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 Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 2  |  Issue : 1  |  Page : 82-84

Challenges in the management of intraocular parasitic infections


Department of Opthalmology, Sadguru Netra Chikitsalaya, Jankikund, Chitrakoot, Madhya Pradesh, India

Date of Web Publication14-Jan-2015

Correspondence Address:
Dr. Ashish Mitra
Sadguru Netra Chikitsalaya, Jankikund, Chitrakoot - 210 204, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2348-3334.149357

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  Abstract 

Parasitic worms in eye is something which is not very uncommon these days. People who eat undercooked food and have pets at home are at more risk to have parasitic infections. Chemoparalysis has been reported in literature using either viscoelastics or preservative free lidocaine (intracamerally) to paralyze the worms that help in retrieval, but still one can face tricky situations while managing such conditions. Importance lies in the management of such cases as it can be really challenging at times and no report exists in the literature which mentions the importance of topical lidocaine along with viscoelastics or preservative free lidocaine for retrieval of the worm.

Keywords: Chemoparalysis, parasitic infection, topical lidocaine, worm in anterior chamber


How to cite this article:
Mitra A, Sen A, Jain E, Dogney S. Challenges in the management of intraocular parasitic infections. CHRISMED J Health Res 2015;2:82-4

How to cite this URL:
Mitra A, Sen A, Jain E, Dogney S. Challenges in the management of intraocular parasitic infections. CHRISMED J Health Res [serial online] 2015 [cited 2019 Nov 17];2:82-4. Available from: http://www.cjhr.org/text.asp?2015/2/1/82/149357


  Introduction Top


Parasitic worms are responsible for some of the most debilitating and chronic infectious diseases of the human and animal population. [1] A study done in southwestern Nigeria on the environmental risk factors at open vegetable markets revealed 68.3% of the vegetables to be positive for intestinal parasites eggs, of which water leaf recorded the highest (100%) contamination. [2] Parasites were found to be highly prevalent in pet animals, but the pet owners were not aware of the risk involved. [3],[4] Despite, it is difficult to ascertain the source of infection.

Herein, we present a series of four cases of intra-ocular parasites. In all our cases, vision was recorded at presentation and at each follow-up. The B scan and ultrasound biomicroscopy (UBM) were routinely done to rule multiple worms, including the angle of eye. Deworming therapy included antifilarial regimen (since this area is endemic for filariasis) along with albendazole was given by the treating physician for appropriate duration.


  Case Report Top


Case 1

A 19-year-old female presented to our out-patient department with complaint of mild irritation in the right eye (RE) since 1 month. She was diagnosed as having worm by a local Ophthalmologist [[Figure 1]a]. She had taken deworming therapy and was on oral wysolone and topical prednisone drops. Examination revealed motile worms in RE with + 1 cells in anterior chamber and visual acuity of 6/6. Fundus of the RE showed subretinal tracts depicting the movement of worm in retina [[Figure 1]d]. Fundus of the left eye (LE) was normal.
Figure 1: (a-c) showing live worm in anterior chamber, (d) showing subretinal tracts depicting movement of the worm, (e) showing cysticercosis cyst with localised retinal detahment, (f) showing post-operative settled retina after removal of cyst and retinal detachment surgery

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On dilated fundus evaluation to look for any other worms, resulted in the disappearance of worm, posteriorly, and was not located even on detailed fundus examination by Indirect Ophthalmoscopy and UBM. Although, in literature it is mentioned that giving prone position to the patient may facilitate migration of worm back into the anterior chamber. [5] In our patient advising prone position was not helpful. Since the patient was on oral steroids and topical steroids, she was symptomatically better so as both the forms of therapy were tapered and she was advised to be on regular follow-up. At 2 and 4 months of follow-up visual acuity were 6/6 with no reaction in anterior chamber and no presence of worms located on detailed fundus examination. In the natural course, the worms will die off after sometime and may cause inflammation in the eye requiring steroid therapy.

