Cysticercosis of extraocular muscle

Orbital cysticercosis: clinical features and management outcomes

AIM

To describe the clinical and radiological features of orbital cysticercosis and its management outcome.

MATERIAL AND METHOD

A retrospective analysis of consecutive cases of orbital cysticercosis between January 2008 and January 2018. The management outcome was classified into good, fair, and poor depending upon the resolution of the clinical features and status of the cyst and scolex in the imaging studies.

RESULTS

A total of 61 patients with a mean age of 24.33± 31.04 years were included. The male: female ratio was 1.9:1. Pain, with or without prominence of the eye was the most common presenting symptom (n = 35, 57.4%). The mean duration of symptoms was 3.65 +/-8.56 months. Ocular motility restriction was the most common sign (n = 52, 85.2%). Fifty-five (90.16%) patients had myocysticercosis with inferior rectus being most commonly involved (n = 17, 27.9%), while 6 (9.83%) cases had orbital cysticercosis without any ocular muscle involvement. Four patients had compressive optic neuropathy. Subjectively, good clinical outcome was documented in 37 (60.65%), fair in 17 (27.87%) and poor in 7 (11.47%) patients. Objectively, imaging studies showed complete resolution of the cysticercosis lesion in 18 (45%), partial in 19 (47.5%), and no change in 3 (7.5%) patients.

CONCLUSION

A high index of suspicion and a thorough knowledge of the clinical and radiological features are necessary for the proper diagnosis and management of orbital cysticercosis. Medical management with oral albendazole combined with oral steroids leads to desired outcome in the majority.

Orbital cysticercosis: clinical manifestations, diagnosis, management, and outcome

PURPOSE

To describe the clinical manifestations, diagnosis, management, and outcome of orbital cysticercosis in a tertiary eye care center in Southern India.

DESIGN

Retrospective observational case series.

PARTICIPANTS

A total of 171 patients with orbital cysticercosis.

METHODS

Retrospective case series involving consecutive patients with orbital cysticercosis from March 1990 to December 2001.

MAIN OUTCOME MEASURES

Clinical resolution and significant residual deficit.

RESULTS

The median age at presentation was 13 years (range 2-65 years), and 93 patients (54.4%) were male. The 3 main symptoms at presentation were periocular swelling (38%), proptosis (24%), and ptosis (14%) with a median duration of 2 (range 0-24) months. The 3 main signs at presentation included ocular motility restriction (64.3%), proptosis (44.4%), and diplopia (36.8%). The cyst locations in the decreasing order of frequency were anterior orbit (69%), subconjunctival space (24.6%), posterior orbit (5.8%), and the eyelid (0.6%). In all, 80.7% of patients had cysts in relation to an extraocular muscle. The superior rectus (33.3%) was the most commonly involved extraocular muscle. Contact B-scan ultrasonography was diagnostic of cysticercosis in 84.4% of patients. Orbital cysticercosis was managed medically in 158 of 166 patients. Although 149 patients received a combination of oral albendazole and prednisolone, 1 patient received oral albendazole alone, 7 patients received oral prednisolone alone, and 1 patient received oral praziquantel. Surgery was performed in 8 patients. Clinical resolution was seen in 128 of 138 patients (92.8%) at 1 month and 81 of 85 patients (95.3%) at 3 months. A significant residual deficit was present in 29 of 138 patients (21.0%) at the final follow-up and included proptosis in 7 patients, ptosis in 6 patients, ocular motility restriction in 3 patients, diplopia in 2 patients, strabismus in 2 patients, and a combination of the above in 9 patients.

CONCLUSIONS

Orbital cysticercosis is a common clinical condition in the developing world. It typically affects young individuals and has a wide spectrum of clinical manifestations. Both B-scan ultrasonography and computed tomography scan are useful in confirming the diagnosis. Despite resolution of cysticercosis with medical management, a significant proportion of patients may have residual functional deficits.

Extraocular muscle cysticercosis: clinical features and management outcome

BACKGROUND

Extraocular muscle cysticercosis is rare and can be classified based on the stage of evolution as viable, degenerating, and inactive. A tailored approach to therapy using a combination of albendazole and steroids has been proposed. In this study, we have evaluated the clinical features and response of "viable" extraocular muscle cysticercosis to a tailored therapy with oral albendazole and steroids.

METHODS

A retrospective review of 32 patients with viable extraocular muscle cysticercosis was performed over a 3-year period. Ultrasound examination was performed at 3 weeks and 6 weeks for resolution of the cyst and clinical signs following treatment with oral albendazole and prednisolone. The clinical presentation, ocular alignment, motility restriction, and ultrasound examination details were recorded on serial visits.

