a biological support (haptic) made from human living tissue. Currently available KPro (kerato- prosthesis) devices range from totally synthetic such as the Boston KPro, to the totally biological tissue engineered artificial cornea [15]. The OOKP combines both a synthetic optic with a biological haptic [16]. The OOKP is a true heterotopic auto graft made of living long lasting human tissue.
CASE SCENARIO A female patient aged 30 years presented to the UTHs-EH complaining of poor vision in both eyes. The patient gave a report of having reacted to anti-tuberculosis drugs while in Zambia. After being diagnosed with SJS in 2016, she sought medical advise in the United States of America (USA) where OOKP was conducted successfully on the left eye and vision improved and was able to carry out normal activities. In May 2019, she noticed that her vision was gradually decreasing. she later presented to UTHs – Eye Hospital with poor vision 6 months later. On examination, there was an obvious symblepharon in the right eye and OOKP in the left eye (fig.1). The visual acuity in both eyes was hand movement (HM). On slit-lamp examination, the right eye had symblepharon of upper and lower eyelids and opacification of the cornea. The left eye had a total permanent tarsorrhaphy with Osteo-Odonto-Keratoprosthesis (OOKP). Fundoscopy of the LE showed optic disc cupping of about 0.9 cup disc ratio (CDR) whereas fundoscopy was not possible to perform in the RE due to the scarred cornea. The intraocular pressures were 18 mmHg RE and was not measured in left eye. The patient was started on acetazolamide (Diamox) 500 mg stat then 250 mg three times a day for three days.
Figure 1. The left eye after osteo-odonto-keratoprosthesis
The patient consented to have this case report published.
DISCUSSION
Osteo-Odonto-Keratoprosthesis is a vision restoring surgical technique where the patient’s opaque cornea is replaced with an artificial device. In this case, the patient had end stage corneal blindness and hence, OOKP was done on the left eye as a way of restoring her vision [11]. The optical device is made up of a PMMA (Polymethylmethacrylate) cylinder which acts as an artificial cornea. It is particularly resilient to a hostile environment such as the dry keratinized eye. Patients are advised to quit smoking and practice measures that will improve their oral hygiene so as to increase the chance of survival of the buccal mucous membrane graft. In this case the patient was neither smoking nor consuming alcohol. Therefore, the buccal mucous membrane could survive longer [12-14]. The success rate of the OOKP surgery vary from different studies, Lui C, et al (1998) reported excellent long-term retention of 85% in 18 years [3]. According to Herold et al., (1999), 80% of OOKP patients achieved improvement of vision [16]. Lui C, et al., (2005), stated that OOKP described by Falcinelli gives the best long-term results for visual acuity of 75% with 6/12 or better and retention of 85% for up to 18 years [15].
Follow up visits is life-long in order to detect and treat complications which include oral, oculoplastic, glaucoma, vitreo-retinal complications and extrusion of the devise [17]. Follow ups are done at weekly interval for 1 month, then monthly for six months, then every 2 months for six months, then every four months for stability of the prosthesis and intraocular pressure measurement. Once it is stable, follow up can be at longer intervals [10, 11]. In this case the patient did not adhere to follow up schedule and the doctors who performed the procedure did not forward the report to the doctors of the patient’s residence for effective follow up. So, when the vision started deteriorating, the patient could not be attended to promptly to establish what was causing that. There was also lack of communication between the primary OOKP team and the patient which created a huge gap for follow up. Therefore, the vision was not good as expected or it could be that the patient could have fallen in the 15% of OOKP patients reported not to have good vision by Lui et al., 2005.
Giancarlo et al., (2005), described the long term anatomical and functional outcome in 181 cases and the results indicated that modified OOKP surgery can provide favourable anatomical and function results, which are stable in the long term and retaining an intact OOKP was 85% [9]. Just as in this case, the patient retained good anatomical and functional of OOKP. Tan DT et al., 2008 treated 29 cases to restore sight with OOKP surgery and found excellent results without any instability problems or extrusion [6]. The OOKP in this case report was very stable and there were no signs of extrusion. Hughes et al., 2008, reported vitreo-retinal complications of the OOKP in a retrospective review of 35 patients after a mean 57 months follow up which revealed 9 vitreo-retinal complications in 8 patients (23%) [18]. In this case, there were no vitreo-retinal complications. Kumar et al., 2009, did a study to report diagnostic modalities and treatment options for glaucoma in 15 eyes that underwent OOKP surgery and they concluded that visual field testing and optic disc assessment with optic disc photographs seem to be effective methods to monitor glaucoma and treatment strategies include oral medication (acetazolamide 500mg twice a day) to lower intraocular pressure and cyclo-photocoagulation [19]. Due to inadequate follow up, the patient was not fully evaluated for glaucoma and as a result she ended up with a CDR of 0.9 in the LE.
The OOKP is considered the only devise capable of offering long term visual rehabilitation in patients with end-stage ocular surface disease and severe tear deficiency (with or without eyelid defect based on the studies of cases that were done before [5].
Thorough patient preparation physically and psychologically is required in order to have good results and to make patient understand the importance of follow up visits to the hospital in order to diagnose and manage post-operative complications early. Good general health and oral hygiene are important for this procedure to be successful. This technique demands the involvement of both dental and ophthalmic surgeons to complete the procedure [19].
Thus, it is necessary for both surgeons to understand the finer details of the procedure and its possible complications which can be avoided with adequate precautions during surgery and its timely follow up of the patients.
CONCLUSION
Osteo-Odonto-Keratoprosthesis is the ocular surgical procedure of choice for restoring sight in patients with end stage corneal scarring. Frequent follow up and good follow up plan for Osteo-Odonto-Keratoprosthesis is critical in order to diagnose and treat complications as early as possible so that restored vision is not lost.
Trichiasis a medical term for abnormally positioned eyelashes that grow back toward the eye, touching the cornea or conjunctiva. This can be caused by infection, inflammation, autoimmune disorders, congenital defects, eyelid agenesis and trauma such as burns or eyelid injury. Trachomatous trichiasis is the result of multiple infections from childhood with Chlamydia trachomatis, which causes recurrent chronic inflammation in the tarsal conjunctiva. This produces conjunctival scarring, entropion, trichiasis, and ultimately blinding corneal opacification. It is the leading cause of infectious blindness in the world.A 24-year-old female patient presented to Senanga’s Mata Rural Health Centre (RHC) where she was referred for eye check up due to a chronic eye condition she had. The patient was a confirmed psychiatric case. Examination revealed severe misdirected eyelashes, cornea opacities and tearing bilaterally. A diagnosis of Trachoma Trichiasis was made. Despite the mental illness, Trachoma Trichiasis surgery was performed successfully, and the patient healed well.
Introduction:
Trachoma is a disease of the eye caused by infection with the bacterium Chlamydia trachomatis which leads to Trichiasis after a chronic phase [1]. Trachomatous trichiasis (TT) is referred to asa cicatricial entropion of the upper eyelidwhichresults into inward turning of eyelashes rubbing on the cornea causing constant pain and light intolerance [2]. If Left untreated, this condition can lead to corneal ulceration resulting in corneal opacification and eventually visual impairment or blindness [3]. TT can affect anyone regardless of their mental state. Mentally ill patients tend to be uncooperative, restless, mobile, illogical and impulsive making it difficult to handle them [4]. While it is necessary to gain understanding that TT can occur in either mentally ill or sound patients, Tarsal Plate Rotation Surgery remains the reliable option for Trachoma Trichiasis Management in our Zambian setting [5].
Case Scenario:
A 24-year-old female mentally ill patient presented to Senanga District Health TT Case management team with complaints of loss of vision, painful eyes, tearing, headache, foreign body and pricking sensation in her eyes which had been there for more than eight years. The mental illness had also been there for eight years. The patient was the eighth and last-born child. The patient had had the eye condition for over 8 years for which she received traditional medicines and all sorts of concoctions such as herbs mixed with fertilizer or sugar. Whenever she visited the nearest health facility situated 25 km away, she was only given some unknown eye ointments. Despite her being a known psychiatric patient, she was not on any anti-psychotic treatment as access to a psychiatric facility was a challenge to the family.
On account of being a mentally ill patient, her mother consented for her surgery and use of her information in any medical/clinical publication.
Though difficulty to handle due to her mental state, her visual acuity was checked, and findings were; light perception in both eyes.
Other examination findings were; entropion, turned in eye lashes touching the globe (Figure 1), mucopurulent discharge, upper tarsi scaring, cornea opacities in both eyes, hyper photosensitivity and failure to open her eyes. The face was dirty, and she was generally in a poor state of hygiene. Her Blood Pressure was 110/70mmHg.
Fig1: Showing bilateral ectropion and house flies on the face
Considering her mental status, she was subjected to retroviral test and Rapid Plasma Reaction (RPR) in order to rule out other causes of mental illness. Both tests were negative.
