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Year : 2023  |  Volume : 3  |  Issue : 2  |  Page : 266-267

Exposing ophthalmia nodosa – The double eversion way

Department of Paediatric Ophthalmology and Strabismus, Aravind Eye Hospital, Madurai, Tamil Nadu, India

Date of Submission10-Oct-2022
Date of Acceptance30-Dec-2022
Date of Web Publication28-Apr-2023

Correspondence Address:
Priyarthi Pradhan
Department of Paediatric Ophthalmology and Strabismus, Aravind Eye Hospital and Post Graduate Institute of Ophthalmology, Madurai - 625 020, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJO.IJO_2643_22

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Ophthalmia nodosa is an inflammatory response of ocular tissue to caterpillar hair or any other insect hair that comes in contact with the eye. A young child with a painful red eye was found to have a dead caterpillar embedded in the upper tarsal conjunctiva. We describe the management and the need for creating awareness among doctors for timely suspicion of a foreign body.

Keywords: Caterpillar foreign body, corneal epithelial defect

How to cite this article:
Sankar J, Pradhan P, Shetty SB. Exposing ophthalmia nodosa – The double eversion way. Indian J Ophthalmol Case Rep 2023;3:266-7

How to cite this URL:
Sankar J, Pradhan P, Shetty SB. Exposing ophthalmia nodosa – The double eversion way. Indian J Ophthalmol Case Rep [serial online] 2023 [cited 2023 Jun 1];3:266-7. Available from: https://www.ijoreports.in/text.asp?2023/3/2/266/374963

The caterpillar is known to have notorious hair or setae, which may penetrate and cause ocular manifestations anywhere from lids, conjunctiva, cornea, iris, and vitreoretina. We report an interesting case of a completely dead caterpillar on the superior tarsal conjunctiva with a corresponding epithelial defect in the cornea.

  Case Report Top

A 7-year-old boy presented to our clinic with complaints of foreign body sensation, redness, pain, and photophobia in the right eye (RE) for the past four days. He gave a history of playing in fields 4 days prior to his symptoms. He underwent native treatment (foreign body removal with tongue) and further visited a local doctor, who prescribed topical antibiotics and ointment; however, the child found no relief.

At presentation, the visual acuity was 6/36 in RE and 6/6 in the left eye (LE). The anterior and posterior segment examination of the LE was within normal limits. The child had upper lid edema and diffuse conjunctival congestion in the RE. Slit-lamp examination revealed an irregular corneal epithelial defect of size 5 × 5 mm, involving the pupillary axis in the superonasal quadrant, without any inflammatory signs in the anterior chamber. On single eversion of either lid, no foreign body was found; however, on repeated double eversion of the upper lid of the RE, we found a linear foreign body, 8 mm long and 3 mm wide, which was coalesced with conjunctival discharge. The foreign body was grossly identified to be a dead caterpillar. It was then removed with forceps under topical anesthesia and was sent to the laboratory for histopathological analysis [Figure 1]. The remainder of the ocular examination was within normal limits. Topical antibiotic ointment was applied, and the eye was covered with a sterile pad and bandage. He was started on oral antibiotics and steroids for one week. The child was asked to review the next day. On follow-up, he was symptomatically better with partial resolution of corneal epithelial defect [Figure 2]. The child was started on topical antibiotic drops and ointment and advised periodic review. At one month, his best-corrected visual acuity was 6/6 in the RE, with normal anterior and posterior segments.
Figure 1: Complete caterpillar after retrieval from upper tarsal conjunctiva

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Figure 2: Healing epithelial defect, after foreign body removal

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  Discussion Top

The term ophthalmia nodosa was first used in 1904 to describe the granulomatous nodules which were formed on the conjunctiva and iris in response to caterpillar setae.[1] Since the first report in 1861 by Schon, multiple cases have been documented worldwide from time to time.[2] The first case of caterpillar hair involving the eye from north India was reported in 1968 by Gupta & Hari Gopal.[3]

The clinical presentations vary significantly and have been classified by Cadera et al.[4]

Type 1: An acute anaphylactoid reaction to the hairs consisting of chemosis and inflammation, which begins immediately and can last for some weeks.

Type 2: Chronic mechanical keratoconjunctivitis caused by hairs lodged in the bulbar or palpebral conjunctiva, leading to linear corneal abrasions.

Type 3: Formation of gray–yellow conjunctival granulomatous nodules. The setae may be subconjunctival or intracorneal, and the patient may be asymptomatic.

Type 4: Iritis secondary to penetration of setae in the anterior segment.

Type 5: Vitreoretinal involvement (l 0–20%) after hair penetrates the posterior segment. The effects range from mild vitritis with or without cystoid macular edema to a frank endophthalmitis and may present even years later.

