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ARTICLES
Year : 1973  |  Volume : 21  |  Issue : 4  |  Page : 204-207
 

Ocular rhinosporidiosis - (a study of twenty one cases)


1 Department of Oto-, Rhino-, Larygology, Tirunelveli Medical College Hospital, Tamilnadu, India
2 Department of Ophthalmology, Tirunelveli Medical College Hospital, Tamilnadu, India

Correspondence Address:
S S David
Department of Oto-, Rhino-, Larygology, Tirunelveli Medical College Hospital, Tamilnadu
India
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How to cite this article:
David S S, Sivaramasubrahmanyan P. Ocular rhinosporidiosis - (a study of twenty one cases). Indian J Ophthalmol 1973;21:204-7

How to cite this URL:
David S S, Sivaramasubrahmanyan P. Ocular rhinosporidiosis - (a study of twenty one cases). Indian J Ophthalmol [serial online] 1973 [cited 2014 Jul 13];21:204-7. Available from: http://www.ijo.in/text.asp?1973/21/4/204/34631


Rhinosporidiosis is due to the fungus Rhinosporidium Seeberi. It has an affinity for the mucous membranes. The disease is characterized by the formation of friable polyps. It affects the nose, conjunctiva, nasopharynx and lacrimal sac in the order of frequency. Other rare sites of involve­ment are fauces, tonsils, epiglottis, larynx, trachea, bronchus, skin, penis, ear, maxillary antrum, parotid gland, and viscera.

The organism has not been cultivated so far. Transmission of the disease experimentally to man and animal has been a failure. There is no intermediate host outside the human body (Karunaratne[3]).

The growth consists of very vascular fibromyxomatous connective tissue. It is covered by stratified squamous epithelium. The presence of sporangium surrounded by white blood cells is a characteristic feature of the micros­copic picture [Figure - 1]. A ripe sporangium is 250-3O0µ in diameter and just visible to the eye.

The modes of infection and trans­mission are not known definitely. WRIGHTS states that the position of the growth suggests water or dust transmission. Trauma to the mucosa is an essential predisposing factor for the entry of the spores to the human system. In cases without apparent trauma, mechanical pressure of the spores containing secretion facilitates infection (KARUNARATNE [3] 1964). Haematogenous spread of the disease to distant organs, such as spleen, kidney, liver, lung and brain does occur, but is not common.

Recurrence of the growth after surgical removal is a common feature, for it is not possible to eradicate entirely the sub-epithelial extensions. A case of spontaneous retrogression of a growth in the upper lid of a girl aged 11 has been reported.

The first case of conjunctival infec­tion was noted by KIRKPATRICK [4] in India and in 1916 he published the first case of lacrimal sac involvement. The disease usually affects the palpebral conjunctiva and less com­monly, the bulb, limbus, caruncle or canthi. The disease occurs universally. It is endemic in India in the states of Kerala, Tamil Nadu, Maharashtra, Madhya-Pradesh, Bihar and Orissa.


   Material and Methods Top


The material of this analysis comprises 21 cases collected from the departments of E.N.T. and Ophthal­mology of our hospital during the year 1972. The diagnosis was based on clinical features and biopsy reports. There were 13 males and 8 females. The youngest patient was a male aged 8 and the oldest also a male aged 60. The disease is more common in the first and second decades of life. The palpebral conjunctiva is involved in 76.2% of cases and lacrimal sac in 28.6%. The most common site off infection is the lower palpebral con­junctiva 66.6%. The duration of the disease ranged from 2 months to 12 months. Out of 21 cases only one female patient aged 17 had recurrence. All the patients hailed from agricultural areas.

Clinical Features

The growths were pink or red, granular, lobulated sometimes flattened out like a pancake to accommodate itself between the lids and the globe. [Figure - 2] These were either sessile or stalked. There was swelling of the right lower lid [Figure - 3] and bleeding from the nose on pressing the lacrimal sac swelling in one case.

Differential Diagnosis

Conjunctival growths should be differentiated from the granuloma of a burst chalazion, a haemangioma, caruncle in old people and lacrimal sac growths from decryocystitis and ethmoidal mucocele. White seed­like sporangia on the surface should distinguish rhinosporidiosis from other conditions. Lacrimal sac growths will be boggy to the touch, and cannot be flattened on pressure, but will give an impression of being filled with granulations. Associated lesions in the nose and conjunctiva and excessive bleeding during operation should suggest the diagnosis. In the case of ethmoidal mucocele X-ray will show replacement of cells by one cystic cavity.