She received her trachoma surgery after sedation with Diazepam intravenously. Both eyes were operated in one sitting in order to avoid going through the same challenges the next time. Local anaesthesia (lignocaine 2% with Adrenaline) was then infiltrated in her eyelids. Posterior Lamellar Tarsal Plate Rotation (Trabut) was successfully performed. After surgery, tetracycline eye ointment was applied in both eyes and thereafter padded for 24 hours. Painkillers were given to her and the following day the eye pads were removed. On her first day post operatively, her visual acuity improved to hand movements. One week follow up was done and her visual acuity was 6/36 in both eyes. A week after surgery, the patient seemed oriented in time and place although she exhibited inappropriate behaviour and she was a bit cooperative and calm. The TPR surgery outcome was successful as shown in figure 2 below.
Fig 2: Showing successful outcome of TPR surgery at 2 weeks
Discussion:
Classically, the sequalae of trachoma trichiasis is visual impairment due to cornea opacities [6]. The patients with TT who are mentally stable are easier and straight forward to manage because of their being cooperative and heading to instructions. This is a clear demonstration that illnesses can affect anybody without considering mental status. Due to her mental state, it is possible that she could have had severe Trachoma infection which could have complicated with TT at a tender age of 24. Such people do not need sedation or general anaesthesia (GA) to undergo an operation. This patient was young and mentally ill. She presented with all sorts of challenges as outlined above. She had to be sedated for the surgery to take place. GA could have been the best option, but the place where surgeries were conducted from had no GA facilities.
Trachomatous visual impairment and blindness, which result from corneal opacification, have generally been thought of as irreversible [7]. On the contrary, the patient recovered good sight of 6/36 in both eyes after surgery.
As a result of the unpredictability of mentally ill patients a more individualized management approach with them is cardinal and their management needs patience, tolerance and good clinical acumen [4, 8]. In this case, the patient had to be sedated for the TPR surgery to be carried out.
Patients with mental illness can have significant and rapid mood and behavioural changes as well as sudden, volatile and aggressive outbursts which can be both verbal and physical. Therefore, staff members who interact with the patient are at risk of being victims of outburst [4, 9] hence proving difficulty to handle when conducting surgical management of TT. Equally in this case, the patient was aggressive, uncooperative that she had to be handled skilfully by the team to be sedated and for surgery to be done successfully. Despite all these challenges, the patient was managed successfully with some endurance.
Conclusion:
Surgery to correct TT is a key component of all trachoma blindness control programmes in endemic countries. Therefore, mental state of an individual should not be a barrier to accessing TT surgery. World Health Organization recommends that TT surgery should be performed when the opportunity arises.
References:
1. World Health Organization (2012) Global WHO alliance for the elimination of blinding trachoma by 2020. Weekly Epidemiological Record 87: 161–168. Pmid: 22574352
2. World Health Organization (2014) WHO Alliance for the Global Elimination of Blinding Trachoma by the year 2020. Progress report on elimination of trachoma, 2013. Pmid: 25275153
4. Karen Appold (2016), hhtps://www.the-hospitalist.org>article;Experts Suggest Ways to Deal with Challenges Surrounding Care of Psychiatric Patients. The Hospitalist.
5. Baltussen R.M. et al, (2005), Cost-effectiveness of trachoma control in seven world regions. Ophthalmic Epidemiol; 12:91–101. [PubMed]
6. Bailey R., et al, (1999), The duration of human ocular Chlamydia trachomatis infection is age dependent. Epidemiol Infect.123:479–486. [PMC free article]
7. Barber K., Dabbs T. (1988), Morphological observations on patients with presumed trichiasis. Br J Ophthalmol. 1988; 72:17–22. [PMC free article]
8. Barry and Nilsson (2019), https://www.lexology.com>library: Challenges for Staff in Mental Health Wards.
A 35-year-old, male factory employee with retained subconjuctival foreign body in form of a glass particle in the left eye (LE) presented at Mazabuka General Hospital Eye Unit with chronic painful red eye, photophobia and epiphora for two months. On examination, his visual acuity was 6/6 for the right eye (RE) and 6/9 for the LE. There was mild upper eyelid swelling and ecchymosis. The posterior segment of both the right and left eyes had normal findings. A clinical diagnosis of the left eye ocular trauma was made with suspected scleral tear near the limbus at 9 O’clock position. Examination under local anaesthesia revealed a foreign body which was later removed. The sclera was found to be intact.
INTRODUCTION
Eye trauma refers to damage caused by an injury to the eye [1]. Trauma may affect not only the eye, but the adnexa, including adjacent tissue and bone structure [1,2]. There are many different forms of trauma, varying in severity from minor injury like eye foreign bodies to medical and surgical eye emergencies [1,2].
An ocular foreign body is any abnormal substance or object that is found on the eye, but does not belong to the eye [2,3]. The incidence of ocular foreign body is high especially in the industrial towns. It can occur at any age and in both genders. It affects the eye by mechanical effects, by introduction of infection or by specific reaction [1-3].
The reaction of the eye to a retained foreign body varies with the composition of particle [4]. The ocular reaction may be of three types in the first place, inorganic substances cause no specific reaction except for mechanical irritation and an exudative and fibroblastic isolation of the foreign body [4,5]. Secondly, a chemical reaction may produce a nonspecific or occasional specific damage. In the third place, organic material tends to set up a proliferative response characterized by the formation of granulation tissue with the giant cells [4,5].
Foreign bodies on the conjunctival surface are best recognized with slit-lamp examination. Foreign bodies can lodge in the inferior cul-de-sac or can be located on the conjunctival surface under the upper eyelid [4]. It is imperative to evert the upper eyelid to examine the superior tarsal plate and eyelid margin in all patients with a history that suggests a foreign body [4]. If several foreign bodies are suspected double eversion of the eyelid with a Desmarres retractor or a bent paperclip is advised to allow the examiner to effectively search the entire arc of the superior cul-de-sac [4].
Usually the materials of extra ocular foreign body are coal, dust, sand, iron particles, glass, eye lashes, wood piece, husk of seed and wings of insect among others. The Intra Ocular Foreign Body (IOFB), which penetrate the eye and retained are minute chips of iron or steel, stone, glass, lead pellets, copper, spicules of wood to mention but a few [1,3].
Occupational eye injuries represent 63% of all occupational injuries. Workers in construction, manufacturing and mining are particularly at risk. Fifty two percent (52%) of all occupational injuries in manufacturing are eye injuries [4]. Most occupational eye injuries are foreign bodies (FB) in the eye (71.5%) [4] . Up to 90% of eye injuries are preventable with effective interventions including education, professionals can play an important role in promoting and prescribing eye injury prevention strategies to help reduce this avoidable cause of vision loss. [4]
Vision is intimately linked with one’s ability to navigate the environment and can strongly affect our mental, physical and economic well-being. Losing one’s vision through an eye injury can lead to substantial long-term costs, and impact on an individual, their family and community
CASE SCENARIO
A 35 year-old male factory worker from Mazabuka district in Southern Province of Zambia presented to Mazabuka General Hospital eye unit complaining of chronic painful red eye with sentivity to light, tearing, headache and blurred vision for two months.
He constantly got permission from work to seek medical attention for his eye condition of which he lost many man hours from work. He had received medical attention and treatment at several public and private health centres with no improvement. The pain remained the same despite receiving different types of topical medication and oral pain killers. He also received traditional herbs and tattoos without any improvement at all. He eventually sought for help from local private optician where he was prescribed plono photochromic spectacles.
He could not recall any history of ocular infection or trauma to the eye prior to the onset of this problem. He could not recall any history of work related accidents prior to the onset of the pain. However, he reported history of working under various departments, including factory maintenance department where he was attached a week prior to the onset of his ordeal. He was a constant user of safety glasses at work and he reported that the company was strict with the policy of safety attire at work stations. There was no history of known allergies in the family.
On examination, his Visual acuity was 6/6 on the RE and 6/9 on the LE. He had photophobia and tearing in the LE with subconjuctival haemorrhage. Slit lamp examination did not reveal any apparent corneal or conjuctival foreign body or lacerations and fluorescein staining was negative. There was mild upper eyelid swelling and ecchymosis. The posterior segment of the LE had normal findings. The RE was quiet with normal anterior and posterior segment findings and his vital signs were normal.
A diagnosis of LE blunt ocular trauma was made with suspected scleral tear near the limbus at 9 O’clock position. After taking written informed consent, this patient was taken to theatre for further examination and possible suturing of the suspected scleral tear. Under aseptic conditions the LE was given peribulbar injection as local anaesthesia while being mindful of ocular pressure. The conjunctiva was separated from the sclera to expose the source of the haemorrhage. A small piece of glass approximately 0.3 mm diameter was exposed and removed but the scleral was intact. The scleral blood vessels were cauterised and subconjuctival steroid antibiotic injection was given. Topical drugs, eye pad and analgesics were given. The patient was discharged the following day and reviewed after fourteen days. The pain and haemorrhage had subsided significantly and the patient was happy with this outcome.
