#ciliary body

page 172 - this is what I feel like the morning after. The week after, more like. I’m getting OLD! And EXTREMELY MALNOURISHED!

pages 171c and 172 - That. Party. Was. Crazy.

At one point I thought someone had taken their shirt off and my eyes had left my head and started to float around the room.

I stabbed my eyes in the direction of the topless person only to discover it was some sort of slime mould growing on the wall in the shape of a breast. Don’t touch things with your open eyes, kids, because It really stung and now I can’t see anything.

pages 171c and 172 - This is my kind of crew!

Helmet protects your head.

Goggles protect your eyes.

page 172 - is this owl holding:

a - delicious nuts

b - the eyes of another owl

Abstract

Objective: To describe a clinical case of external ophthalmomyiasis in a 55 year old man from Umbria, Italy. We are also taking into consideration a differential diagnosis of Onchocerciasis and Cisticercosis.

Design: Case Report Interventional

Participants:1 patient, 2 eyes in an interventional case report

Methods:biomicroscopic examination, surgical removal of the larve, medical treatment, laboratory examination of the specimen and blood screening

Main Outcome Measures:It was not possible to obtain microscopic evidence of the larvae. Blood screening and examination of the specimen was negative but the biomicroscopic evidence of the parasites, together with documented information, made the diagnosis relatively easy

Conclusions:The difference in clinical signs and negative laboratory tests allowed us to exclude all the diseases mentioned above. With case study, we hope to be able to aid in simplifying the diagnosis of this pathology for our colleagues.

Keywords: Ocular Pain; Melanoma; Ciliary Body; Cataract

Abbreviations: BCVA: Best-Corrected Visual Acuity; NMR: Nuclear Magnetic Resonance

Introduction

Ophthalmomyiasis is an infection of the eye by Diptera larvae. Oestrus Ovis is the most frequent cause of ocular myiasis especially in countries with tropical or mild climates [1]. The presence of this pathogen is widely seen in Central and Southern Italy and the islands where sheep farming is common [2]. Ophthalmomyiasis, based on its location, is classified as external, internal and/ or orbital. In its external form the larvae are found on the conjunctiva or on the edge of the eyelid [3]. With accidental contact this can give rise to inflammation of the conjunctiva. The patient may also experience lacrimation, photophobia and foreign body sensation in the eye.

Case History

55 year old male patient, telephoned from Umbria where he was attending an open air public manifestation. He stated that, whilst sitting under a tree the previous evening, he had the sensation that something had “hit” his left eye. He complained of foreign body sensation, pain and photophobia throughout the night. He was advised to come to our private practice. At 14.00 h he arrived. His general condition was good. His left eye was red, painful and intensely photophobic. A biomicroscopic examination revealed numerous tiny worms in rapid movement (Figure 1). The worms were removed by using forceps, cotton buds and continuous irrigation of the inferior and superior conjunctival sac with a iodopovidone 5% solution and netilmycin sulphate 0.455g eye drops equal to 0300g. The patient was then treated with netilmycin sulphate ointment every two hours. At 22.00 h after a second biomicroscopic examination more larvae were removed. Some larvae were preserved in test tubes containing tears and others were placed on slides to be microscopically examined in the laboratory.

The specimens (slides and lacrimal liquid collected in tubes) were examined immediately. One drop of physiological solution at 0, 9% was added to the lacrimal fluid and placed on dry glass slides and observed microscopically (first at 10x field and then 40x). No Diptera larvae were found, because they had dissolved. Giemsa slides at 3% were prepared next. This stain is used to highlight the visibility of other forms of parasites, particularly nematodes and larvae of platelminta cestodes. Thin films of lacrimal liquid were fixed with methanol and then stained with Giemsa at 3% Microscopic examination, at 1000x with an oil immersion lens revealed no parasites.

The following day a blood sample was drawn and biomicroscopic examination revealed the presence of a few slow moving larvae. These were removed with forceps. A complete and thorough examination (vision, IOP, anterior chamber, vitreous and fundus) was normal aside from conjunctival injection. An examination two days later showed the presence of cysts situated in the conjunctiva (Figure 2). The base of the cysts was pearl in color but the upper part was transparent. Haemato chemical tests were negative and a diagnosis of ophthalmomyiasis was made based on physical evidence. An examination six days later revealed a slight reduction in the size of the cysts and an absence of larvae. After eight days the cysts were in a phase of regression and the conjunctiva was no longer inflamed.

