Indian Journal of Ophthalmology - Case Reports

CASE REPORT
Year
: 2022  |  Volume : 2  |  Issue : 3  |  Page : 688--690

Ophthalmia nodosa presenting as pan-uveitis and infective scleral abscess


Radhika Thundikandy, Rajesh Vedhanayaki, S Anjana, SR Rathinam 
 Uvea Services, Aravind Eye Hospital, Tamil Nadu, India

Correspondence Address:
Dr. Radhika Thundikandy
Consultant, Uvea Services, Aravind Eye Hospital and Post Graduate Institute of Ophthalmology, Madurai, Tamil Nadu
India

Abstract

A 38-year-old gentleman presented with bilateral ocular inflammation following fall of caterpillar hair. Examination revealed caterpillar hairs embedded in the palpebral conjunctiva, corneal abrasions, and anterior chamber reaction. The hairs were removed and topical antibiotics were initiated. Later, he presented with multiple scleral abscesses, retinal exudates, and sub-tenons fluid on B scan. The scleral abscesses were drained and treated with appropriate antibiotics and oral steroids. The abscesses and retinal exudates resolved with scleral thinning. This is the first report of ophthalmia nodosum presenting with scleral abscesses and panuveitis.



How to cite this article:
Thundikandy R, Vedhanayaki R, Anjana S, Rathinam S R. Ophthalmia nodosa presenting as pan-uveitis and infective scleral abscess.Indian J Ophthalmol Case Rep 2022;2:688-690


How to cite this URL:
Thundikandy R, Vedhanayaki R, Anjana S, Rathinam S R. Ophthalmia nodosa presenting as pan-uveitis and infective scleral abscess. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Sep 26 ];2:688-690
Available from: https://www.ijoreports.in/text.asp?2022/2/3/688/351157


Full Text



Ophthalmia nodosum is an inflammation caused by the hairs of certain insects, especially caterpillars. The hairs get embedded in the palpebral conjunctiva causing severe tissue reactions. The tissue reaction is due to the mechanical and toxic effects of the glandular secretion at the base of the hair.[1] It can manifest as severe conjunctivitis, chemosis, corneal abrasions, iridocyclitis, and panuveitis.[2],[3]

 Case Report



A 38-year-old male patient presented with acute pain, irritation, and pricking sensation in both eyes, and defective vision in the right eye following the fall of caterpillar larvae while cleaning the roof of his house. Vision in the right eye was 6/36 and in the left eye was 6/12. The intraocular pressures were normal in both eyes as measured by a non-contact tonometer. There was gross lid edema, conjunctival congestion, and chemosis. Multiple caterpillar hairs were detected in the upper and lower palpebral conjunctiva with small follicles where the caterpillar hairs were embedded. The cornea showed vertical and horizontal criss-cross abrasions.

The hairs were meticulously removed with fine forceps. Hairs that were embedded deeper and that could not be removed with forceps were teased out using a 26 G needle attached to a syringe. The patient was given topical chloramphenicol eye drops and ointment for both eyes for a week. On review, chemosis and corneal abrasions had reduced but he had developed multiple scleral abscesses in his right eye [Figure 1]. There was moderate-to-severe anterior chamber reaction and posterior synechia. The posterior segment showed vitritis and retinal exudates in the inferotemporal quadrant [Figure 2]. The B mode ultrasonogram of the right eye showed sub-tenons fluid and localized choroidal thickening [Figure 3].{Figure 1}{Figure 2}{Figure 3}

The scleral abscesses were incised and drained pus was sent for culture. The culture showed growth of Pseudomonas aeruginosa and the patient was given a course of parenteral amikacin with oral levofloxacin for a week according to the sensitivity report. The scleral abscesses healed well and there was resolution of the retinal exudates. The scleral inflammation and choroidal thickening persisted but eventually resolved after a short course of low-dose oral corticosteroids [Figure 4]. Repeat B scan showed resolving sub-tenons fluid and choroidal thickening [Figure 5]. However, the involved sclera was grossly thinned out.{Figure 4}{Figure 5}

 Discussion



Insect hairs enter the eyes by direct contact with the insect or are blown by the wind. In a majority of case reports, caterpillars are encountered in the homes where they hide during pupation.[4] They are sometimes found in the gardens and plantations and fall into the eyes when the branches are cut. Our patient fell prey to the caterpillars while cleaning the roof. When hairs are blown by the wind, the insect is not sighted. One needs to have a strong index of suspicion, especially when severe acute blepharospasm is associated with corneal abrasions.