Permission to publish this case was granted by the patient.
DISCUSSION
The subconjunctiva is a rare site for lodgement for ocular foreign body. Seventy five percent (75%) of conjunctival foreign bodies lodge on the conjunctiva surface of the upper eye [4]. Conjunctiva foreign bodies of the eye are common and can be removed with proper technique [4]. A conjunctival foreign body should be suspected if a patient present with a sensation of something in the eye. Patients with a conjunctival foreign body often state that their eye feels as if an irritating object (grit), sand, or glass is in the eye but that they cannot localize exactly where the sensation is [7,8]. The foreign body sensation is often worse upon blinking when the foreign body is located on the conjunctival (inner) surface of the upper lid. Corneal foreign bodies are easily detected as they are exposed clearly on the clear cornea and because it is highly innervated there is severe pain [7,8].
In this patient, the signs of conjuctival foreign body was not obvious as that of irritating eye object (grit) and sand sensation demostrating that ocular foreign bodies can lodge without eliciting clear signs and symptoms. He did not give any account of trauma prior to the onset of his ordeal. He recalls strict adherence to safety goggles at work. He did not notice at any point that a foreign particle had lodged in his left eye neither did any of the staff who attended to him at various health centres, including our team at Mazabuka General Hospital on first examination.
Glass particles and insect hairs are often difficult to see, but a careful search of the cul-de-sac with high magnification aids in identification and removal. In case of conjunctival foreign bodies there is need to search for signs of globe perforation [7,8] In this case, glass particle foreign body embelded subconjunctivally on to the sclera surface, which presented as a small conjunctival growth and caused local inflammatory response.
Eye injuries in the workplace are very common. More than 2,000 people injure their eyes at work each day. About 1 in 10 injuries require one or more missed workdays to recover from. Of the total amount of work-related injuries, 10-20 % will cause temporary or permanent vision loss [4]. Common causes for eye injuries are: flying objects (bits of metal, glass), tools, particles, chemicals, Harmful radiation and any combination of these or other hazards. Many times these foreign particles are missed and intervention is only sought 24 to 72 hours later [5]. There are three things one can do to help prevent an occupational eye injury; (1) know the eye safety dangers at work place (2) complete an eye hazard assessment (3) eliminate hazards before starting work [4].
The most recommended management of ocular foreign bodies is prevention by use of safety eyewear protection which includes non-prescription and prescription safety glasses, goggles, face shields, helmets and full-face respirators. The type of safety eye protection one should wear depends on the hazards at the workplace. Safety glasses with side protection (side shields) are recommended for particles, flying objects, or dust areas. Goggles are recommended for chemicals. Special-purpose safety glasses, goggles, face shields, or helmets are designed for near task radiation (welding, lasers, or fibre optics) [4,5,].
Prompt referral to specialised emergency centres is recommended once ocular trauma is suspected or identified at first contact [6,8].
CONCLUSION
This case report highlights the importance of thorough ocular examination and good clinical acumen to avoid vision threatening complications because of retained foreign bodies. Glass particles are often challenging to identify and requires skill to manage successfully.
Disclosure Statement
The authors have no conflicts of interest.
REFERENCES
Agarwal PK, Kumar H, Srivastava PK (1993) Unusual Orbital Foreign Bodies. Indian J Ophthalmol 41: 125-127.
Angra SK, Mohan M (1980) Intralenticular foreign bodies. Indian J Ophthalmol 28: 145-149.
Boyd BF (1997) Highlights of Ophthalmology 3:186
Bahrain Med Bull 2017; 39(2): 82 – 84- Occupational Eye Injury: The Neglected Role of Eye Protection Bahrain Medical Bulletin, Vol. 39, No. 2, June 2017
Khurana AK (2007) Ocular foreign body (4thEdn) pp: 409-412.
Mehrotra AS, Ignatius NK (1978) Retained intra ocular foreign body from bursting of the barrel of gun. Indian J Ophthalmol 26:17-18
Somashekar P. Biradar, A Study on Industrial Eye Injuries, Journal of Clinical and Diagnostic Research. – Arvind H.S 2011 October, Vol-5(5): 1076-108
Bahrain Med Bull 2017; 39(2): 82 – 84- Occupational Eye Injury: The Neglected Role of Eye Protection Bahrain Medical Bulletin, Vol. 39, No. 2, June 2017
Alstir K.O. Denniston, Philip L. Murry, Ocular Trauma, Oxford University Press 2014. 1108-1110
Khurana A K.,Comprehensive Ophthalmology 6th Edition 2015, Jaypee Brothers Medical Publishers (P) Ltd
A 55-year-old female patient presented at Kasama General Hospital’s Eye Clinic with painful eyes, excessive tearing, foreign body sensation and blurred vision in both eyes. After examination the patient was diagnosed with Trachoma Trichiasis (TT), ectropion, exposure keratitis and facial nerve palsy. Patient underwent simultaneous multiple management involving Tarsal Plate Rotation (TPR), ectropion correction, physiotherapy and was treated for keratitis successfully.
INTRODUCTION
Normally, the upper and lower eyelids close tightly, protecting the eye from damage and preventing tear evaporation. If the edge of one eyelid turns inward (entropion), the eyelashes rub against the eye, which can lead to ulcer formation and scarring of the cornea. If the edge of one eyelid turns outward (ectropion), the two eyelids cannot meet properly, and tears are not spread over the eyeball [1]. These conditions are more common among older people due to increased tissue relaxation with age, eye changes caused by infection, surgery, or injury and people who have blepharospasms. Ectropion may occur in people with facial nerve palsy [2]. These eyelid pathologies are characterised by common presentation such as redness, tearing, irritation of the eyes and altered balance of the anterior and posterior lamellae of the eyelids. They involve more frequently the inferior eyelid and the therapy is mainly surgical [3].
Trachoma is the leading infectious cause of blindness world-
wide. Overall it is the eighth commonest blinding disease [1].
Trachoma is caused by the obligate intracellular bacterium C.
trachomatis. Recurrent episodes of conjunctival infection and the
associated chronic inflammation it causes initiate a scarring
process that ultimately leads to irreversible blindness. There is a
worldwide effort underway to try to control blinding trachoma;
this is lead by the World Health Organization (WHO) with the
Global Alliance for the Elimination of Blinding Trachoma
(GET2020).
It is estimated that approximately 1.3 million people are blind
from this disease and probably a further 1.8 million have low
vision [2]. Trachoma is endemic in more than 50 countries,
predominantly in sub-Saharan Africa, the Middle East, and Asia
[3]. The burden of trachoma on affected individuals and
communities can be huge both in terms of the disability it causes
and the economic costs that result. In this paper we review the
available data on the prevalence of the disease and estimates of its
burde
CASE SCENARIO
A female patient aged 55years came to the eye clinic from Kasama village with complaints of tearing, eyelashes rubbing onto the cornea, pain, redness and poor vision for one year. The patient reported history of epilation to relieve pain. On examination visual acuity was 6/12 Right eye and 6/36 Left eye. The eyelashes were rubbing on the cornea and there was dryness of the eye. The conjucntiva was injected and patient was in pain. The face was drawn on the left side due to facial nerve palsy on the right side (Fig 1). Diagnoses of Bilateral trachoma trichiasis (TT), Bilateral ectropion, Facial palsy affecting left side and Bilateral keratitis was made.
Surgical correction involved Tarsal plate rotation and blepharoplasty. Medical management with antibiotics and physiotherapy was initiated.
Consent for publishing this case and patient’s pictures was obtained from the patient herself.
Fig 1: Showing facial asymmetry
DISCUSSION
All cases of trachoma trichiasis including ectropion should be subjected to corrective surgery of the eyelids. If left unattended to, these conditions can lead to an impaired optical function of the ocular surface through chronic irritation of the conjunctiva and the cornea [4]. The patient discussed in this case report had a rare presentation of trichiasis and ectropion that complicated to keratitis [5,7]. It was determined that early intervention was required in order to stabilise the tear film and to prevent recurrent corneal abrasions, corneal ulceration, corneal opacities and eventually vascularization as well as scarring of the cornea and conjunctiva as suggested by other researchers [6].
To address these multiple eye problems, a combination of Tarsal Plate Rotation (TPR) and blepharoplasty was conducted to correct entropion and ectropion respectively. Following surgery, there was improvement of the patient’s vision and the pain was no longer there. The causes of ectropion include Facial nerve palsy and involutional. Normally, these two causes occur independent of each other. Strangely this patient had both situations occurring simultaneously. This posed a challenge in the management of such a combination of the two conditions. However, this was skilfully excuted to the satisfaction of the patient. This demanded good planning and teamwork as other disciplines were involved. Keratitis was treated with tetracycline eye ointment and the patient equally responded well. Unfortunately, in literature there was no information regarding management of such combination of conditions. The management purely depended on experience and extensive consultation.
CONCLUSION
This case report shows that one can have multiple occurrence of ocular conditions with atypical presentation. Management of such a combination of ocular conditions requires experience, collaboration and skilfulness.