RESULTS

The mean age was 19.5 years. The most common presenting signs included limitation of ocular motility in 75%, conjunctival mass in 37.5%, diplopia in 28.1%, and proptosis in 28.1% of the patients, respectively. Ocular alignment evaluation revealed esotropia in 3.1%, exotropia in 12.5%, and hypertropia in 6.25%. Restriction of abduction and abduction in elevation was present in two patients each. The average time for complete resolution was 65.9 days. All the patients had resolution, except four, who had residual motility limitation but were asymptomatic.

CONCLUSIONS

Combination therapy with oral albendazole and steroids is effective in the management of viable extraocular muscle cysticercosis. However, residual motility restriction may persist despite treatment.

Optic nerve cysticercosis

Optic nerve cysticercosis is rare but causes significant visual morbidity. A high index of suspicion is warranted for patients in endemic areas who present with sudden vision loss. Visual morbidity can be prevented by early imaging studies and therapeutic interventions.

Extraocular muscle cysticercosis: clinical presentations and outcome of treatment

PURPOSE

To report various clinical presentations and treatment outcomes in a series of patients with extraocular muscle cysticercosis.

METHODS

This retrospective study reviewed the charts of 43 patients diagnosed with extraocular muscle cysticercosis with computed tomography and orbital B-scan ultrasonography between January 1991 and December 2002. Clinical presentation, results of investigations, treatment, and outcome were recorded.

RESULTS

The superior rectus was the most commonly affected extraocular muscle. Restricted ocular motility was present in 88% of patients, and inflammatory signs were noted in the involved quadrant in 70% of patients. Eleven patients were treated with oral albendazole alone and 31 patients were treated with oral albendazole and prednisolone. Four extraocular muscle cysts were excised surgically, and five extruded spontaneously. Inflammatory signs subsided in all patients, and residual restriction of ocular motility was seen in 16 (50%) of 32 patients at a mean follow-up of 5 months. Type of treatment made no significant difference in the ocular motility outcome.

CONCLUSIONS

Extraocular muscle cysticercosis should be considered in patients who present with restricted ocular motility and inflammatory signs. The direction of motility restriction does not indicate the muscle involved. Residual restriction of ocular motility is common despite the addition of corticosteroids to albendazole therapy.

Uniocular ptosis due to cysticercosis of extraocular muscle

Involvement of extraocular muscle by Cysticercus cellulosae is very rare. Rarer still is the isolated involvement of the levator palpebrae superioris muscle presenting clinically as ptosis. We report here such a presentation in an eleven years old girl.

Orbital and adnexal cysticercosis

Orbital and adnexal cysticercosis is emerging as a far commoner disease than previously considered, both in endemic and nonendemic areas of cysticercosis. A review of the literature on orbital and adnexal cysticercosis found that it has a predilection for children and young adults with no definite sex predilection. The extraocular muscle form is the commonest type of orbital and adnexal cysticercosis. Lodgement of cysts in the subconjunctival space is another common site, followed by the eyelid, optic nerve, retro-orbital space and lacrimal gland. Association of orbital cysticercosis with systemic cysticercosis is quite rare. The clinical manifestations of orbital or adnexal cysticercosis are entirely different and depend on the location, size, relation to adjacent structures and stage of evolution of the cyst. Diagnosis of cysticercosis is based mainly on orbital imaging because of its highly specific appearance. Tissue diagnosis is not essential for initiating treatment. Medical therapy is the recommended treatment for the extraocular muscle form and retro-orbital cysticer-cosis. Surgical removal is advocated for subconjunctival and eyelid cysticercosis. Because of the limited number of cases of optic nerve and lacrimal gland cysticercosis, their treatment is controversial.

Bilateral cysticercosis of the optic nerve

Bilateral cysticercosis of the optic nerves affected a man who presented with features suggestive of optic neuritis. Ultrasonography revealed bilateral sonolucent cystic lesions with central echo-dense, highly reflective structures behind the optic nerve heads. A subretinal cyst was present in one eye. Magnetic resonance imaging of the brain and orbit revealed multiple cysticerci in the brain, orbit, and eye. The subretinal cyst was removed by pars plana vitrectomy, and the other cysts resolved on treatment with albendazole.

Extraocular muscle cysticercosis presenting as Brown syndrome

PURPOSE

Report of a case of acquired Brown syndrome caused by infestation of the superior oblique muscle by Cysticercus cellulosae.

