|Year : 1975 | Volume
| Issue : 4 | Page : 1-4
Rhinosporidiosis and the eyes
V Suseela, KS Subramaniam
Prof of Ophthalmology, Medical College, Alleppey, Kerala, India
Prof of Ophthalmology, Medical College, Alleppey, Kerala
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Suseela V, Subramaniam K S. Rhinosporidiosis and the eyes. Indian J Ophthalmol 1975;23:1-4
Rhinosporidiosis affecting the eyes and adnexa is a not uncommon condition in the coastal districts of Kerala State. The disease appears to be endemic in certain areas, and is known to occur in South East Asia, South America and rarely in Africa and Eourpe. In India, most recorded cases are from Bengal, Bihar, Orissa, Maharashtra, Madhya Pradesh and Kerala.
Ashworth has worked out the structure and life history of the organism in detail. The casual agent is the fungus Rhinosporidium seeberi. The mature spores, 8-9 microns in diameter are contained in sporangia which may reach a size of 300 microns [Figure - 1]. Several sporangia in different stages of evolution are seen in the lesion [Figure - 2]. The fully developed sporangium on the surface of the lesion is seen as a pinhead sized slightly elevated yellowish pink nodule. Many such on the surface give the lesion a strawberry like appearence which is very characteristic. Rupture of the sporangium produces seeding of the spores into the tissues, and these spread by the lymphatics. The fungus has not been grown on any culture medium or a laboratory animal.
The fungus is found in the soil. Direct human infection from the soil is probably rare, as the incidence in children is much less than in adults. The reservoir of infection is probably more in horses and cattle. The site of lesion in them is in the anterior naries, where the anchoring rope produces abrasions and provides a foothold for the fungus. The mode of transmission to man is not clear. The generally accepted view is that infection occurs in people who bathe in ponds, the water of which has been contaminated by cattle with the disease. Direct man to man transmission is practically unknown. Since the mode of transmission and other features of the disease are still incompletely understood, a study was undertaken on this subject.
| Materials and Methods|| |
All cases suspected of rhinosporidiosis which came to the Ophthalmic Hospital, Trivandruni, in 1972-73 were examined, treated and followed up for two years. Out of nearly 50,000 out-patients seen during that year, there were 49 cases giving an incidence of about 0.1 %.
A detailed history was taken in all cases with particular reference to occupation, bathing habits, contact with animals, epistaxis, and previous eye or nasal operations.
All patients had a thorough ocular examination including testing of visual acuity and tonometry. Nasolacrimal duct syrirging was done in all cases. E.N.T. and general examination were also done as a routine. The lesion was excised and subjected to histopathological examination. The diagnosis of rhinos poridiosis was thus confirmed.
| Observations|| |
In our series of 49 cases, the minimum age of incidence was 3 years, and the maximum was of 61 years. Maximum number of cases were seen in the age group 15-25 years (22 patients). Thirty four cases were males and fifteen were females giving a ratio of approximately 2:1. Only seven of our patients were agriculturists giving history of contact with animals. Twenty eight of our patients were students.
All the patients gave a history of bathing in public ponds. Even though there were many members in each family, no other member showed evidence of the disease. The main site of lesion was the palpabral conjunctiva (38 cases). In none of these 38 cases nasal involvement was there. Primary conjunctival involvement is therefore quite common here.
In seven cases the lacrymal sac was involved. None of these showed conjunctival involvement; but all of them had lesions in the nose.
In four cases the bulbar conjunctiva and sclera were involved leading to scleral staphyloma.
All cases were subjected to excision biopsy. None of the cases with conjunctival involvement showed recurrence. Five out of seven cases affecting sac came back with recurrence. In the cases with staphyloma, biopsy of the conjunctival granuloma was done to establish the diagnosis, No treatment was attempted for the staphyloma.
| Discussion|| |
The main sites of infection in man are the nose, nasopharynx, conjunctiva, lacrimal sac and larynx. Other mucous membranes are not exempt. Rarely the organism may be widely disseminated in the body. The incidence of 0.1% of ocular involvement in our cases compares favourably with figures previously reported. Anand et al. found an incidence of 11 in 15,000 E.N.T. cases giving an incidence of .074%.