REFERENCES
Matthew J. B. et al,British Medical Bulletin (2007) Vol 84,issue 1 pages 99-116 London, United Kingdom
James Garrity, MD, Entropion and Ectropion (2019); page1, Kenilworth, NJ, USA).
Minerva Chirurgica, Journal of Surgery (2013); page 1, University of Turin, Italy.
Mwale.c. et al, Ophthalmic epidemiology, Trachoma Prevalence in 67 Districts of Zambia (2018);2-3, Lusaka-Zambia
Michael giese, Northwest Eye Surgeon Insight Journal (2015) 1-4, Seattle, USA.
Stefanyszyn, M.A., Pathology of Entropion and Ectropion, presented at the Washington Hospital Centre Silver Jubilee Oculoplastic Symposium (March 25, 1983),2-4, Washington D.C.
Seunghyun Lee, Helen Lew, Department of Ophthalmology, Management of Facial nerve palsy patients, 2018;3-4, Seongnam, Korea.
An increasing number of cases of ocular non-Hodgkin’s lymphoma (HL) is being reported. While ocular involvement in Hodgkin’s lymphoma is rare, it is a frequent affection in non-Hodgkin’s lymphomas (NHL). A 13-year-old boy presented to Chongwe District Hospital (CDH) with pan uveitis. The patient presented with blurred vision in his Left Eye (LE), skin rash and dry cough over a period of three months. He had not sought any medical attention prior to his visit to eye unit. Slit lamp examination revealed bilateral non-granulomatous keratic precipitates and flare. Physical examination revealed cervical and inguinal lymph nodes. His laboratory work up including rheumatoid factor and serum protein electrophoresis tests were all normal. A diagnosis of pan uveitis was made and the patient was treated with topical and systemic steroids over a period of six months without improvement. The patient was counselled and referred to a pediatrics hospital where an excisional biopsy for inguinal lymph nodes confirmed Hodgkin’s lymphoma. Appropriate systemic treatment was given for Hodgkin’s lymphoma.
INTRODUCTION
Hodgkin’s lymphoma (HL) is a disease originating from lymphoid tissue and accounts for less than 1% of all cancers [1]. As lymph nodes are distributed throughout the body, lymphomas may manifest with involvement of various body parts [2]. This can cause difficulties in diagnosis as well as delayed treatment. Ocular involvement is more prevalent in non-HL compared to HL [3]. A number of case reports of ocular HL following the diagnosis of systemic HL have been documented [4, 5, 6]. Though rare, HL can initially present with ocular manifestations [7, 8]. According to 2016 revision of the World Health Organization (WHO) classification of lymphomas, approximately 15% of lymphomas are classified as HL; the remainder are classified as Non-HL [9]. This recognizes >40 mature B cell neoplasms and <25 mature T and NH (natural killer) cell neoplasms [9].
This case report is about a 13- year-old patient who presented with complaints of low vision, watering eyes and photophobia. The patient had other systemic infections in which after medical testing was diagnosed with HL. This case report also examines the relationship between ocular findings and HL within the context of literature, and to raise awareness of this condition.
CASE SCENERIO
A 13- year-old male patient presented with skin rash, dry cough, and reduced vision in his left eye for 3 months. There was history of the child being sickly of more than 3 months, weight loss, no night sweats and could not attend school due to illness. This was the first presentation to the hospital and was not on any treatment.
On general examination the child was ill looking, febrile, pale, slightly jaundiced, not cyanosed, had no finger clubbing and was not breathless. Head and neck examination showed a buffalo face appearance. Systemic examination revealed multiple cervical and inguinal lymphadenopathy bilaterally. On ocular examination, visual acuity was 6/6 Right Eye (RE), 6/36 Left Eye (LE), bilateral non-granulomatous keratic precipitates (KPs) and grade two flare. The KPs were more pronounced in the LE. Fundus examination was normal in the RE, while macula edema and vitritis were observed in the LE, though there was no vitreous turbidity. His laboratory investigations, which included rheumatoid factor, serum protein electrophoresis and other tests were all normal. A diagnosis of chronic posterior uveitis secondary to HL was made and ocular treatment was initiated, and the child was referred to the paediatric hospital where the excisional biopsy of the inguinal lymph nodes was done. The histology results confirmed the HL diagnosis and the patient was commenced on appropriate management. The child was followed up for a period of one year and the HL resolved including the uveitis. Currently the child is on permanent follow up with the children’s hospital and the eye unit at CDH. Considering that the patient is under the age of 18, the mother consented for publication.
DISCUSSION
HL is usually seen in individuals aged 15-34 years and those over 55 years old [1]. The child reported in this case was 13 years old demonstrating that HL can still occur in children younger than 15 years. The incidence of pediatric HL tends to rise as family size increases and socioeconomic status decreases; the opposite has been reported with the adult form, which is associated with high socioeconomic status in industrialized nations [10]. The child discussed in this report was the sixth born and came from a poor socioeconomic status justifying the incidence occurrence. Although HL is more prevalent among males in all age groups, the nodular sclerosis subtype is more common among females [10]. This is consistent with what has been reported as the victim is male child. Unlike most other cancers, HL can be cured through a combination of medical management. Towler et al., 1999, reported achieving complete remission of ocular inflammation with chemotherapy [8, 11] just as the child in this case was treated successfully.
Ocular involvement in HL occurs by various mechanisms including direct lymphomatous or metastatic involvement of the choroid and the retina; paraneoplastic vasculitis; and iatrogenic complications arising from HL treatment or immunosuppression [5-7, 12]. In this case, the child was not immunosuppressed and could have been metastatic. These patients may exhibit infiltration of the ocular structures, retinal periphlebitis, focal chorioretinitis, vitritis, papillary edema, exudative retinal detachment, soft exudates, retinal hemorrhages, necrotizing retinitis, peripheral retinal exudates, and retinal white spots [3, 13]. The child under discussion exhibited with vitritis and macular edema just as described above.
CONCLUSION
This case demonstrates the occurrence of ocular Hodgkin’s Lymphoma despite it being rare. It also highlights the fact that ocular Hodgkin’s Lymphoma can occur in younger age. Hodgkin’s Lymphoma is treated with successful remission.
REFERENCES
Knowles MD. Neoplastic hematopathology (2nd edition) New York
Young GA. Lymphoma at uncommon sites. Hematol oncol. 1999; 17:53-83. [PubMed]
Simsek HC, Akkoyun I, Yilmaz G Hematolojik Hastaliklarda Goz Bulgulari Retina-Vitreus. 2014; 22:85-92.
Mosteller MW, Margo CE, Hesse RJ. Hodgkin’s disease and granulomatous uveitis. Ann ophthalmol. 1985;17:787-790.[PubMed]
Thomas RK, Re D, Zander T, Wolf J, Diehl V. Epidemiology etiology of Hodgkin’s lymphoma. Ann Oncol. 2002; 13: 147-156. [PubMed]
Seker M, Mengi A, Bilici A, Ustaaloglu BB, Kefeli U, Ozseker NI, Mayadagli A, Salepci T, Gumus M. Hodgkin lenfoma olgularinin retrospektif degerlendirilmesi ve prognostic faktorlerin saptanmasi turk J Oncol. 2011; 26:108-114.
Sacks EL, Donaldson SS, Gordon J, and Dorfman RF. Epithelioid granulomas associated with Hodgkin’s disease: clinical correlation in 55 previously untreated patients. Cancer. 1978; 41:562-567. [PubMed]
Mateo-Montoya A, Bonnel S, Wolff B, Heron E, Sahel JA. White dots in the eye fundus revealing Hodgkin’s lymphoma. Eye (lond). 2010; 24:934-937. [PubMed]
Diabetic retinopathy (DR) is a common blinding ocular complication of diabetes mellitus (DM). Its manifestation depends on a patient’s glycaemic control, duration of DM and the type of DM. It mostly affects patients with type 2 DM. Children are almost never affected by DR.
The University Teaching Hospitals – Eye Hospital (UTH-EH) had an unusual presentation of Proliferative Diabetic Retinopathy (PDR) in a female patient aged 16 with Type 1 Diabetes Mellitus (T1D). The patient was referred from Lewanika General Hospital where Diabetic Retinopathy (DR) was elicited. The patient complained of poor vision in both eyes for 2 months. On examination visual acuity (VA) was 6/12 right eye (RE) and 6/18 left eye (LE). Funduscopy revealed neovascularisation elsewhere (NVE’s) in both eyes. A diagnosis of PDR was made, and the patient was managed with Pan-retinal photocoagulation (PRP).
INTRODUCTION
Diabetes mellitus is the third most common chronic disease among children [1]. The incidence and prevalence of T1D varies among different populations and appears to be based upon several factors including racial composition, age distribution and geographic location. The Centers for Disease Control report that approximately 1 in 400 American children has diabetes [2] and Lueder estimated that 1 of every 500 has T1D [3]. The rising prevalence of childhood type 1 and type 2 DM possess a huge risk of visual impairment and blindness due to DR which is an important complication of DM [4].