Treatment

Conjunctival growths were excised and the base cauterized. Lacrimal sac growths were treated by dacryocys­tectomy.


   Discussion Top


In 21 cases studied there was only one case of history of trauma preceding infection. However minor trauma to the eye of which the patients were not aware of cannot be excluded. The reason for the preponderance of infection in the lower palpebral con­junctiva is not well understood. It may be due to the fact that the lower palpebral conjunctiva may be easily everted and exposed to dust and water. The downward flow of the lacrimal fluid may also aid the spores to settle down in the lower palpebral conjunctiva.

According to RAMBO a surlling in the lower lid is suggestive of chinos­poridiosis of the lacrimal see. It is believed that the spores exist in the soil. The eye may be affected either by air-borne or water-borne spore, taken up from the soil.

There were four cases, of involve­ment of nose and lacrimal sac. The patients gave a history that the development of nasal growth preceded the appearance of lacrimal sac swelling. The lacrimal sac cannot be infected through the nasolacrimal duct, because the lacrimal fold acts as a flap valve to prevent the secretion of the nose from being driven up into the duct. Possibly the infection would have reached the lacrimal sac from the nose via the sub-epithelial lymphatic channels

In the case, where lacrimal sac alone was involved, it being a hollow protected viscus, the infection either would have reached the sac from the nose or eye through the lacrimal canaliculi, without infecting the nose or the eye.

The conjunctiva, limbus, lacrimal sac and nose were affected in one case. The patient stated that the nasal growth appeared first followed by the swelling of the lacrimal sac and eye lesions. The transference of infection from the nose to the eye by means of fingers should be considered in this case since the secretions of the nose also contained the spores. But mostly infection of contiguous areas are by permeation through sub-epithelial lymph capil­laries. If the eye is the primary site, the nose can be affected by way of nasolacrimal passages.

The patient with swelling of the right lower lid [Figure - 3] gave a history of injury due to a fall, in the lacrimal sac region prior to the development of swelling of the sac and lid. Probably this could have been the predisposing cause for the spores to gain access to the lacrimal sac. He also mentioned that he was accustomed to frequent diving in a tank common to the place. MANDLIK [5] suggested that diving, through increased water pressure, forces the spores against the nasal mucosa for successful grafting.

The disease mainly affects people who live in agricultural areas. In these patients, the wells and tanks used for irrigation purposes and bathing, may be the source of infection or infection can occur from the soil through air­borne spores.

Two cases of bulbar conjunctival rhinosporidiosis were seen by the 2nd author associated with ciliary staphyloma without involvement of the palpebral conjunctiva. They do well following excision of the con­junction and using a siloplastic sponge to strengthen the sclera[8].


   Summary Top


Twenty one cases of ocular rhinos­poridiosis are presented and a critical study made.

 
   References Top

1.Allen, F. R. W. K. and Dave, M. L.: The treatment of rhinosporidiosis in man based on the study of sixty cases. Ind. Med. Gaz. 71: 376-395 (1936).  Back to cited text no. 1    
2.Ashworth, J. H.: On Rhinosporidium Seeberi (Wernicke, 1903) with special reference to its sporulation and affinities. Trans. Roy. Soc. Edin. 53: part 2, 301-342 (1923).  Back to cited text no. 2    
3.Karunaratne, W. A. E.: Rhinospori­diosis in man. The Athlone Press. University of London (1964).  Back to cited text no. 3    
4.Kirkpatrick, H.: Two cases of Rhinosporidium Kinealyi affecting the conjunctiva. Ophthalmoscope. 10: 430-432 (1912).  Back to cited text no. 4    
5.Mandlik, G. S.: A record of rhinos­poridial polypi with some obser­vations on the mode of infection. Ind. Med. Gaz. 72: 143-147 (1937).  Back to cited text no. 5    
6.Rambo, V. C.: Rhinosporidiosis of the lacrimal sac; swelling of the lower lid a warning of its possible presence. Pro. All-India Ophth. Soc. 10: 72-76 (1949).  Back to cited text no. 6    
7.Satyanarayana, C.: Rhinosporidiosis. Clinical Surgery-11. Ear, Nose and Throat. Edited by Maxwell Ellis Butterworths. London (1966).  Back to cited text no. 7    
8.Wright, R. E.: Rhinosporidium Kinealyi of the conjunctiva. Ind. Med. Gaz. 57: 82-83 (1922).  Back to cited text no. 8    


    Figures

  [Figure - 1], [Figure - 2], [Figure - 3]
 
 
    Tables

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