The most common method of presentation is a red polypoidal granuloma in the nose, obstructing breathing. The conjunctival lesions look soft, fleshy, red and have a strawberry like appearance. They are usually flat and measure ½ to 1 cm across. It is usually seen on the palpebral conjunctiva close to the lid margin, and may resemble a ruptured chalazion granuloma [Figure - 3]. Primary conjunctival involvement was seen in 76% of our cases.
This is comparable to the figures of Shukla et al. who reported an incidence of 70% in their cases.
The method of lacrimal sac infection is not clear. The usual sequence of chronic inflammation and stricture of the nasolacrymal duct, followed by mucocele of the sac, is not seen here. Not only is the lacrimal fossa eroded and enlarged as mentioned by Shukla et al., but the nasolacrymal duct was also found markedly widened in our cases. This was noticed when passing a probe down the duct after sac excision. Moreover, in our seven cases of sac involvement, none had associated conjunctival involvement, but all of them had the nasal lesion. We believe, therefore, that the sac is involved by upward extension of the mass from the nose, and in this process both the duct and the fossa get dilated. We have been able to demonstrate patency of the nasclacrymal duct in some of these cases, since probably the mass did not fully occupy the dilated passages. This is shown radiographically by dacryocystography [Figure - 4] a and b. In one instance, pinching the nose and forced expiration allowed the air to go up the tear duct and balloon the sac region.
The infected tear sac has a soft boggy feel, and may be quite large even 3 or 4 cm. across [Figure - 5]. The skin over the sac is thickened, and the lesion lies diffusely over the inner angle of the eye and cheek. Pressure ever the sac does not empty it. It may feel like a bag of worms. Rarely there may be regurgitation of mucopus or bleeding into the conjunctiva or nose.
In four of our male cases there was a solitary ciliary or equatorial staphyloma covered by the upper or lower eyelid [Figure - 6]. One was as large as 1.5 cm. in diameter. All these cases showed a mulberry like mass on one side of the staphyloma, biopsy of which confirmed the diagnosis. Presumably the rhinosporidium got fixed to some minor abrasion on the bulbar conjunctiva, and gradually eroded the underlying sclera to produce the staphyloma. The eyes were otherwise normal in all respects. We did not come across any case of intraocular or intraorbital lesions.
Treatment of the conjunctival lesion was easy and satisfactory. Excision and thermocautery of the base was done. No recurrence occured. Difficulty was with lacrimal sac infections. Severe bleeding usually occured from the highly vascular lesion, and complete excision became extremely difficult. Recurrence was therefore common. The subsequent lesions in the sac region were more extensive, extended subcutaneously onto the cheek, and removal became still more difficult. For staphyloma, Kuriakose suggested pushing the staphyloma inwards and suturing the scleral edges, after lowering the ocular tension by paracentesis.
| Summary|| |
The results of a study of 49 cases of rhinosporidiosis affecting the eyes and adnexa are presented. Majority of our cases primarily affected the eyes and involved the palpebral conjunctiva. Transmission was probably through contaminated water of ponds.
Lacrimal sac infections were found always associated with nasal lesions, and we suggest that sac involvement is by ascending infection from the nose. This accounts for the potency of the tear passages to syringing and the dilated tear ducts and lacrimal fossa. The results of treatment are reviewed.
| Acknowledgement|| |
We wish to thank Dr. Rajamma Rajan, E.N.T. Surgeon, Medical College, Trivandrum and the department of radiology for their help.
| References|| |
Anand et al., 1975, J.I.M.A., Vol. 64, No. 2.
Ashworth, 1923, On R. Seeberi with special reference to its sporinlation and affirmities: Trans: Rog: Soc. Edin., 53, 301.
Elliot and Ingram, 1912, Ophthalmoscope 10428.
Kirkpatrick, 1916, Ophthalmoscope, 14477.
Kuriakose 1972, Proc. A. I.O.S.,
Shukla, I.M. et al., 1971, Ocular Rhinosporidiasis. Proc. A.I-O.S.
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6]