Diabetic retinopathy has been well described in children. The majority of affected patients do not develop vision-threatening retinopathy until after the teenage years [1]. The risk of developing DR is greater in patients who are diagnosed during or after puberty [5] and studies demonstrate a higher incidence of DR in late puberty than early puberty despite similar durations of disease [6]. Some adolescents lose vision due to macular edema or, more commonly, PDR. Furthermore, a number of adolescent patients rapidly develop progressive DR that leads to irreversible blindness unless it is detected early and treated aggressively [7, 8]. Therefore, early detection of DR and other blinding conditions through screening programmes is critical for preserving vision in patients with diabetes [7.8].
Treatment for PDR is by Pan Retinal Photocoagulation (PRP). However, having been treated with PRP still renders patient at increased risk of reverting to new proliferative disease, without the development of all the classical features of pre-proliferative disease if DM is poorly controlled [9].
CASE SCENARIO
A 16-year-old female from Western Province of Zambia presented to the UTH-EH with complaints poor distance vision in both eyes for two months. She presented to Lewanika General Hospital (LGH) in comatose state where she was diagnosed with Diabetic Ketoacidosis and a diagnosis of Type 1 DM was made. Treatment with insulin was initiated. When the patient’s condition was brought under control and became stable, she complained of poor vision in both eyes following which she was attended to at LGH Eye Unit where she was subsequently referred to the UTH-EH for DR management.
On examination at UTH-EH, she appeared appropriate for age and of good nutritional status. Visual Acuity (VA) was 6/12 RE and 6/18 LE. The VA in both eyes could not improve with the pinhole. Her weight was 43.3 kgs, height – 1.6 m, which gave a Body Mass Index (BMI) of 16.9 kg/m2. The Blood Pressure (BP) was 120/70 mmHg.
Retina examination in both eyes had dot blot and flame shaped haemorrhages, cotton wool spots, hard exudates and new vessels elsewhere (NVEs). The Fasting Blood Sugar (FBS) was 16.3 mmol/l and renal function tests were all within normal range. Fundus Fluorescein Angiography (FFA) findings showed multiple areas of increasing fluorescence suggesting leakage and confirming NVEs, (Figs 1 and 2).
Fig 1: RE FFA confirming NVEs
Fig 2: LE FFA confirming NVE’s
The patient underwent PRP I and PRP II in both eyes. The two were performed a week apart for each eye, (Figs 3 – 6). A week after PRP II her vision improved to 6/9 in both eyes. Subsequent review at 3 months showed that her vision was restored to 6/6 in both eyes. The patient was put-on long-term DR follow up plan.
Fig 4: Fresh LASER marks RE
Fig 5: LASER marks LE
Fig 6: LASER marks LE
Considering the fact that the patient was below 18 years, her mother consented to the publication of the case including the pictures.
DISCUSSION
Diabetic retinopathy in children has been well described in the developed world where as in the developing countries it is yet to be described properly. Initially the thinking was that DR could not occur in children, but it evidently occurs as demonstrated by Forlenza and Stewart, 2013. Just as established by Forlenza and Stewart, this report confirms a DR case in a 16-year-old. It has been reported that the majority of affected patients do not develop vision threatening retinopathy until after the teenage years. Some adolescents lose vision due to macular edema or, more commonly PDR. In this case report the patient was an adolescent and a teenager with a huge risk of developing PDR which was the final diagnosis in the patient. From history this had developed rapidly and as reported by other researchers such as Soffer et al. (2003) and Maguire et al. (2006) [7, 8]
Treatable DR is extremely rare among paediatric Type 1 DM [10]. On the contrary, this case had vision threatening DR within 2 months of diagnosis with T1D and her condition needed DR treatment. Moreover, DR can become quite advanced before children recognize and report changes in vision, thus further emphasizing the need for regular screening programs [1]. The case under discussion reported poor vision four days upon recovery from the comatose state during which she was first diagnosed of having T1D.
A number of adolescent patients develop rapidly progressive DR that leads to irreversible blindness unless it is detected early and treated aggressively [7, 8]. Timely treatment with laser photocoagulation can prevent visual loss in vision-threatening retinopathy [11]. Fortunately, this PDR case was diagnosed at the right time and managed aggressively with LASER with good visual outcome.
Treatment of affected adolescents is generally the same as for adults – focal or grid laser photocoagulation for macular edema and pan-retinal photocoagulation (PRP) for PDR. Intravitreal injections of anti-VEGF drugs have recently become the standard-of-care for adults, but neither anti-VEGF drugs nor intraocular corticosteroids have been used to treat DR in children due to concerns regarding ocular and systemic side effects [1]. In line with the treatment recommendations for PDR in children, this case was treated with PRP on time, adequately and successfully.
Following the increasing number of children with DR, a number of organisations and institutions have come up with recommendations on follow up of DM patients for DR screening. The American Academy of Pediatrics (AAP) recommends ophthalmologic examinations starting “3 to 5 years after diagnosis if the patient is 9 years of age and above” with annual follow-up examinations [12]. The American Academy of Ophthalmology (AAO) preferred practice pattern recommends the first examination “3-5 years after diagnosis” with yearly follow-up examinations [13]. The American Diabetes Association (ADA) position statement recommends the first eye exam “within 3-5 years after diagnosis of diabetes once the patient is age 10 years or older” with yearly follow-up examinations [14]. The newly published Canadian Ophthalmological Society (COS) guidelines recommend that screening for DR should be initiated “5 years following the diagnosis of diabetes” or at puberty with yearly follow-up examinations [15]. In the Zambian situation the guidelines are that every diabetic child who is ten years and above is subjected to annual DR screening. However, the process of developing protocols is still under way.
CONCLUSION
This case report demonstrates that diabetic retinopathy can occur in children with diabetes mellitus regardless of the type of diabetes. Timely management with LASER can help in maintaining or restoring vision and preventing blindness. Therefore, early detection of DR and other blinding conditions through screening programs is critical for preserving vision in patients with diabetes.
REFERENCES
Forlenza G and Stewart MW, Diabetic Retinopathy in Children, 2013, Pediatric Endocrinology Reviews (PER) ● Volume 10 ● No 2 ● January; P217-227
Centers for Disease Control and Prevention. National diabetes fact sheet: national estimates and general information on diabetes and prediabetes in the United States, 2011. Atlanta, GA: U.S. Department of Health and Human Services
Lueder GT, Silverstein J. Screening for retinopathy in the pediatric patient with type 1 diabetes mellitus. Pediatrics 2005;116:270-273
Dabelea D, Mayer-Davis EJ, Saydah S, et al. SEARCH for Diabetes in Youth Study. Prevalence of type 1 and type 2 diabetes among children and adolescents from 2001 to 2009.2014;311:1778–86.
Kunin M, Tossavainen P, Hannula V, Lahti S, Hautala N, Falck A. (2011) Prevalence of retinopathy in Finnish children and adolescents with type 1 diabetes: a cross-sectional population-based retrospective study. Arch Dis Child
Kernell A, Dedorsson I, Johansson B, Wickstrom CP, Ludvingsson J, Tuvemo T, Neiderud J, Sjostrom K, Malmgren K, Kanulf P, Mellvig L, Gjotterberg M, Sule J, Persson LA, Larsson LI, Aman J, Dahlquist G. (1997) Prevalence of diabetic retinopathy in children and adolescents with IDDM. A population-based multicentre study. Diabetologia;40:307-310
Soffer B, Zhang Z, Miller K, Vogt BA, Shahinfar S. A double-blind, placebo-controlled, dose-response study of the effectiveness and safety of lisinopril for children with hypertension. Am J Hypertension 2003;16(10):795-800
Maguire A, Cusumano JM, Craig ME, Donaghue KC. The case for biennial retinopathy screening in children and adolescents: response to Stefansson. Diabetes Care 2006;29:178-179
Diabetic Retinopathy Screening training Module 5 Part 1 – Grading DR (2016)
Treatable Diabetic Retinopathy Is Extremely Rare Among Pediatric T1D Exchange Clinic Registry Participants Diabetes Care 2016;39:e218–e219 | DOI: 10.2337/dc16-1691
Early Treatment of Diabetic Retinopathy Study Research Group. Photocoagulation therapy for diabetic eye disease. JAMA. 1985;254:3086
American Academy of Pediatrics, (1998) Section on Endocrinology and Section on Ophthalmology. Screening for retinopathy in the pediatric patient with type 1 diabetes mellitus. Pediatrics.