Discussions

The term myiasis means the invasion of human tissue by parasites of the type Diptera. The first case of ocular myiasis was described by Keyt in the 1900s [1]. The ocular form can be external, internal or orbital and is commonly associated with Oestrus Ovis [4]. Infestation occurs when the female lays her eggs on the skin or mucous membrane. Stimulated by the warmth these eggs evolve into larvae that are about 1.5 mm in size. The larvae then penetrate the skin or mucous membrane in a few minutes. Penetration inside the eye occurs from perforation of the sclera which allows the larvae to move below the retina. This may leave a hypopigmented trail. Entry into vitreous chamber may occur due to a break in the retina. The larvae can be trapped in the vitreous and gain entry into the anterior or posterior chambers. The risk is partial dislocation or dislocation of the lens and damage to suspensory ligaments (zonulules) [5]. The signs and symptoms of internal ophthalmomyiasis vary accordingly to anterior or posterior positioning of the larvae. The signs of anterior positioning are recurring iritis associated with partial displacement or total displacement of the lens. In posterior positioning one can see vitreous turbidity and possible detachment of the retina [6].

External opthalmomyasis presents symptoms similar to acute catarrhal conjunctivitis as in the case presented. However it is necessary to pay much attention to the treatment, because it could have serious complications such as conjunctival ulceration, endophtalmitis and invasion into other regions of the eye and orbit [4]. Diagnosis is based on anamestetic and clinical data. Identification of the parasite if it is microscopically present. The typical parasitological aspects are, length a little over 1 mm, offwhite color and two hooks in the cephalic segment. Examined under a light the fissures appear tiny and fusiform with cylindrical translucid elements and a black mark at one end. This allows the parasite to be highly mobile and capable of penetrating the conjunctiva [2]. Note, it is extremely difficult to remove and preserve these larvae due to their fragility. Even though some were rapidly placed on slides and others saved in lacrimal liquid in the test tubes, it was not possible for the laboratory to examine them as they dissolved. Treatment requires continual removal of the larvae and antibiotics to prevent further bacterial infection.

We found that irrigation of the conjunctiva with a solution of iodopovidone 5% and nethilmycina, did reduced the number of larvae which helped lower the risk of further infection. It is also necessary to be on the lookout for other conditions that could occur due to larvae having entered the eye. We refer in particular,to cysticercosis and onchocercosis, which , initially, had been considered as possible differential diagnosis.

Cysticercosis is a parasitic disease caused by larvae of platelminta cestode of taenia type A. This cestode has man as its final host and pigs are the intermediary hosts [7]. Clinical symptoms depend on the site of infection and migration. One can see conjunctivitis, iridocyclitis, displacement of the lens, retinal detachment, vitritis, etc. Decreased vision, pain and foreign body sensation are symptoms that the patient may experience [8]. Diagnosis is made by looking for anti cysticercus serum antibodies; enzyme linked immunoelectro transfer blot (EITB).

Onchocercosis is an infectious disease caused by infestation of nematode filariform onchocerca volvulus. The incubation period of 3-12 months shows no clinical signs [9]. The first sign is usually the appearance of subcutaneous nodes. Lesions to the eye, starting at the cornea, begin with opaque white infiltrates and keratitis, followed by corneal opacities. Microfilarie found in the anterior chamber can cause iridocyclitis and glaucoma, whereas, regardless of microfilarie in the posterior chamber, it is possible to find atrophied areas of the retina and choroid. Involvement of the retina can lead to damage of the optic nerve causing reduced vision or eventually blindness [10-11]. Diagnosis is made through anamnestic and laboratory data: an increase in eosinophil, immunoenzymatic tests and the presence of microfilarie. Sample is taken during the night when reproduction of filarie is at its highest.

Conclusion

Although it was not possible to obtain microscopic evidence of larvae, the symptoms, the biomicroscopic aspect of the parasites, together with documented information, made the diagnosis relatively easy. The difference in clinical signs and negative laboratory tests allowed us to exclude any of the diseases mentioned above. With case study, we hope to be able to contribute and aid in simplifying the diagnosis of this pathology for our colleagues.

For more Open Access Journals in Juniper Publishers please click on: https://juniperpublishers.com

For more articles in JOJ Ophthalmology please click on: https://juniperpublishers.com/jojo/index.php

Abstract

The Ciliary body is an unusual location of uveal melanomas and usually these kinds of tumors appear with a reduction of vision due to the formation of sectorial cataract or retinal detachment when the tumor spread to a posterior position. We present a 57 years old woman with sudden and severe ocular pain. Ophthalmologic examination showed a hyper mature cataract and superior displacement of the lens with sectorial angular block. The intraocular pressure was 22 mmHg. After papillary dilation aciliary body tumor was observed. The ultrasound study and magnetic resonance imaging confirmed the diagnosis of uveal melanoma.

Keywords: Ocular Pain; Melanoma; Ciliary Body; Cataract

Abbreviations: BCVA: Best-Corrected Visual Acuity; NMR: Nuclear Magnetic Resonance

Introduction

Uveal melanomas are the most frequent intraocular primary tumors in adulthood. However, ciliary body location is very uncommon regarding iris or choroidal melanomas. Furthermore, ciliary body location gives symptoms later, which also gives a worse prognosis.

Materials and Methods

Materials and Methods Biomicroscopy, dilated indirect ophthalmoloscopy, Goldmanntonomter, B-Mode echography and ultrasound biomicroscopy were performed. Subsequent RMN imaging was also obtained.

