Delhi Journal of Ophthalmology

A Rare Case of Ophthalmia Nodosa

Aman Gaur1, Jolly Rohatgi2, Shachi Srivastava2
1CGHS Specialist Wing & Deptt of Ophthalmology, VMMC & Safdarjung Hospital, New Delhi, India
2Deptt of Ophthalmology, UCMS & Guru Teg Bahadur Hospital, New Delhi, India

Corresponding Author:

Shachi Srivastava
Department of Ophthalmology
UCMS & Guru Teg Bahadur Hospitial,
New Delhi, India
Email id: dr.shachi.sri@gmail.com

Received: 12-AUG-2019

Accepted: 05-SEP-2019

Published Online: 26-DEC-2019

DOI:http://dx.doi.org/10.7869/djo.484

Abstract
Ophthalmia Nodosa is an ocular inflammatory response to foreign bodies like insect hair. Initially it manifests as marked lid edema and intense congestion with associated multiple corneal abrasions. Later, entry of insect hair in ocular tissues may result in nodular conjunctivitis, iridocyclitis, vitritis and panophthalmitis. Here, we present a similar case of insect hair in eye with recurrent attacks of conjunctivitis and ophthalmia nodosa which required multiple follow ups of hair removal and later surgical excision of nodular conjunctival lesions containing insect hair.

Keywords :Ophthalmia nodosa, caterpillar hair, insect hair, setae

Introduction

Ophthalmia Nodosa is an inflammatory reaction in the eye due to foreign bodies such as insect hair or vegetable material1. It can manifest as nodular conjunctivitis, marginal keratitis, iridocyclitis and pan ophthalmitis.1 Fine insect hair (setae) however extraocular if not removed have the capability to enter the eye. Frequent follow ups may be required for complete removal. We hereby report a case of ophthalmia nodosa which was successfully managed by meticulous hair removal in multiple follow ups.

Case Report

A 23-year-old female presented with severe pain and redness in right eye following an insect crawling on her eye during sleep. She had swollen eyelids with diffuse conjunctival congestion. Slit lamp examination under fluorescein staining revealed a large inferior paracentral epithelial defect, measuring approximately 4×3.5 mm with multiple small abrasions and criss cross lines across entire cornea (Figure 1). She also brought along with her the insect which went into her eye. It was approximately 5-6 cms long with fine hair all over its body and multiple legs (Figure 2).

Similar multiple fine hair were seen embedded in the upper and lower palpebral conjunctiva, bulbar conjunctiva and fornices under slit lamp examination (Figure 3&4). Patient was bandaged for one day with antibiotic ointment and it was possible to remove setae on slit lamp, in multiple follow-ups only. She was symptomatically relieved in 1 week on topical steroids and lubricants. However, she had an episode of pain/redness after one month and subsequent episodes thereafter. In each of these episodes, 1-2 fresh setae were found embedded and partly extruding from palpebral conjunctiva and lid margin. These were removed and topical steroids were given after each episode.


The patient was asymptomatic for 6 months, after which she again presented with redness and irritation. On examination she was found to have multiple conjunctival nodules containing fine setae (Figure 5).


These conjunctival nodules were excised, and patient was started on topical steroids following which she improved. No setae were found in anterior and posterior chamber. Also, no episode of pain or redness was reported by patient thereafter.

Discussion

First description of ophthalmia nodosa was given by SchÖn in 1861.2 Since then many cases have been reported in literature. Wagenmann (1890) called it pseudotuberculosis.3 Later the term ophthalmia nodosa was given by Saemisch (1904)4.
Insect hair enter the eye either by direct contact or they are blown away by wind into conjunctival fornices, generally when patient is outdoors.5 Unlike majority of reported cases, in our case the insect was encountered in the house when patient was asleep. Similar, indoor cases have also been reported by Sethi and Dwivedi.6 Caterpillars have tendency to seek dark secluded places during pupation and are generally active at night to avoid falling prey. In our case the patient was able to recover the insect, so there was no difficulty in making a diagnosis. But in many cases nature of such injury cannot be ascertained. So, there should be a high index of suspicion when setae like foreign bodies are seen in a congested eye, especially in winter and autumn when caterpillars are plenty. Also, criss cross pattern on fluorescein staining may provide a clue to diagnosis. Lids and fornices should be carefully examined for any hair. Multiple followups may be required for removal.
Initially there is an intense inflammatory reaction which may be attributed to the release of toxin. This results into marked lid and periorbital edema or allergic dermatitis. In conjunctiva, it can cause catarrhal conjunctivitis or marginal keratitis. This acute inflammatory stage is followed by a quiescent period during which the foreign body or hair migrates through cornea and outer coats of eye, later resulting into recurrent attacks of iritis or conjunctivitis. The duration of this quiescent period is generally 6-8 weeks in a typical case7 and can be even several months in some cases.5 Possibility of retained hair should be considered if symptoms recur.


In our case recurrence was seen after one month and nodular conjunctivitis after 6 months of follow up. Setae were found in each episode with their pointing edge exposed, which were subsequently removed. In dealing with treatment of this condition, Villiard and DeJean8 have emphasized on educating the patient regarding dangerous consequences involved and avoiding frequent rubbing of eyes. Copious irrigation and early removal of hair is indicated whenever practically possible. Careful examination for retained hair foreign bodies and meticulous removal is required. Surgical treatment may be helpful in conjunctival nodules and enucleation is reserved for painful pthisical eyes.8

Conclusion

Meticulous and repeated examination on slit lamp and removal is required in such cases to prevent intraocular penetration or development of ophthalmia nodosa.

References
  1. Duke-Elder Sir S, and MacFaul, P.A. System of Ophthalmology, London, Henry Kimpton, Vol. XIV, Part 2; 1972; p. 1197-1202.
  2. Schön, J. M. A. Beitr. prakt. Augenheilk.; 1861; p. 183.
  3. Wagenmann, A. Albrecht v. Graefes Arch. Ophthal. pt. 1; 1890; p. 126.
  4. Saemisch T. Graefe-Saemisch Handbiuch der gesamten Angenheilkunde, 2nd ed., vol. 5, pt 1; 1904; p.548.
  5. Watson PG, Sevel D. Ophthalmia Nodosa. Br J Ophthalmol, 1966; 50(4): 209–217. doi:10.1136/bjo.50.4.209
  6. Sethi P K, Dwivedi N. Ophthalmia Nodosa. Indian J Ophthalmology, 1982; 30:11-14.
  7. Corkey JA. Ophthalmia nodosa due to caterpillar hairs. Br J Ophthalmol, 1955; 39(5):301–306. doi:10.1136/bjo.39.5.301.
  8. Villard H, DeJean C. Arch. Ophtal. (Paris); 1934; p. 51, 719.

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Gaur A, Rohatgi J, Srivastava SA Rare Case of Ophthalmia Nodosa.DJO 2019;30:62-64

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Gaur A, Rohatgi J, Srivastava SA Rare Case of Ophthalmia Nodosa.DJO [serial online] 2019[cited 2020 Jan 27];30:62-64. Available from: http://www.djo.org.in/articles/30/1/A-Rare-Case-of-Ophthalmia-Nodosa.html