|Year : 1982 | Volume
| Issue : 3 | Page : 163-165
TM Muddappa, PN Srinivasa Rao
O. E. U. Institute of Ophthalmology. Kasturba Medical Colleee. Manipal, India
T M Muddappa
O.E.U. Institute of Ophthalmology, Kasturba Medical College Hospital Manipal-596119
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Muddappa T M, Srinivasa Rao P N. Ocular tetanus. Indian J Ophthalmol 1982;30:163-5
Ocular tetanus has become an unusual disease after the advent of tetanus toxoid and the proper management of the wounds of the eye. We are presenting here a case of ocular tetanus following penetration of the globe with a iron piece.
| Case report|| |
C.D. male aged 26 years presented with the history of injury to the right eye of two days duration when a foreign body struck at the right eye while chipping the stone with a iron hammer. Patient noticed the vision failing immediately with much pain and redness of right eye.
On examination right eye showed blepharospasm, circum-corneal congestion and ciliary tenderness. An horizontal line of penetrating corneal opacity was just below the centre of the cornea. There were turbid aqueous, posterior synechiae, and cataractous lens. Left eye was normal Visual acuity in R.E. was Finger counting at 1 foot distance in L.E. 6/6
Fundus R. E.-No view, L.E.-Normal;
Intra ocular pressure : R.E.-Digitally soft
L.E. - Digitally normal. General and systemic examinations were normal.
Suspecting an intra ocular foreign body in the right eye, the patient was admitted. Systemic and local antibiotic injection were started in addition to local mydriatics and antibiotic drops. Tetanus toxoid 1 cc IM was injected on admission. X-ray of the orbit with limbal marker showed the radio-opaque foreign body in the vitreous cavity at 6 o' clock meridian 1 I mm away from the limbus. This was removed with the help of a a giant magnet under general anaesthesia through the pars plana at 6 O'clock meridian. Lens aspiration was done through a separate incision at the temporal limbus.
But on the 15th day after the injury the patient complained of difficulty in swallowing and opening the mouth. Detailed examination showed spastic contraction of the jaw muscles, in addition to medial rectus palsy in the injures eye. The paralytic divergent squint was 45 There was neck rigidity also.
Suspecting cephalic tetanus with ocular involvement the patient was put on active treatment for the same i.e.
- Inj. Antitetanus serum 50,000 units I.V. slowly after test days.
- Tab. Robinax 2 TID for two weeks.
- Cap. Ampicillin 500 mg 6 hourly for 10 days.
- Tab. Calmpose 10 mg TID for two weeks.
- Tab. Phenobarb 60 mg TID for two weeks
Patient recovered and was discharged two weeks later. But the right eye was divergent by more than 25° with restricted medial movement. Patient was reviewed two months later, the right eye was still divergent by 25°, but the medial rectus was only slightly restricted.
Visual acuity : R.E.-F.C. in front of the face L.E. - 6/6
Right fundus revealed multiple fibrous bands in the vitreous with a poor glow. When the patient was reviewed a year later, the right eye still had divergent squint by 25°, but the medial rectus had recovered its function almost completely. The eye remained divergent as the vision was very poor in that eye.
| Discussion|| |
Tetanus caused by Clostridium tetani affects by its exotoxins. It is a anaerobic spore bearer. Perforating wound of the eye provides an ideal anaerobic condition for the mollification of the bacilli. Injuries to the eye have infrequently resulted in tetanus. Only about 30 cases are reported in the literature. Panophthalmitis greatly favours the development of tetanus. The exotoxin travels through the peripheral nerves or perineural lymphatics or blood and affect the myoneural junction, trunk or the nucleus to cause ocular palsies. 3rd cranial nerve is the commonest of the ocular nerve involvement. Less commonly the 4th and 5th cranial nerve involvement or any sort of combination of palsies. Almost always the side affected is the ipsilateral and sometimes the other side. In our case only the medial rectus of the ipsilateral side was involved. Single muscle involvement is rare.
The usual incubation period is 5-12 days. It may be longer. The first evidence of the disease is stiffness of the muscles of the face and jaw giving an appearance of the fixed grin called risus sardonicus. Recovery is invariable if the patient survives 10 days. Stark reported a case after penetrating corneal injury which recovered after antitoxin. Localised form has a prolonged incubation period and better prognosis. The cephalic form develops from the infection of the face, head, neck and rarely eyes. Blepharospasm is the commonest presentation. Ptosis is frequent. Active divergence is seen in acute stage. Facial paralysis is common. Wettler says ocular palsies are the first evidence of cephalic tetanus. Other symptoms of cephalic type are : dysphagia, aphonia, cyanosis, retention of urine and faeces, epigastric pain, profuse sweating, asphyxia, increased body temperature. Here the prognosis is bad.
Our patient developed ocular tetanus inspite of the tetanus toxoid injection, is probably because he never had primary immunisation in childhood.
| Summary|| |
A male stone cutter affected by ocular tetanus following intra ocular foreign body of ferrous nature. Medial rectus alone was involved. Patient recovered almost completely after the treatment.
| References|| |
Wetzel, J.O., 1942, Amer J. Ophthalmol. 25: 933.
Duke Elder, S. 1971,-System of Ophthalmology: 1971. Henry Kimpton. London. Vol. XII, Page 761.
Walsh and Hoyt, 1969, Clinical Neurophthal mology : Williams and Wilkins Company, Baltimore, 1470-1475.
Stark, A., 1950, Klin. Mgl. Augenhei:k 84: 144.
Wettler, H., 1953, Ophthalmologica (Basel) 125 373.
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