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Sep 2017 ( Volume -11 Number -9)

Article 2
Ophthalmomyiasis in an Adolescent Boy
Ghulam Nabi, MD; Khalid Al Khatheri, MBBS, Arab Board (Jord); Omar Nabi Siraj, MBBS
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Ophthalmomyiasis in an Adolescent Boy

Ghulam Nabi, MD; Khalid Al Khatheri, MBBS, Arab Board (Jord); Omar Nabi Siraj, MBBS

Introduction

Myiasis is the infestation of tissue with fly larvae, commonly referred to as maggots. Human beings and vertebrates are affected by larvae of some Dipteran flies, which at least for a brief period feed on the host's tissues, body fluids, or ingested food1. Ophthalmomyiasis specifically refers to the infestation of the human eye, and it may occur in external, internal, or orbital forms, depending on the location of the larvae2. The most commonly encountered form of ophthalmomyiasis is the external ophthalmomyiasis. In this form, infections of superficial periocular tissue, including the eyelids, conjunctiva, lacrimal sac and nasolacrimal ducts have been recorded, but conjunctival myiasis appears to be the most common3. The most damaging type is the orbital myiasis where the larvae get their way to the orbital structure and cause serious damage. It is widespread in the tropics and subtropics of Africa and the Americas, and occurs in other areas of the world. Greater awareness on the part of physicians about clinical symptoms and relevant exposure histories would improve the expediency and efficacy of treatment for patients with myiasis.

Keywords: Myiasis ophthalmica, myiasis, ophthalmomyiasis

Case report

18 years old, Syrian male patient attended our hospital clinic with complaints of severe tearing, redness and a moving foreign object in his right eye. He also had pain, slight pruritus, and edema in his right inner canthus. There was no history of previous ocular surgeries, and he was not taking any ocular medications (Figure 1). He was in good general health with no systemic symptoms. On examination, he had a visual acuity of 20/20 with nospectacles correction, a normal extraocular motility and fundus findings. Intraocular pressure was normal bilaterally. Anterior and posterior chamber examination was normal. A small erythematous lesion with a demarcated punctum in the center and periorbital edema were noted in the right inner canthus. On slit-lamp examination, a small yellowish organism and a serous-purulent fluid drained from the punctum. The larva was then easily grasped with forceps and gently removed without making any incision into the lesion (see the picture of larva in Figure 2. Courtesy: Nature.com). The other eye was normal. Patient improved with the treatment.

 

Discussion

Myiasis is the parasitic infestation of the body of a live mammal by fly larvae (maggots) that grow inside the host while feeding on its tissueFlies are most commonly attracted to open wounds and urine, feces and soaked fur. Some species including the most common myiatic flies, the botfly, blowfly and the screwfly can create an infestation even on unbroken skin and have been known to use moist soil and non-myiatic flies such as the common housefly as vector agents for their parasitic larvae. The most common site for infestation is skin, but eyes, nose, paranasal sinuses, throat and urogenital tract might also be infested4. Keyt first described an ocular myiasis case in 1900 then Elliott notified ophthalmomyiasis from India in 19105.

Ophthalmomyiasis due to Oestrus ovis was firstly described by James in 19456. Oestrus ovis is the most common agent for external ocular myiasis. The majority of the cases have been reported from the Mediterranean countries and Middle East region7. In the external type, the patients may present with classic conjunctivitis, pseudomembranous conjunctivitis, punctuate keratitis and/or keratouveitis and mimics allergic or viral conjunctivitis8. Ophthalmomyiasis is an infestation ofthe eye with larvae of most commonly O. ovis and these larvae (maggots) are ejected in a milky fluid by the female fly while it is in a flight9. The maggots are tiny translucent worms, 1–2mm in length with dark heads and a couple of distinct dark brown oral hooks and numerous hooks of the bodycan be seen crawling over the conjunctiva or swimming in the vitreous cavity and/or sub retinal space10. Patients complain of pain, burning, itching, redness, and watering in the affected eye, with an abrupt onset, accompanied by sensations of larvae moving in the eye. If timely management isnot done, the larvae penetrate the sclera and reach the vitreous and sub retinal space, causing ophthalmomyiasis internal as a complication. This manifests as pigmented and atrophic retinal pigment epithelial tracts in multiple crisscross patterns, in conjunction with fibrovascular proliferation, hemorrhage, and exudative detachment of the retina leading to blindness. Maggots can also infiltrate the lacrimal sac and can migrate through the lacrimal canal to the nasal cavity. Extension to the cranial cavity is a possibility, due to the close proximity to the base of the skull. Myiasis varies widely in the forms it takes and its effects on the victims. Such variations depend largely on the fly species and where the larvae are located. Some flies lay eggs in open wounds, other larvae may invade unbroken skin or enter the body through the nose or ears, and still others may be swallowed if the eggs are deposited on the lips or on food.

Types of Ophthalmomyiasis:

External type where the infestation is on the external ocular surface. Here the patient presents with conjunctivitis, cellulitis and/or keratouveitis.

Internal type where the larvae penetrate into the glove and the larvae can be seen within the vitreous cavity and/or sub retinal space. This is the destructive type.

The 3rd Type, which is more destructive is the orbital myiasis where the larvae penetrate deep into the orbital cavity and destroy the tissue11. Our case is exclusively of the external type where the larvae were seen on the conjunctiva surface with normal posterior segment.