All her systemic examination, complete blood picture (CBC), stool and urine examination all were within normal limits.

Case 2

A 25-year-old male presented to our OPD with complaints of blurring and irritation in RE and visual acuity was 6/36 at presentation. On ocular examination, he had motile worm in his RE with corneal edema and 1+ cells [[Figure 1]b]. Fundus of the same eye showed subretinal tracts depicting the movement of worms in the retina. Rest ocular examination was within normal limits in both eye.

On removal by performing paracentesis in an undilated pupil, side port was made to use intracameral viscoelastics to paralyze the worm without using topical licopcaine, the worm being so small and highly motile was removed but lost in the irrigating fluid. Patient was started on topical gatifloxacin and prednisolone drop for 4 weeks in tapering doses. At 1, 3 and 6 months follow-up there was no recurrences. However, his visual acuity was 6/36 due to scarring corresponding to subretinal tracts (depicting worm migration).

Case 3

A 28-year-old male presented to our OPD with complains of blurring of vision, irritation in LE since 2 months. He had no complaints in RE.

Visual acuity in RE was 6/6 and anterior and posterior segments were within normal limits.

Best corrected visual acuity (BCVA) of his LE was 6/36. Circumciliary congestion along with corneal edema and cells 2+ were present in anterior chamber along with a highly motile worm [[Figure 1]c]. Fundus dilatation was done using topical lidociane to make the worm slightly sluggish to prevent migration of worm posteriorly and rule out any other worms involving posterior segment. Rest ocular examination was within normal limits.

The worm was removed using topical lidocaine and and then intracamerally (to paralyze the worm) along with topical pilocarpine (to constrict the pupil and prevent posterior migration) [Figure 2].
Figure 2: Histological analysis of worm retrieved in Case C

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Patient was started on topical therapy (antibiotic steroid combination - Topical flouroquinolone plus prednisone drops were prescribed along with cycloplegic drops) and his BCVA improved to 6/6 in 3 weeks time and there was no recurrences till 6 months follow-up.

Case 4

A 32-year-old male presented to our OPD with diminution of vision in RE since 2 months. On examination, his anterior segment was within normal limits in both eyes. Visual acuity in RE was 6/24 and LE was 6/6. Fundus examination revealed sub retinal cyst with localized retinal detachment involving superior arcade and ocular cysticercosis [[Figure 1]e].

Patient underwent 20G pars plana vitrectomy with removal of cyst by enlarging vitrectomy cutter port, endolaser and silicon oil insertion was done. Silicon oil was removed three months after surgery and patient attained BCVA of 6/18 [[Figure 1]f].

In Cases B, C and D - systemic examination, complete blood picture, stool and urine examination all were within normal limits except for eosinophilia and all the patients were advised deworming therapy.


  Discussion Top


Worms in anterior and posterior chamber have been reported but importance lies in management of such cases. [5],[6],[7],[8],[9],[10] All our patients were non-vegetarian and had pets at home.

In Case A, the worm being small, we did not realize that dilatation could cause the worm to move posteriorly and so making it unretrievable. In Case B, viscoelastics was used to paralyze the worm but the worm being highly motile was lost with the irrigating fluid as topical lidocaine was not used to make it sluggish and so it was removed but could not be retrieved. In Case C, the worm was live large and highly motile, we used topical lidocaine before dilatation to make the worm sluggish (to prevent posterior migration) and we had a detailed fundus examination. Pilocarpine (to constrict the pupil) and topical lidocaine along with chemoparalysis was used before surgical removal. Fourth case was managed surgically and attained good visual acuity.