American Academy of Ophthalmology Retina Panel (2008), Preferred Practice Pattern Guidelines. Diabetic Retinopathy. San Francisco, CA: American Academy of Ophthalmology
American Diabetes Association, (2002) Diabetic Retinopathy. Diabetes Care
Canadian Ophthalmological Society (2012), Diabetic Retinopathy Clinical Practice Guideline Expert Committee. Canadian Ophthalmological Society Evidence-Based Clinical Practice Guidelines for the Management of Diabetic Retinopathy. Can J Ophthalmol
A 1year 8 months old baby girl presented to Arthur Davidson Children’s Hospital with a 4 month history of segmental haemangioma affecting the Left upper which caused mechanical ptosis obstructing the visual axis, with supraumbilical raphe, sternal cleft defect and ventricular septal defect. The clinical features were consistent with PHACES syndrome. Three monthly doses of intralesional methyl-prednisolone were administered with complete regression of the haemangioma.
Introduction
Infantile haemangioma (IH) is the most common tumour in infancy. They occur in up to 2.6% of neonates and up to 12% of children by the first year [1,2,3]. A subgroup of patients with IH exhibit associated structural anomalies of the brain, cerebral vasculature, eyes, aorta, and chest wall in the neurocutaneous disorder called PHACES syndrome. IH typically present in 2 phases; a phase of rapid proliferation which occur in the first year of life, followed by a slow gradual involution over the next 5 to 7 or more years. IH remain asymptomatic and can, therefore, be managed by close observation. Indications for immediate management include; IH that might cause significant complications such as amblyopia, airway obstruction, bleeding and ulceration, high output cardiac failure [1].
Case Report
A 1 year 8 months old girl with congenital sternal defect was referred from Roan General Hospital to Arthur Davidson Children’s’ Hospital for further management. The patient was born at term via spontaneous vaginal delivery at the university Teaching Hospitals Women and New-born Hospital with no perinatal complications. She presented with a 4/12 history of swelling on left upper eyelid, left side of the face and lower lip which increased in size progressively. The patient being a child, consent to have the case report published was obtained from the mother.
On examination, patient had a stable general condition, Visual acuity (VA) in both eyes was central, steady and maintained, that is, the patient was able to fix and follow moving targets. The intraocular pressure was 11 mmHg and 12 mmHg in the right and left eyes respectively. The right eye had normal anterior and posterior segments. Left eye had a lesion, measuring about 6 by 4 cm, on the upper eyelid which was blanching with pressure. There was mechanical ptosis on the affected eye and smaller other lesions were noted on lower lips also (figs 1 and 2). Systemic examination revealed a sternal cleft deformity with a holosystolic murmur, and supraumbilical raphe. Chest x-ray revealed an enlarged cardiac shadow and a small ventricular septal defect (VSD) was noted on echocardiogram. The ECG and abdominal u/s were normal. The parameters on Full blood count were within normal limits. Unfortunately, MRI or CT scan of the brain and orbit were not done because the patient’s care-givers could not afford to do the investigations due to the cost involved.
A diagnosis of PHACES syndrome was made based on above findings and multi-disciplinary approach was employed in the management of the patient. The teams involved were Ophthalmology, Paediatric Surgery, General Paediatrics, and Cardiology. Monthly doses of intralesional methylprednisolone were administered for 3 months. The outcome was complete resolution of the lesions as shown in fig 3.
Fig 1: Showing the child with a swollen left eye upper eyelid
Fig 2: Showing lesions on the lower lip
Fig 3: Showing a regressed lesion after treatment
DISCUSION
PHACES syndrome is a group of disorders characterized by posterior fossa abnormalities, haemangioma, arterial lesions, cardiac abnormalities/coarctation of the aorta [1,2,3]. The first description of PHACE syndrome with brain abnormalities was reported in 1978 by Pascual-Castoviejo [4] in 1996 while acronym PHACE was created by Frieden et al in 1996; this gave the details of the most representative features of the syndrome [1]. The acronym has been expanded to PHACES which includes supraumbilical raphe and sternal clefting ) [5].
In 2009, a consensus to define the diagnostic criteria for PHACES syndrome was arrived at. These criteria were divided into 2 categories that is PHACES syndrome or possible PHACES syndrome. Major and minor criteria were determined for the following organ systems: cardiovascular, cerebrovascular, ocular, structural brain, ocular, and ventral/midline.The diagnosis of PHACES Syndrome requires the presence of a characteristic segmental haemangioma greater than 5cm on the face or scalp plus 1 major criterion or 2 minor criteria while possible PHACE requires the presence of a characteristic segmental haemangioma greater than 5cm on the scalp or face plus 1 minor criterion [6]. Our patient presented with a haemangioma affecting the left upper eyelid about 6x 4 cm in size, sternal cleft deformity, umbilical raphe and as small ventricular septal defect. Sternal cleft deformity and umbilical raphe represented the major criteria while ventricular septal defect the minor criteria. Therefore, the presence of above features in our patient satisfied the criteria for diagnosis of PHACES syndrome.
Haemangiomas in PHACES syndrome are more common in female with a female: male ratio of 9:1 ratio for the latter [1]. They are typically bulky, plaque-like lesions involving several cervicofacial segments, but without being confined by their boundaries. They have a segmental distribution which partially corresponds to developmental facial prominences. Facial haemangioma patterns have been described into four segments: frontotemporal (S1), maxillary (S2), mandibular (S3) and frontonasal (S4) segments. The majority of PHACE patients have haemangioma involving the S1 segment regardless of other segment involvement. The facial segmental involvement is also associated with clinical manifestation. Haemangiomas located in the S1 & S4 segments are associated with structural brain, cerebrovascular and ocular anomalies, while those located in the S3 segment are associated with sternal defects or supraumbilical raphes. About 22% of patients present with extracutaneous haemangioma with the most affected ones having only one extracutaneous manifestation to fulfil a diagnosis of PHACE syndrome; the most common ones being CNS anomalies [1,7].
The first description of the association of PHACE syndrome with brain abnormalities was reported in 1978 by Pascual-Castroviejo. He reported that between 43% and 90% of patients with PHACES have a CNS structural malformation.[8] Malformations typically involve the posterior fossa, presenting as a Dandy-Walker complex, isolated cerebellar hemispheric hypoplasia, or a combination of the 2. Dandy–Walker malformation is the most common associated developmental abnormality [1,7].
Vascular anomalies are the most frequent malformation associated with cutaneous haemangioma–vascular complex syndrome. Absence of the internal carotid and/or vertebral arteries and persistence of the trigeminal artery are the most common malformations [8]. Cardiac anomalies include; patent ductus arteriosus, ventricular septal defects, arterial septal defects, pulmonary stenosis, tricuspid aortic valve, arterial enlargement, ventricular hypertrophy, tetralogy of Fallot, and patent foramen ovale. The case we presented had a Ventricular septal defect which was confirmed by echocardiogram [1].
Approximately one-third of the PHACE(S) syndrome cases have eye involvements [6]. In a recent study on 23 cases of PHACE(S) syndrome, 14% of the cases showed ocular involvement [9]. The reported ocular manifestations of this syndrome could be posterior segment abnormalities which include morning glory disk anomaly, retinal vascular anomalies, optic nerve hypoplasia and atrophy, while anterior segment abnormalities include cataract, microphthalmia, conjunctival haemangioma, posterior embryotoxon, Mittendorf dots, corneal opacity, sclerocornea, iris coloboma, iris heterochromia, iris hypoplasia, and iris vessel hypertrophy. There can also be presence of miscellaneous ocular abnormalities such as congenital glaucoma, cryptophthalmos, proptosis, Horner syndrome, congenital 3rd or 4th nerve palsies, strabismus, and ptosis [10].
Sternal defects and supraumbilical raphe were encountered in 43 patients with PHACES syndrome. Matry et al. reported three patients with subtle sternal pits without underlying soft-tissue or bony loss in a series of 14 patients with PHACES syndrome. Our patient presented with both sternal defect and supraumbilical defect [1].
Observation remains the mainstay of treatment of capillary haemangiomas since most lesions regress on their own. However, intervention is indicated in the following circumstances; occlusion of the visual axis, optic nerve compression, severe proptosis, anisometropia, maceration and erosion of the epidermis, infection, and cosmetic disfigurement [11]. Obstruction of the visual axis in our case was the reason why we had to intervene in order to prevent amblyopia. The management option can either be surgical ormedical depending on the size and location of the lesion. Medical management options include; Steroids- topical, intralesional or systemic, interferon alfa-2a therapy, Vincristine, Propranolol therapy or timolol therapy. Our patient responded well after administration of 3 doses of intralesional methyl-prednisolone [1,11].
Conclusion
Intralesional injection of corticosteroids has proven to be effective in the management of cutaneous infantile haemangiomas. In this case we highlighted the successful management of a 1 year 8 months old girl who presented with a haemangioma affecting the left eyelid and causing mechanical ptosis and had other features of PHACES syndrome. The haemangioma was successfully treated with intralesional steroid injections.
