Management of presumed trematode induced granulomatous uveitis in pediatric patients

Metagenomic analysis of the ocular toxoplasmosis in children uveitis from Fayoum governorate, Egypt

Granulomatous anterior uveitis with single or numerous gelatinous nodules was found in children living in rural Egypt. All ocular diseases were originally thought to be water-born and related to digenic flukes. The current study sought to learn more about the causes of anterior granulomatous uveitis in Egyptian youngsters who used to swim in rural water canals. 50 children with eye lesions that had not responded to medical treatment were recruited. Four samples were surgically extracted and examined using real-time PCR, transmission electron microscopy (TEM), and shotgun metagenomic sequencing (SMS). Toxoplasma gondii was detected free within the syncytium's distal section, while the proximal part exhibited active synthesis of a presumably extra-polymeric material, possibly released by the microbial population. Toxoplasma gondii was found in 30 samples. Serologically, distinct anti-Toxoplasma antibodies were not found in 91.6% of patients. SMS showed that the T. gondii ME 49 strain had the greatest percentage (29-25%) in all samples within an Acinetobacter-containing microbial community. These findings suggested that these bacteria entered the body via the exterior route rather than the circulatory route. The lack of genetic evidence for subsequent parasite stages invalidates the prior findings about the assumed trematode stage.

Posterior Segment Involvement in Childhood Presumed Trematode Induced Granulomatous Anterior Uveitis

PURPOSE

To outline posterior segment characteristics of presumed-trematode induced granulomatous uveitis.

DESIGN

A cross-sectional case series.

METHODS

The study included 56 patients (60 eyes) presented with anterior chamber (AC) granulomas. Involvement of the posterior segment structures has been documented and reported.

RESULTS

The mean age of the patients was 11.8 years (range 6-14 years). Posterior segment findings were vitritis in 9 eyes (15%), optic disc granuloma in 2 eyes (3.3%), optic disc hyperaemia in one eye (1.7%), macular oedema in 2 eyes (3.3%), epiretinal membrane in 3 eyes (5%), retinal vasculitis in one eye, a peripheral focus of retinitis in one eye (1.7%), and choroid thickening in 10 eyes (6.7%), with localised choroidal granuloma in one eye (1.7%).

CONCLUSION

Presumed trematode-induced anterior chamber (AC) granuloma is not only restricted to the anterior segment of the eye, but posterior segment associations that may threaten vision should also be considered.

Management of presumed trematode-induced granulomatous intermediate uveitis

PURPOSE

To describe the surgical management of presumed trematode-induced granulomatous intermediate uveitis (PTIGIU) not responding to medical treatment in controlling the inflammation.

METHODS

A prospective, interventional, single-center study in which patients with a history of fresh canal water contact and PTIGIU were enrolled. All patients underwent lensectomy-pars plana vitrectomy (PPV) and post-operative control of inflammation, functional and anatomical outcomes were assessed.

RESULTS

Fifteen eyes of 12 patients were included in the study with median age of 11.6 ± 4 yrs. Six months following lensectomy-PPV, inflammation was well controlled in all patients. The eyes were divided into two groups: Group A: 10 patients with an attached retina while Group B: 5 patients who were in the cicatricial stage with tractional retinal detachment. All patients in group A had CDVA of 20/40 or better, unlike patients in group B who failed to achieve a CDVA better than 20/70 throughout their follow-up. In group B, final anatomical success was achieved in only 40% with hypotony occurring in 20%.

CONCLUSION

PTIGIU is associated with the presence of ciliary body granuloma which, if left untreated, can lead to drastic outcomes. Early lensectomy-PPV represents a viable management option in cases resistant to medical treatment, with a favorable outcome.

Argon laser photocoagulation for treatment of presumed trematode-induced granulomatous anterior uveitis in children

Background/Aims

To assess the safety and efficacy of argon laser photocoagulation as a new modality for the treatment of presumed trematode-induced granulomatous anterior uveitis (PTGAU) in children.

Methods

Forty-eight eyes of 48 children with PTGAU with pearl-like nodule(s) in the anterior chamber were included in this prospective non-randomised controlled clinical trial. The patients were divided into two groups: those in Group A (23 eyes) were treated with one session of argon laser applied to the anterior chamber nodules and those in Group B (25 eyes) received medical treatment in the form of topical steroid and cycloplegic eye drops with trans-septal triamcinolone injections. All cases were followed up for 3 months with measurement of visual acuity (VA), assessment of the anterior chamber reaction and measurement of the pearl-like nodule size.

Results

In Group A, 22 eyes (95.65%) showed regression of the pearl-like nodules with resolution of the anterior chamber reaction (flare and cells) and improvement in visual acuity from 0.52±0.12 to 0.06±0.08 logMAR (p<0.001). Such improvement was maintained within the 3-month follow-up period. In Group B, 23 eyes (92%) showed initial regression of the granulomas, which was maintained in only 14 eyes (56%),with nine eyes experiencing recurrence after 3 months of follow-up.