Case report

We report a case of a 57 years old woman who came to the emergency department with a sudden and severe pain in her right eye. The patient also related that she had had a decrease in her visual acuity for last two months. She was a nonsmoker, but would occasionally drink alcohol. Family history was unremarkable for malignancy. Medical history only included controlled hypertension and cholesterolemia. Best-corrected visual acuity (BCVA) at first was 20/200 in the right eye and 20/30 in the left eye.

The examination of the right eye showed a brown pigmented lesion in the lower region of iris, without satellites lesions or papillary deformity. She also presented a hyper mature cataract antero-superiorly displaced endangering the anterior chamber space and the iridocorneal angle (Figure 1). The intraocular pressure was 22 mmHg in the right eye and 16 mmHg in the left eye. After papillary dilation, we found a pigmented tumoral mass behind the iris which was situated between 4 to 6 hours and produced the dislocation of the lens (Figure 2).The retinal examination was of no value because of the presence of the mature cataract. The ophthalmoscopic examination of the left eye was normal.

Results

The study with B-Mode echography and ultrasound biomicroscopy (OTI HF 35-50 Ultrasound System ®) demonstrated a 15 X 10 mm tumor which came from ciliary body and displaced the lens (Figure 3). The nuclear magnetic resonance (NMR) with gadoline confirmed the existence of an intraocular tumor with hyper intense signal in T1 and hypo intense in T2 (Figure 4) with a size of 15 x 10 x 8 mm and heterogeneous catchment of contrast (Figure 5). With these results a ciliary body melanoma was suspiciously diagnosed. The extensive study was negative and a brachytherapy with of iodine 125 (I125) treatments was decided. Actually and after cataract surgery our patient is asymptomatic and without signs of recurrence.

Discussion

Ocular melanoma is the most common intraocular primary tumor in adulthood, which mainly affects white males between fifty and sixty years old. It represents 3.7% of cases of melanoma and it is the second most usual location after cutaneous melanoma [1]. Its incidence is nearby 4.3 cases per million populations [2]. And its most common position is the uveal tract, which is supposed the origin of the 82.5% of intraocular melanomas [1]. Although inside this rate, ciliary body melanoma only represents 12% of uveal melanomas its location is a factor of poor prognosis [3].

The majority of these tumors are asymptomatic until their growth produces a decrease of visual acuity due to the formation of a sectorial cataract or retinal detachment [2]. The presence of dilated episcleral vessels near the tumor (sentinel vessels) is also frequent [4]. Unusually these tumors may also produce an increase in intraocular pressure because of the angular closing by the pigment dispersion produced by myeloma [5] a uveitis due to necrosis of tumor [6] or aleukocoria in children [7]. There is no existing record of a case of ciliary body melanoma that appears with sudden and severe eye pain without a significant increase of intraocular pressure. In the case I am talking about this circumstance happens as well as other manifestations like the presence of a mature cataract, lens subluxation and a sectorial angular closure.

The diagnosis of this pathology is clinical using the slit lamp, accompanied by additional tests such as mode A ultrasound (presence of kappa angle); mode B ultrasound or ultrasonic biomicroscopy (the size, location and extent of tumor is characterized) and orbital NMR (show tumor mass as a hyper intense on T1 and hypo intense on T2) [8]. The confirmation of the diagnosis is obtained by the histological study of the lesion.

Pathological study is also important to establish the prognosis of these melanomas because there are some factors that can add to a worse prognosis for this kind of tumors like epithelioid cell line, high mitotic activity, necrosis of tumor, lymphocytic infiltration or extra sclera extension [9]. Genetic factors are other important prognostic. The mutation in genes 3 and 8 is related to poor prognosis in these tumors [10].

Regarding the treatment of these tumors, there are several alternatives such as radiotherapy, brachytherapy or external beam radiation; local excision (iridocyclectomy) or enucleation. Depending on the size of the tumor and the presence or absence of distant metastases we would choose a treatment or another. Our patient has been treated with brachytherapy due to the characteristics of the tumor and the absence of extraocular disease.

Ciliary body melanomas have a rate of distant metastasis of19% and 33% at 5 and 10 years respectively, being the most frequent liver, lung or bones metastases [1]. This rate is the highest of uveal melanomas, which makes the survival from these tumors, also lower [3].

Conclusion

In conclusion we suggest that sudden ocular pain is a very unusual presentation of already unusual ciliary body melanoma. The objective of this article is describing this way of atypical debut. These tumors are the most metastatic inside the group of intraocular melanomas. However the brachytherapy treatment can be a good choice for this kind of tumors if we detect them before extra ocular dissemination.

For more Open Access Journals in Juniper Publishers please click on: https://juniperpublishers.com

For more articles in JOJ Ophthalmology please click on: https://juniperpublishers.com/jojo/index.php

Cilia in bronchiole of lung