References
Sami N. Alsuwaidan. PHACES syndrome in association with airway haemangioma: First report from Saudi Arabia and literature review. Ann Thorac Med. 2012 Jan-Mar; 7(1): 44–47
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A 47-year-old male presented to the Ophthalmology department at Ndola Teaching Hospital with a discharging wound extending from the lower eyelid on the lateral aspect of the right eye and a melted cornea. He had a history of having undergone a surgical procedure for a conjunctival growth, 6 months prior to presentation. He was a known retroviral disease patient with poor compliance to antiretroviral medication. He also history of tuberculosis. Orbital cysticercosis was diagnosed following clinical examination and investigations and anti-helminthic therapy was instituted.
INTRODUCTION
Cysticercosis is a parasitic infection that is caused by the larvae of Taenia Solium, which is a pork tapeworm [1]. The infection is acquired through ingestion of contaminated food and water transmitted through the faecal–oral route [1]. Neurocysticercosis is a central nervous system variant of the infection, responsible for causing seizures worldwide [1]. The infection is postulated to cause twice as many epilepsy occurrences compared to developed countries.
In the United States and other areas with large immigrant populations, there has been wide spread recognition of neurocysticercosis as a common infection, not just in developing countries [2]. The highest prevalence rates have been documented in South and Central America, Africa and Asia particularly in areas of poor sanitation and low socioeconomic status [3]. In Africa, it has been noted that Taenia Solium is transmitted around most of the continent but not in the strictly Muslim areas of North and sub-Saharan Africa where pork is not consumed [4]. As in Asia, concomitant localization of subcutaneous lesions with intracerebral infection is common in Africa. A different picture is seen however in the United States where intracerebral infection rarely occurs together with subcutaneous lesions [5].
One of the challenges in Africa and inmost endemic countries, is the lack of awareness within communities as well as lack of adequate reports and study findings on cysticercosis [6]. This can be attributed to the lack of advanced diagnostic facilities and technology that would allow prompt screening and identification of infected individuals [7] Few countries however, such as South Africa, Zimbabwe, Madagascar and other countries in Central, East and West Africa have been able to produce scientific reports although data still remains limited [7]. Consent for the case report publication was obtained from the patient.
In Zambia, the full countrywide extent, of the impact of cysticercosis in terms of prevalence, endemic areas as well as socioeconomic effect is not fully appreciated. Several studies however, have been carried out in Eastern province, tackling aspects such as prevalence of cysticercosis in bovine as well as human hosts as well as effectiveness of control measures for the prevention of spread of infection. Human cysticercosis prevalence has been reported to range from 6-13% based on circulating antigen detection whereas bovine cysticercosis prevalence was reported to range from 8.2-64.2%, in Eastern province [8].
CASE SCENARIO
A 47 year old male from Ndola city on the Copperbelt province of Zambia presented to the eye department at Ndola Teaching Hospital complaining of a painful right eye with a discharging wound for one week. These symptoms were said to have begun after he fell in the bathroom, whilst taking a bath. There was also a history of having had a growth on the white part of the eye (conjunctiva) excised from the same eye, one year prior. A sample was taken for histopathology but the results were not followed up. Five months after excision, another growth was noticed in the same eye, which he opted to have removed with a blade at home, by a relative. A few days later, he started experiencing the pain and discharge and presented to the eye department a week later. There was also history of having been on antiretroviral therapy (ARVS) for the past seven years for Human Immunodeficiency Virus (HIV), with poor compliance to medication. Anti-tuberculosis medication had been completed 7 months prior to presentation.
On general examination, the patient was ill looking and irritable but had normal vital signs (blood pressure, pulse, temperature, respiratory rate), with palpable cervical lymph nodes. Ocular examination revealed visual acuity (VA) of perception of light (LP) for the right eye and 6/6 for the left eye. Intraocular pressure (IOP) could not be taken in the right eye, but was 14.3mmHg in the left eye. The right eye had ecchymosis on the eyelids with a laceration extending from the lower eyelid to lateral canthus and past the margin. There was also a foul smelling, purulent, blood stained discharge covering the anterior aspect of the eye. The cornea was melted and the rest of the anterior segment structures could not be appreciated. Extraocular motility was not well appreciated due to the patient’s demeanour. The left eye had normal anterior and posterior segment findings.
Differential diagnoses included right lid laceration with corneal ulcer, osteomyelitis, orbital cellulitis and squamous cell carcinoma of conjunctiva and eyelid. Full blood count, differential count, renal and liver function test results were all within normal ranges. The CD4 count was 65cells/uL. The skull x-ray showed a homogenous opacity in the right lateral orbital region. Computed Tomography scan (CT scan) of the head showed small, numerous hypodense opacities scattered throughout the brain parenchyma, including the right orbital region; features consistent with cerebral, subarachnoid and right orbital cysticercosis.
The patient was initiated on albendazole 400mg, orally, once a day for 3 days, praziquantel 2,600mg orally, once a day for 15 days with daily wound cleaning with povidone iodine three times a day. A week later, the patient was referred to the HIV/AIDs specialists for further assessment, counselling and drug therapy re-assessment, and was recommenced on antiretroviral therapy (Tenofovir/Lamivudine/Efavirenz).
By the third review, the patient’s laceration had healed and the discharge was no longer present. The patient however still had a melted cornea and a VA of LP in the right eye. A B-scan performed on the fourth visit indicated the absence of cysts in the posterior segment and orbit.
Figure1: patient’s right eye with laceration wound, absence of lower lid lashes and chemosis.
Figure 2: Right eye with melted cornea.
Figure 3: skull x-ray; Anterior-Posterior view showing homogenous opacification in the orbit-right eye.
Figure 4: CT-Scan of the head with numerous well circumscribed hypodense lesions in the brain.
DISCUSSION
Cysticercosis is a condition caused by the tapeworm species Taenia Solium (mainly), Taenia Saginata and Taenia Asiatica [9]. It is commonly associated with a low socio-economic status, in areas with free-roaming pigs and low hygiene standards. Despite the condition being generally known to be caused by infected pork, it has been noted that cysticercosis is caused by re-infection, that is, ingestion of cysts passed out through stool. The infection obtained through direct ingestion of infected, undercooked pork, water, fruit and vegetables is referred to as taeniasis.
In the past, neurocysticercosis (NCC) was referred to as a neglected disease together with echinococcosis but is now recognised as a major neglected tropical disease in the world[10]. This can be attributed to the increase in cases being diagnosed in tropical regions but without sufficient and accurate data on prevalence rates and the full extent of the infection[11]. Perhaps the absence of sensitization and lack of knowledge within communities on the existence of the disease can also be considered as a contributing factor to why some cases are missed. With the prevalence of HIV/AIDs, cysticercosis is now a frequent opportunistic infection, responsible for focal brain lesions in patients with HIV[12].
The patient presented with symptoms at the age of 47. However, most literature states that individuals often present in the first and second decade of life. In a study carried out in India to determine the clinical manifestations, diagnosis, management and outcome of orbital cysticercosis, the median age at presentation was found to be 13 years [13].
NCC commonly affects the brain parenchyma but can also be found in the ventricles, meninges, spinal cord, eye and subarachnoid spaces. Occurrence of these cysts in other sites has been associated with racemose cysts, which predispose to an even more complicated disease process [4].
In the case of our patient, the cysts occurred in the brain parenchyma and the orbit. The main symptom was presence of a painful discharging wound on the right lower eyelid, associated with poor vision. Studies have however shown that most patients with NCC present with seizures and NCC is considered to be the most common cause of adult-onset epilepsy in the United States [11]. A study carried out in 1993 involving extrapolation of the population at risk and adjusting for disease other than seizures indicated that 400,000 people had symptomatic NCC in Lower Middle-Income Countries (LMICs) [14]. This was deduced by estimating mainly the active epilepsy, by subtracting epilepsy rates in non-endemic regions from rates in endemic regions in Peru [14]. This information may not be applicable to all LMICs however, as differences do exist in terms of individual country population and endemicity. Recent studies have however, through determination of active epilepsy rates from 0.6% to 1.8%, indicated that between 450, 000 and 1.35 million people in LMICs suffer epilepsy due to NCC [14, 15, 16]. The seizures are due to calcified granulomas which may develop sporadic episodes of oedema, and in later stages, cause inflammatory responses [17].
Orbital cysticercosis occurs in approximately 4% of individuals with ocular cysticercosis. Despite occurring in the vitreous, subretinal space and subconjunctiva, the orbit is occasionally the site for cyst lodgement [18].
Ocular manifestations of NCC usually worsen as the larvae increase in size and may lead to blindness in 3 to 5 years. The parasites release toxins which cause severe inflammatory reaction and eventually lead to destruction of the ocular structures [19].This was noted in our patient, who presented with a wound on the lower eyelid as well as corneal melting that is corneal ulceration and stromal dissolution. The presence of a profuse purulent discharge clinically indicated superimposed bacterial infection although pus swab examination did not identify any growths on the media. The presence of the discharge can also be attributed to immunosuppression as a result of HIV/AIDs co-infection which pre-disposed the patient to other infections.