The caterpillar hairs get embedded in the upper and lower palpebral conjunctiva and the fornices. There is an intense inflammatory reaction due to the release of toxins at the base of the hairs. This results in lid edema, conjunctival chemosis, and congestion. Vigorous rubbing of the eyes leads to the migration of the hairs into the deeper tissues within the eyes. This leads to iridocyclitis and even panuveitis. Mechanical rubbing of the lids against the cornea results in vertical and oblique abrasions, which on fluorescein staining give a criss-cross pattern. Caterpillar hairs may sometimes be embedded in the corneal stroma surrounded by a localized inflammatory reaction. In one study, deep intracorneal setae were found to be the only risk factor for intraocular penetration.[5] Our patient however did not have any demonstrable corneal stromal hairs and we believe penetration through the scleral has resulted in intraocular inflammation.

Caterpillar hairs may have barbs or they may be smooth without barbs. Hairs without barbs tend to gain easier access to the ocular tissues by the mechanical action of the lids, movement of the globe, or rubbing. In our patient, the hairs embedded in the sclera had resulted in multiple scleral abscesses, which subsequently showed secondary infection with Pseudomonas. The inflammatory response in the anterior chamber, vitreous and retinal exudates are due to the presence of caterpillar hairs that have gained intraocular access. We strongly believe that the localized choroidal thickening with sub-tenon fluid is caused by embedded hair.

Primary management includes meticulous removal of all caterpillar hairs under the slit lamp, followed by topical steroid and antibiotic drops. Hairs that were missed in the initial examination or that protrude out in the subsequent visits will continue to cause pricking pain and inflammation. Removal of these setae is mandatory for complete resolution. Scleral abscesses, if present, as in our patient, need surgical drainage and appropriate antibiotic therapy for the infection, followed by oral corticosteroids to control the residual scleral and intraocular inflammation. Usually, caterpillar hair causes significant ocular inflammation requiring the use of corticosteroids alone. However, our patient had an associated infective scleral abscess. The use of corticosteroids alone in the management of this patient would have been detrimental. So, we treated the infection with drainage of the infectious abscesses, followed by topical and systemic antibiotics and oral corticosteroids. Furthermore, conjunctival nodules with embedded setae require surgical removal.[6]

 Conclusion



The fall of an insect in the eyes can cause a wide range of manifestations ranging from conjunctivitis to severe intraocular infection and inflammation including panuveitis, pan ophthalmitis, and scleral abscesses. There is a need for meticulous removal of the setae and repeated examination each on every visit until all the setae are removed. Scleral abscesses require surgical drainage of the pus. The pus has to be cultured and antibiotic treatment instituted according to the sensitivity. Oral corticosteroids should be added for inflammatory control. Prognosis is usually good provided the condition is diagnosed early and treated appropriately.

Declaration of patient consent

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

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Lamy M, Pastureaud MH, Novak F, Ducombs G, Vincendeau P, Maleville J, et al. Thaumetopoein: An urticating protein from the hairs and integument of the pine processionary caterpillar (Thaumetopoea pityocampa Schiff, Lepidoptera, Thaumetopoeidae). Toxicon 1986;24:347-56.
2Grewal SS, Sud RN. Ocular injuries due to caterpillar hairs. Indian J Ophthalmol 1976;24:14-7.
3Horng CT, Chou PI, Liang JB. Caterpillar setae in the deep cornea and anterior chamber. Am J Ophthalmol 2000;129:384-5.
4Sethi PK, Dwivedi N. Ophthalmia nodosa. Indian J Ophthalmol 1982;30:11-4.
5Sengupta 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.
6Gaur A, Rohatgi J, Srivastava S. A rare case of ophthalmia nodosa. Delhi J Ophthalmol 2022;30:62-4. DOI: http://dx.doi.org/10.7869/djo.484.