METHOD

Case seen in a referral practice. A 20-year-old man presented with recurrent attacks of conjunctivitis and diplopia in upgaze. Clinical examination of ocular motility established a diagnosis of acquired Brown syndrome of the right eye. Computed tomography of the right orbit unequivocally established the diagnosis of superior oblique muscle cysticercosis. The patient was started on systemic steroids and albendazole in the prescribed doses for a month.

RESULT

Serial computed tomography scans of the orbit revealed resolution of the cystic lesion after a month. Clinically, although there was restoration of ocular motility in upgaze, mild restriction of movement of the right eye in levoelevation persisted. However, the patient was symptomatically better with amelioration of the recurrent conjunctivitis and diplopia in primary gaze.

CONCLUSION

Extraocular muscle cysticercosis should be considered in the differential diagnosis of acquired motility disorder. The presentation of extraocular muscle cysticercosis as an acquired Brown syndrome is unusual. Response to medical therapy was satisfactory.

Nonthyroid causes of extraocular muscle disease

Extraocular muscle involvement in orbital disease is most frequently seen as a feature of thyroid orbitopathy (Graves' disease). However, a wide range of other conditions may alter the size, shape, and function of these muscles, with characteristic clinical manifestations or abnormalities visible on orbital imaging. The differential diagnosis of muscle disease can be narrowed by careful analysis of clinical features and ancillary tests. Imaging facilitates recognition in many cases, but in some instances, accurate diagnosis requires biopsy. This review highlights the differential diagnoses for diseases of extraocular muscles based on the clinical and investigative records of 103 patients at our institution combined with data from the world literature. We found that the most common nonthyroid causes of muscle disease were inflammatory, vascular, and neoplastic processes (in decreasing order of frequency). Emphasis is placed on investigations that provide a logical approach to, and appropriate management of, disease of the extraocular muscles.

Ultrasonological characteristics of extraocular cysticercosis

Cysticercosis is a common ophthalmic parasitosis wherein humans are the intermediate hosts in the life cycle of the tape worm Taenia solium. While intraocular cysticercosis is more common and is more readily diagnosed clinically, recognition of extraocular cysticercosis needs supplementary imaging. Computed tomography (CT) and magnetic resonance imaging (MRI) have been extensively used to diagnose and characterize neurocysticercosis. Since the orbit is easily accessible to ultrasonography (USG), we evaluated its role in the diagnosis and management of extraocular cysticercosis. Serial A- and B- scan ultrasonograms from 24 patients with extraocular cysticercosis were analyzed to determine features at various stages of evolution of the lesion and an attempt was made to classify the lesion on this basis. Of 24 patients, 23 had a cyst clearly demonstrable by USG: 22 within or attached to an extraocular muscle (with or without myositis) and one free in the orbit. One patient had an optic nerve cyst not detected by USG but by CT scan. Cysts at various stages of evolution were found - viable, degenerating and inactive. The therapeutic response of the cyst to treatment with oral albendazole could be effectively studied and monitored by sequential USG. Orbital ultrasound is a practical, precise and cost-effective imaging modality to diagnose, manage and monitor extraocular cysticercosis, although it can not completely replace CT and MRI.

Optic neuritis following albendazole therapy for orbital cysticercosis

PURPOSE

To report the occurrence of optic neuritis following oral albendazole therapy for orbital cysticercosis.

METHODS

Two patients having definitively diagnosed orbital cysticercosis at the orbital apex developed an acute visual loss 1 week after initiation of oral albendazole. Ultrasonography and magnetic resonance imaging determined that the cause was optic neuritis due to disorganization of the cyst with inflammation of the adjacent optic nerve.

RESULTS

Oral corticosteroids (prednisolone 1 mg/kg per day) given for a period of 4 weeks led to resolution of the optic neuritis, with full visual recovery.

CONCLUSION

Corticosteroids should be given in addition to albendazole in the treatment of orbital cysticercosis when cysts are in close proximity to the optic nerve.

Spontaneous extrusion of extraocular cysticercus cysts

PURPOSE

We treated two patients who had spontaneous extrusion of cysticercus cysts and subconjunctival swelling. Additionally, one patient had severe myositis and restriction of ocular movements.

METHODS

The patients were prescribed oral albendazole, 15 mg/kg of body mass per day. Systemic corticosteroids were also given to the patient who had severe myositis.

RESULTS

Spontaneous extrusion of the cysts occurred in both patients within three to five days of starting albendazole therapy. The conjunctival defects healed without any surgical intervention. The ocular motility in the patient with myositis returned to normal.

CONCLUSION

As extrusion happened soon after the start of albendazole therapy, it is uncertain whether this therapy played any role. Additionally, it is not clear if systemic therapy must be continued in the absence of systemic and neurologic manifestations.