Conclusion

Argon laser photocoagulation is a safe and effective novel treatment for PTGAU with pearl-like nodules in the anterior chamber in children. Larger studies with longer follow-up periods are needed to confirm these results.

Spread of An Avian Eye Fluke, Philophthalmus gralli, Through Biological Invasion of An Intermediate Host

Philophthalmus is a genus of globally distributed parasitic eye flukes with some members of the genus found in disparate locales. In particular, Philophthalmus gralli, a zoonotic trematode, appears to be a relatively new introduction to the Americas, facilitated by spillover from the invasive snails Melanoides tuberculata (red-rimmed melania) and Tarebia granifera (quilted melania), which were introduced via the aquarium trade, and perhaps furthered by avian dispersal. Given that two known intermediate hosts of Philophthalmus flukes are actively expanding their range as a result of human activities, we hypothesize that this spread is also associated with the spread of Philophthalmus flukes. To address this, we systematically reviewed the literature and examined whether the global expansion of P. gralli flukes is associated with the spread of invasive snails M. tuberculata and T. granifera. Here, we show that (1) specimens of P. gralli are only found in intermediate snail hosts M. tuberculata or T. granifera, suggesting intermediate host specificity for these 2 species, and (2) specimens of P. gralli have rarely been found outside the ranges (native and introduced) of M. tuberculata or T. granifera. Given the importance of distribution information of parasites in the role of identifying parasite invasions, we also review the known distribution of all Philophthalmus species. Considering recent outbreaks in humans and wild and domestic animal species, the continued spread of Philophthalmus presents a potential threat to veterinary and public health and conservation.

Argon Laser Photocoagulation for Treatment of Presumed Trematode-induced Granulomatous Anterior Uveitis in Children.. [DOI: 10.1101/2020.12.30.20248850]

Background/Aims

To assess the safety and efficacy of argon laser photocoagulation as a new modality for the treatment of presumed trematode-induced granulomatous anterior uveitis (PTGAU) in children.

Methods

Forty-eight eyes of 48 children with PTGAU with pearl-like nodule(s) in the anterior chamber were included in this prospective non- randomised controlled clinical trial. Patients were divided into two groups: group A (23 eyes) was treated with one session of argon laser applied to the anterior chamber nodules, and group B (25 eyes) received medical treatment in the form of topical steroid and cycloplegic eye drops with trans-septal triamcinolone injection.All cases were followed up for 3 monthswith measurement of VA, assessment of anterior chamber reaction, and size of the pearl-like nodules.

Results

In group A, 22 eyes (95.65%) showed regression of the pearl- like nodules with resolution of the anterior chamber reaction (flare and cells) and improvement in visual acuity from 0.52±0.12 to 0.06 ± 0.08logMAR (p value <0.001). Such improvement was maintained within the 3-month follow-up period. In group B, 23 eyes (92%) showed initial regression of the granulomas,whichwas maintained in only 14 eyes (56%),with 9 eyes experiencing recurrence after 3 months of follow-up.

Conclusion

Argon laser photocoagulation is a safe and effective novel treatment for PTGAU with pearl-like nodules in the anterior chamber in children. Larger studies with longer follow-up periods are needed to confirm these results.

PRECIS

Argon laser photocoagulation is a novel non-invasive line of treatment that can be added to the armamentarium for presumed trematode-induced granulomatous anterior uveitis in children.

Anterior chamber granuloma: conservative treatment versus surgical intervention

PURPOSE

A distinct pattern of granulomatous anterior uveitis, with white anterior chamber (AC) granuloma, has been reported in certain endemic areas. The aim of this work was to compare the outcome of conservative treatment to surgical intervention for the treatment of large AC granulomas presenting with moderate-severe anterior uveitis. The secondary outcome is ultrasound biomicroscopy (UBM) characterization of AC granulomas.

METHODS

This is a prospective randomized interventional study including 41 eyes of 39 patients with active AC granuloma ≥3 mm (flare & cells ≥ +2). Patients were randomly assigned to either conservative treatment in the form of topical prednisolone and cycloplegic drops with orbital floor (transseptal) injection of Triamcinolone acetonide (20 eyes) or surgery in the form of granuloma excision and AC wash (21 eyes). As a perioperative care, topical steroids and cycloplegic drops were given few days before surgery and tapered gradually over 6 weeks. Patients were followed up at first day, 2 weeks, 1 and 3 months.

RESULTS

Thirty-seven patients were males, and 2 were females (13.0 ± 3.5 years). After 2 weeks, disappearance/healing of granuloma was achieved in 20 eyes in the surgical group versus 2 eyes in the conservative group (p < 0.0001). This effect was maintained throughout the follow-up period, for the surgical group and reached up to 70%, for the medical group. At every follow-up, BCVA was better in the surgical group, but this was only statistically significant at 1 and 3 months. The granuloma appeared as a homogenous hyperreflective lesion in examined eyes (16 eyes of 15 patients).

CONCLUSION

Surgical treatment of large granulomas leads to a more complete and rapid resolution of inflammation.