Ophthalmomyiasis is rare, the largest series reported by M. Abdel Latif et al12. In the external type the patients may present with classic conjunctivitis, pseudomembranous conjunctivitis, punctuate keratitis and/or keratouveitis. Even rare, ophthalmomyiasis should be in the different diagnosis of unilateral conjunctivitis. The condition is curable, but a delay in removing the causative larvae may lead to their penetration into the inside of the eye or orbit causing a more destructive damage13. Normally, healthy individuals are unlikely to suffer from myiasis. Chronic debilitating conditions, such as leprosy, diabetes mellitus, open wounds, fungating carcinomas, psychiatric illness, intellectual disability, hemiplegia, and immunosuppressive agents may predispose individuals to myiasis. Our patient was young and did not have any systemic disease. Patients most often infested with larva, complain of pruritus and pain, and they may sense movement of the larva. If the larva dies within the cavity, the lesion may be very similar to a chalazion14. The symptoms of ophthalmomyiasis externa are very similar to symptoms of acute catarrhal conjunctivitis. Patients reported itching, burning, mobile foreign body sensation, photophobia, watery discharge and eyelid hyperemia in their eyes. The symptoms begin after larval ovulation with acute onset of eye pain and inflammation unilaterally as a rule. Conjunctival pseudomembrane, follicular conjunctival reaction and punctate keratopathy may accompany the clinical picture. Viral, bacterial or foreign body conjunctivitis may cause the same symptoms but visualization of the larva concludes the diagnosis15.

Conclusion

Although human ophthalmomyiasis is a rare disease but it may be emerging and increasing.  It is considered that many metabolic diseases like diabetes mellitus and cancers like squamous cell carcinoma, as well as poor hygiene can provide a suitable ground for myiasis because of delaying in wound healing in these diseases. Dermatologist and ophthalmologist must be alert about myiasis that parasitic infections of ocular surface may be seen in healthy individuals. Maggots in eye are rare in developed and even in under developed areas due to awareness and relatively easy access to ophthalmic facility as compared to the past16. Sanitation and occupational knowledge is important in parasitic diseases. Prompt diagnosis and treatment prevents serious complications. Fornix examination is essential in the diagnosis of larva. Ophthalmologists must take into consideration ophthalmomyiasis in the differential diagnosis of conjunctivitis.

References:

1.     Francesconi F, Lupi O. Myiasis. Clin Microbiol Rev 2012;25:79–85.

2.     Bose S, Saini S, Barapatre R, et al. Ophthalmomyiasis External: A Case Report. J Clin Diagn Res [serial online] 2012;6:1079–80.

3.     Yar K, Ozcan AA, Koltas IS. External ophthalmomyiasis: case reports. Turkiye Parazitol Derg/Turkiye Parazitol 2011;35:224–6.

4.     Scrimgeour EM, EI-Azazy OME. Significance of cutaneous and ophthalmicmyiasis in Saudi Arabia. Ann Saudi Med. 1995; 15:295-296. 35.

5.     Cameron JA, Shoukrey NM, Al-Garni AA. Conjunctival ophthalmomyiasis causedby the sheep nasal botfly (Oestrus ovis). Am J Ophthalmol. 1991;1l2, 331-334.

6.     Torok PG. Conjunctival ophthalmomyiasis caused by the sheep nasal botfly (Oestrus ovis). Am J Ophthalmol. 1992; 113,222.

7.     Hira PR, Hajj B, AI-Ali F, Hall MJR. Ophthalmomyiasis in Kuwait: first report ofinfections due to the larvae of Oestrus ovis before and after the gulf conflict. J Trop Med Hyg. 1993;96:241-244.

8.     Khurana S, Biswal M, Bhatti H. Ophthalmomyiasis: Three cases from North India. Indian J Med Microbiol. 2010;28(3):257–261.

9.     Khataminia G, Aghajanzadeh R, Vazirianzadeh B, Rahdar M. Orbital myiasis. J Ophthalmic Vis Res. 2011;6(3):199–203.

10.  Massodi M, Hosseini K. External Ophthalmomyiasis caused by sheep botfly (Oestrus Ovis) larva: A report of 8 cases. Arch Iranian Med 2004;7:136-9.  

11.  Dunbar J, Cooper B, Hodgetts T, Yskandar H et al. An outbreak of human external ophthalmomyiasis due to Oestrus ovis in southern Afghanistan Clinc Infect Dis, 46 (11) (2008), pp. e124-e126

12.  Abdellatif MZ, Elmazar HM, Essa AB. Oestrus ovis as a cause of red eye in Aljabal Algharbi, Libya. Middle East Afr J Ophthalmol 2011;18:305–8 .

13.  Odat TA, Gandhi JS, Ziahosseini K. A case of ophthalmomyiasis externa from Jordan in the Middle East. Br J Ophthalmol 2007;91:Video report.  

14.  Externa from Jordan in the Middle East. Br J Ophthalmol 2007;91: Video report.  

15.  Sreejith RS, Reddy AK, Ganeshpuri SS, Garg P. Oestrus ovis ophthalmomyiasis with keratitis. Indian J Med Microbiol, 2010. 28 (4)11:399-402.

16.  Latif I, Qamar RR, Attaullah I, Somro MZ. Ocular Myiasis. Pak J Ophthalmol. 2008. 24 (3).151-5

Author Information: Dr. Ghulam Nabi, MD is Pediatric Consultant and Neonatologist at the Bugshan Hospital, Jeddah, Kingdom of Saudi Arabia. Dr. Khalid Al Khatheri. MBBS; Arab Board (Jordanian) is Consulting ophthalmologist, Bugshan Hospital Jeddah. Saudi Arabia. Dr. Omar Nabi Siraj, MBBS is Head of the Patient Affairs Department, Thumbay Hospital, Ajman, United Arab Emirates. E-mail: omarsiraj@gmail.com

Corresponding Author: Dr. Ghulam Nabi, MD. PO Box: 5860 Jeddah 21432. Saudi Arabia. Mobile. 00966 502310661. Email: drgnabi2@gmail.com

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