Ocular cysticercosis of the anterior segment

Maria A. Cortez, MD,a Gian P. Giuliari, MD,a Luis Escaf, MD,b Sonia Escaf, MD,b and Claudia Vidal, MDb

A 6-year-old girl presented with signs of severe anterior uveitis. After initiating treatment, a cyst like lesion was observed in the anterior chamber that led to the diagnosis of ocular cysticercosis that was ultimately conrmed with histopathologic analysis. Ocular cysticercosis usually affects the extraocular muscle. Infection of the anterior chamber has been described, although to a lesser extent. Because of the usually poor visual prognosis and the controversy in treatment, physicians should be aware of this disease and its different variants of presentation.

he eye is most commonly affected by three major nematode species and one cestode species. Taenia solium, a cestode, has been associated with human ocular cysticercosis.1 There are two clinical subtypes of cysticercosis: focal (orbital cysticercosis) and systemic (ocular cysticercosis).1 We described a rare case of severe unilateral anterior uveitis caused by ocular cysticercosis.

Case Report
A 6-year-old girl presented with decreased visual acuity in her left eye associated with ocular hyperemia and mild pain. Examination of the right eye was within normal limits. In the left eye, visual acuity was counting ngers and intraocular pressure was within normal range. On slit-lamp examination conjunctival injection, corneal edema, cells in the anterior chamber, and 10% hypopyon were noted. The posterior segment, although obscured by the anterior segment ndings, appeared normal. Treatment was initiated with oral moxioxacin 200 mg for 5 days and topical prednisolone 1%. Partial clearing of the ocular media occurred 1 week after the treatment began. At this point, a cystlike lesion was seen in the anterior chamber at 6 oclock (Figure 1). However, the denite diagnosis was delayed by the unrelenting obscured view secondary to the persistent inammatory reaction in the anterior segment. Three weeks later, media opacity completely cleared, and an evident growth of the lesion was observed. Also noted was the exiting of a scolex from the cyst (Figure 2). This

FIG 1. Cystlike lesion in the anterior chamber at 6 oclock.

FIG 2. Same cystlike lesion after 3 weeks, noting a signicant growth. Scolex exiting the cyst.

Author afliations: aCentro de Ciruga Oftamologica, Caracas, Venezuela; and bClinica Oftalmologica del Caribe, Barranquilla, Colombia Submitted April 26, 2007. Revision accepted July 5, 2007. Published online October 8, 2007. Reprint requests: Gian Paolo Giuliari, MD, Valley Retina Institute, PA, 1309 E. Ridge Road, Suite 1, McAllen, Texas 78503 (email: gpgiuliari@gmail.com). J AAPOS 2007;11:628-629. Copyright 2007 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/2007/$35.00 0 doi:10.1016/j.jaapos.2007.07.003

led to the clinical diagnosis of cysticercosis. An excisional biopsy was performed without any complications and the sample was sent for further pathologic analysis, which eventually conrmed the diagnosis of ocular cysticercosis (Figure 3). Magnetic resonance imaging (MRI) was performed to exclude neurocysticercosis. No apparent central nervous system involvement was noted. At 2 month follow-up the patient remained stable with an improved visual acuity of 20/30 in her left eye with a mild residual astigmatism.

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sonography, ELISA testing, and/or tissue biopsy may be required.1 In our case, the diagnosis was conrmed by a positive tissue biopsy and histopathologic analysis. For those lesions that are not surgically accessible, systemic antihelminthics have proven to be a good treatment option. Initiation of systemic antihelminthic therapy can often lead to a severe inammatory response due to the degradation product associated with the death of the parasitic organism.7 This is an important consideration since adjuvant steroids are often required to manage the severe uveitis associated with these difcult cases. Combination treatment of albendazole and prednisolone5 and praziquantal and corticosteroids1 is suggested for such cases. Literature Search MEDLINE was searched for the following keywords from 1970 to the present: ocular cysticercosis, ocular parasites, and infection uveitis. Only articles and abstracts mentioning anterior segment involvement of cysticercosis were considered.
References

FIG 3. Histopathologic analysis of the cysticercus cyst. The head of the scolex is found inside the vesicle. Note the cavity with walls folded in the interior, which is the alimentary canal and laterally the apparatus of suction of the larva, where it has four cupping glasses and one double crown of hooks.

Discussion
There are only a few reports in the literature describing a cysticercal cyst within the anterior chamber, and none of these cases developed anterior uveitis.2-4 In contrast, our patient presented with severe anterior uveitis associated with enlargement of a cysticercal cyst in the anterior chamber. A retrospective study conducted on cases of ocular cysticercosis demonstrated the most commonly affected age group to be between 11 and 20 years.5 The most frequent sites of involvement are the extraocular muscles, the subconjunctival space, the eyelids, the optic nerve, the retroorbital space, and the lacrimal gland.6 Diagnosis can usually be made by direct visualization of cysts in the eye, but when uveitis is present, B-scan ultra-

1. Ament CS, Young LH. Ocular manifestations of heminthic infections: Onchocersiasis, cysticercosis, toxocariasis, and diffuse unilateral subacute neuroretinitis. Int Ophthalmol Clin 2006;46:1-10. 2. Sachdeva R, Manchanda SK, Abrol S, Wadhwa SC, Ramachandran KA. Freely mobile cysticercus in the anterior chamber. Indian J Ophthalmol 1995;43:135-6. 3. Das JC, Chaudhuri Z, Bansal RL, Bhomaj S, Sharma P, Chauhan D. Viscoexpression of anterior chamber cysticercus cellulosae. Indian J Ophthalmol 2002;50:133-5. 4. Beri S, Vajpayee RB, Dhingra N, Ghose S. Managing anterior chamber cysticercosis by viscoexpression: A new surgical technique. Arch Ophthalmol 1994;112:1279-80. 5. Pushker N, Kashyap S, Gautam VP, Bajaj MS. Ocular cystecercosisa prole. Trop Doct 2004;34:256. 6. Pushker N, Bajaj MS, Betharia SM. Orbital and adnexal cysticercosis. Clin Exp Ophthalmol 2002;30:322-33. 7. Guignon B, Trepsat C. Intraocular cysticercosis: A difcult diagnosis. J Fr Ophthtalmol 2002;25:78-80.

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