Investigations carried out included imaging studies such as computed tomography (CT), skull x-ray and ultrasonography (ocular B-Scan). The patient’s CT confirmed the presence of cysts in the brain parenchyma as well as the right orbit-a feature pathognomic with NCC. No cysts were noted in the anterior segment, and the B-scan did not pick any cysts in the posterior segment. Imaging studies such as high-resolution sonography, CT and magnetic resonance (MRI) have been noted to be most beneficial for identifying and diagnosing cysticercosis [19]. Serological tests such as Enzyme-linked immunotransfer blot (EITB) and enzyme linked immunosorbent assay (ELISA) to detect antibodies and co-agglutination were not carried out as resources were unavailable. Recent diagnostic advancements have seen the development of assays that are able to detect parasite antigens in serum and cerebral spinal fluid and can also be used to detect active infections. These assays however, are best used in combination with imaging.
In terms of treatment, larvicidal drugs such as albendazole and praziquantel are often used to kill the larvae[13]. According to WHO, there are currently no standard treatment guidelines for the management of NCC. Proposals have however been made. It has been noted, that the efficacy of albendazole and praziquantel is sub-optimal, with cure rates of 40 to 50% when the recommended dose is used [2]. Therefore, there is need for more effective alternatives. The patient received albendazole (400mg, once a day for three days) and praziquantel (2,600mg once a day for 15 days). Orbital cysts can be treated conservatively with a 4-week regimen of oral albendazole at 15 mg per kilogram per day [20].
The larvicidal drugs may cause an inflammatory response, occurring 2-5days after initiation of therapy and are therefore often combined with a corticosteroid to prevent this from occurring [21]. Rational use of corticosteroids has also been linked to a significant reduction in the occurrence of seizures, though studies are still underway [22]. The patient however, did not receive any steroids in view of the low CD4 count (64 cells/mm3), as a way of preventing further immunosuppression. In a study carried out in Latin America in 2006, in which 3 HIV positive individuals were treated for NCC, it was recommended that the CD4 count be considered in the diagnosis and treatment of NCC in individuals with HIV/AIDs. It was further recommended that a CD4 count of greater than 200, with a definite or probable chance of NCC occurring, should warrant the patient being considered for treatment of NCC [2].
Surgical removal of orbital cysts has not been well documented but has been noted to be very successful for subconjunctival cysts. It is recommended that serial B-Scan, CT and MRI be carried out in order to monitor the resolution of the cysts. Use of ventricular endoscopy to remove accessible ventricular cysts also results in reduced seizures and decreased morbidity [17].
Despite the treatment interventions instituted as well as the significant clinical improvement noted on consequent review appointments, the patient’s vision remained perception of light in the right eye due to the already existing melted cornea.
CONCLUSION
This case highlights the possibility of the occurrence of orbital cysticercosis in the Zambian population. It can present in an unusual form, with a wound on the lower eyelid as well as a melted cornea. The history could be for a longer duration like in this case, with a history of having had a conjunctival growth of one year prior to the presentation. Signs, symptoms and presentation of orbital cysticercosis are often non-specific and therefore require the clinician to have a high index of suspicion, backed by thorough assessment in order to be able to diagnose it.
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Human ocular infestation by a live filarial adult worm is a rare occurrence. These worms are caused by organisms such as Brugia malayi, Wuchereria bancrofti, Dirofilaria repens and many others. An unusual case of periocular filariasis was diagnosed at the Lusaka Eye Hospital in a female patient aged 47 years. This was in a patient whose profession is to deal with animals. She presented with twitching and feeling of movements on the eyelid. Following clinical examination and laboratory investigations, diagnosis of periocular filariasis was confirmed. The treatment consisted of the surgical extraction of the parasite, antibiotics, steroidal anti-inflammatory and anthelminthic drugs. The intraoperative and postoperative evolution of the case was favorable.
INTRODUCTION
The ocular manifestations of filariasis are elephantiasis of the eyelids, iritis, retinal hemorrhages, or the presence of microfilaria in the lacrimal gland secretion [1]. Intraocular infestation by the filarial worm is a rare occurrence in humans and most of the published reports are from Southeast Asia [2]. Entry into the anterior chamber may be through ciliary vessels. Lymphatic filariasis caused by Brugia malayi occurs in Southwest India, China, Indonesia, Malaysia, Korea, Philippines, and Vietnam [3]. Brugian filariasis is mainly a rural disease and is transmitted by mosquitoes of the genera Mansonia, Anopheles, and Aedes. Domestic animals like cats and dogs may serve as reservoirs of infection [4]. During a blood meal, mosquitoes ingest microfilaria and they become infective in 10 days. Humans contract the disease through repeated episodes of mosquito bite.
Dirofilaria repens (Spirurida, Onchocercidae) is a nematode that parasitizes mainly dogs (Canis lupus familiaris) and other mammals, but may also infect humans, being considered a zoonotic agent. The parasite’s most frequent localization in humans is in subcutaneous and ocular tissue (75.8%) [5,6], especially in the ocular area, which is accessible to mosquitoes that act as vectors. Adult parasites are found in subcutaneous tissues while the larvae (known as microfilariae) are found in the blood of the infested animals. They are ingested by mosquitoes of genera Aedes, Anopheles, or Culex during the blood meal. The larvae grow and become infective inside the mosquito’s body. Infective L3 larvae may be transferred to humans through inoculation when the mosquitoes feed.
CASE SCENARIO
A 47-year-old female patient, living in the USA who has frequent trips to Zambia and other African countries to carry out research in animals such as dogs, cats, pigs, rabbits, presented at a private hospital complaining of episodes of swelling of the lower and upper eyelids of the left eye. The patient could feel something moving in her eyelid for a period of 2 months before which she was asymptomatic. She was also complaining of twitching, discomfort in the upper eyelid, generalized body itchiness and episodes of fever. The private hospital referred her to Lusaka Eye Hospital for further management.
Ocular examination revealed a visual acuity of 6/6 in both eyes, normal intraocular pressure (14 mmHg in the right eye RE and 17 mmHg in the LE). A round formation containing a mobile thing in the subcutaneous tissue of the upper eyelid was observed. Examination of the fundus of the eye revealed a well-defined disc and macula and also normal blood vessels without the presence of other larval forms. Ultrasound performed revealed a larva in the eyelid.
General clinical examination did not reveal the presence of subcutaneous nodules. Heart ultrasound, abdominal ultrasound, and chest X-ray showed normal relations. Based on clinical examination and investigations, a diagnosis of subcutaneous ocular parasitosis was made.
The parasite was surgically removed. A worm removed was white, translucent and was measuring 8 cm. Surgery was successful and there were no post-surgical complications. Further treatment was instituted with Diethylcarbamazine 50 mg TID on days 1 and 2, then 100 mg TID on day 3 and 125mg TID on days 4 to 14.
Declaration of patient consent
The author certifies that consent was taken from the patient to publish her case. The patients understand that their names and initials will not be published, and due efforts will be made to conceal their identity.
DISCUSSION
The patient attended to at Lusaka Eye Hospital had a rare presentation of extraocular filariasis which did not give a lot of challenges with the surgical management. Microfilariae are more commonly known to cause intraocular filariasis than adult worms [3]. W. bancrofti and B. malayi are main causative organisms to cause uveitis secondary to intraocular filariasis in the Indian subcontinent [4]. W. bancrofti is a helminth belonging to class nematodes. Man is the definitive host, the intermediate host being species of Anopheles mosquitoes. In this case report, the interaction between the patient and domestic animals predisposed her to mosquito bites through which the larvae could be transmitted to her easily.
Adult worms live in the lymphatic system, discharging live embryos (microfilaria) into the bloodstream. Adult filarial worms are thread-like structures that live in the subcutaneous tissues and the lymphatic system. They sexually reproduce microfilaria, the first larval stage. Microfilariae are ingested by hematophagous arthropods, where they develop into infective larvae that grow in the vertebrate host and mature into adult worms. The exact route of invasion of microfilariae into the eye is still unknown. They enter the eye probably through the long and short posterior ciliary vessels, cerebrospinal fluid, or the optic nerve sheath [5].
Once a parasite is identified, it should be removed live and intact to prevent inflammation, damage to the eye and anaphylaxis. In the patient under discussion surgery was done cautiously in order to prevent any reactions. Ocular Filariasis though not commonly seen in the Zambian community, it is very important to always be on the lookout especially in patients who could present from other parts of the world. In this case the patient was not a resident of Africa but the fact that she handled the definitive hosts of the parasite, infestation could arise from there. It is therefore very important to have a high index of suspicion, to take a good history and perform a thorough ocular examination in patients presenting with ocular swellings. In the same vein the patients with uveitis of suspicious origin associated with diseases like elephantiasis and having had serious contacts with domestic animals must undergo thorough examination to rule out ocular filariasis.
CONCLUSION
Periocular and ocular filariasis is not common in our Zambian population but can be seen in patients coming from outside Zambia especially with the history of interacting with animals such as cats and dogs. Accurate diagnosis and early treatment bring out good outcome.
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