The patients can develop some or all of these features. The causative factor is presumed to be either toxicity from the release of urticating proteins or due to the mechanical effects of a foreign body.[5]

Sengupta et al.[6] reported a retrospective analysis of 544 eyes with caterpillar hair-induced ophthalmitis of which 19 eyes developed intraocular migration of hair. They concluded that the presence of deep intracorneal hair was the only risk factor for intraocular penetration. Agarwal et al.[7] described a single patient having multiple caterpillar hair in cornea, sclera, and pars plana, presenting with recurrent vitritis and pars planitis, which was localized by ultrasound biomicroscopy. The patient underwent pars plana vitrectomy. Sood et al.[8] reported a case series of 136 patients who encountered caterpillar hair injury over a period of 6 months. Patients showed variable features ranging from an acute inflammatory reaction to intracorneal migration of setae; all of them resolved with no long-term sequelae.

A case of unilateral hypertensive keratouveitis was reported by Conrath et al.,[9] which revealed a predescemet caterpillar hair, once cornea cleared after 5 days of treatment. Although the numerous presentation of ophthalmia nodosa is quite common, it can be missed easily, especially in children, where cooperation is often questionable. The conjunctival congestion is usually diffuse but can be localized at times, providing a clue to the presence of the setae. Slit lamp examination commonly reveals linear corneal abrasions indicating a sharp foreign body. The pattern of the abrasions, as seen after fluorescein staining, seems to be very important in locating the setae. Numerous abrasions indicate multiple hairs, while a few scratches are frequently due to a single hair. Finding a large epithelial defect would indicate a large foreign body which can be deeply hidden in the upper tarsal conjunctiva. A thorough search for retained setae is mandatory, including double eversion of the eyelids, as a single eversion may not always reveal the culprit. The patients need to be under regular review to avoid serious vision-threatening complications.

Lid eversion technique: Turning of the eyelid inside out so as to expose the palpebral conjunctiva. For the upper lid, this is accomplished by grasping the lid by the central eyelashes, pulling it downward and forward and then folding it back over a cotton applicator (or thin plastic rod) placed at the upper margin of the tarsus, while the patient continually maintains downward fixation. Return to the normal lid position is obtained by asking the patient to look up and gently pushing the eyelashes in an outward and downward direction. Foreign bodies and even contact lenses are often lodged under the upper eyelid or in the conjunctival fornix of the upper eyelid. To inspect the superior conjunctival fornix, double lid eversion is necessary. Following lid eversion (usually after instilling local anesthesia of the conjunctiva), a retractor is placed between the two skin surfaces of the lid with the retractor engaging the tarsus, and after gently pulling outward and upward, the fornix will become visible. Eversion of the lower lid is performed easily by drawing the margin downward while the patient looks upward.

The majority of cases fall into Type 1 to Type 3 categories, who respond well to setae removal and use of low-dose topical steroids. In patients with large epithelial defect and absence of significant intraocular inflammation, as was in our case, we prefer to avoid topical steroids, at least till the defect resolves.

  Conclusion Top

The report highlights the need for awareness among doctors to suspect the diagnosis of a foreign body in a painful red eye with corneal abrasions. A good history taking along with a meticulous examination of the eyelids, including repeated double eversion, is warranted in such cases, especially in pediatric population.

Declaration of patient consent

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

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Conflicts of interest

There are no conflicts of interest.

  References Top

Saemisch T. Ophthalmia nodosa. In: Graefe-Saemisch Handbuch der gesamten Augenheilkunde. 2nd ed. Vol. 5. Leipzig: W Engelmann; 1904. p. 548-64.  Back to cited text no. 1
Schon MJA. Beitrage zur praktischen Augenheilkunde. Hamburg: Hoffman and Campe; 1861. p. 163.  Back to cited text no. 2
Gupta JS, Gopal H. Orient Arch Ophth 1968;6:306-7.  Back to cited text no. 3
Cadera W, Pachtman MA, Fountain JA, Ellis FD, Wilson FM 2nd. Ocular lesions caused by caterpillar hairs (ophthalmia nodosa). Can J Ophthalmol 1984;19:40-4.  Back to cited text no. 4
Watson PG, Sevel D. Ophthalmia nodosa. Br J Ophthalmol 1966;50:209-17.  Back to cited text no. 5
Sengupta S, Reddy PR, Gyatsho J, Ravindran RD, Thiruvengadakrishnan K, Vaidee V. Risk factors for intraocular penetration of caterpillar hair in Ophthalmia Nodosa: A retrospective analysis. Indian J Ophthalmol 2010;58:540-3.  Back to cited text no. 6
[PUBMED]  [Full text]  
Agarwal M, Acharya MC, Majumdar S, Paul L. Managing multiple caterpillar hair in the eye. Indian J Ophthalmol 2017;65:248-50.  Back to cited text no. 7
[PUBMED]  [Full text]  
Sood P, Tuli R, Puri R, Sharma R. Seasonal epidemic of ocular caterpillar hair injuries in the Kangra District of India. Ophthalmic Epidemiol 2004;11:3-8.  Back to cited text no. 8
Conrath J, Hadjadj E, Balansard B, Ridings B. Caterpillar setae–induced acute anterior uveitis: A case report. Am J Ophthalmol 2000;130:841-3.  Back to cited text no. 9


  [Figure 1], [Figure 2]


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