Few things to remember

  • All worms should be removed as they may cause uveitis with endothelial damage (eg. Live motile worm in anterior chamber) and some worms (eg. helminths) may cause Diffuse Unilateral Subacute Neuroretinitis (DUSN) [10]
  • Dilated fundus examination under topical anesthesia to make the worm sluggish, especially if the worm is small as there is a chance that the worm might go posteriorly; hence, dilated fundus examination is necessary to rule out multiple worms involving posterior segment as in case of posterior segment worm along with anterior chamber worm will require a different approach
  • Removal of worm from anterior chamber of the eye by paracentesis using lidocaine topically initially for four to six times to make the worm sluggish and then use it intra-camerally (preservative free lidocaine)/viscoelastics to paralyze it so as to help retrieval of live worm [8],[9]
  • Pre-operative use of pilocarpine for removing worm from anterior chamber along with lidocaine can also be used to prevent the migration of worm posteriorly
  • In case of posterior migration of the worm, prone positioning coupled with dilatation of pupil can be tried as that may induce migration into the anterior chamber from the vitreous [5]
  • Posterior segment worms/cyst (dormant form) will require Pars plana vitrectomy [10]
  • Pars plana vitrectomy is done for endophthalmitis, vitreo-retinal tractions, and retinal detachments. [10]
  • Dead parasite causing acute uveitis (ruptured cysticercosis) - steroids [10]
  • Dead parasite chronic granuloma - corticosteroids along with surgical removal [10]


With these things in mind one can achieve a better outcome in our patients with such manifestations.

 
  References Top

1.
Peak K, Hoffmann KF. Cross-disciplinary approaches for measuring parasitic helminth viability and phenotype. An Acad Bras Cienc 2011;83:649-62.  Back to cited text no. 1
    
2.
Ogbolu DO, Alli OA, Ogunleye VF, Olusoga-Ogbolu FF, Olaosun I. The presence of intestinal parasites in selected vegetables from open markets in South Western Nigeria. Afr J Med Med Sci 2009;38:319-24.  Back to cited text no. 2
    
3.
Ugbomoiko US, Ariza L, Heukelbach J. Parasites of importance for human health in Nigerian dogs: High prevalence and limited knowledge of pet owners. BMC Vet Res 2008;4:49.  Back to cited text no. 3
    
4.
4. Pfukenyi DM, Chipunga SL, Dinginya L, Matenga E. A survey of pet ownership, awareness and public knowledge of pet zoonoses with particular reference to roundworms and hookworms in 4. Harare, Zimbabwe. Trop Anim Health Prod 2010;42:247-52.  Back to cited text no. 4
    
5.
Chopra R, Bhatti SM, Mohan S, Taneja N. Dirofilaria in the anterior chamber: A rare occurrence. Middle East Afr J Ophthalmol 2012;19:349-51.  Back to cited text no. 5
[PUBMED]  Medknow Journal  
6.
Kai S, Vanathi M, Vengayil S, Panda A. Viscoexpression of large free floating Cysticercus cyst from the anterior chamber of the eye by double incision technique. Indian J Med Microbiol 2008;26:277-9.  Back to cited text no. 6
[PUBMED]  Medknow Journal  
7.
Yadav RY, Ghosh A, Sharma K, Ahmad S. Atypical presentation of live cysticercus larva in anterior chamber. J Indian Med Assoc 2013;111:264-5.  Back to cited text no. 7
    
8.
Thu TP, Nguyen NX, Lan le T, Küchle M. Ocular angiostrongylus cantonensis in a female Vietnamese patient: Case report. Klin Monbl Augenheilkd 2002;219:892-5.  Back to cited text no. 8
    
9.
Mehta DK, Arora R, Chauhan D, Shroff D, Narula R. Chemo-paralysis for the removal of a live intraocular worm in ocular angiostrongyliasis. Clin Experiment Ophthalmol 2006;34:493-5.  Back to cited text no. 9
[PUBMED]    
10.
Rathinam SR, Annamalai R, Biswas J. Intraocular parasitic infections. Ocul Immunol Inflamm 2011;19:327-36.  Back to cited text no. 10
    


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