INFECTIONS OF THE EYE AND ITS ADNEXA

 The histopathologic study of infections of the eye and ocular adnexa

is a daunting undertaking given the variety of tissues comprising this
proportionately small area of the body with extensive exposure to
the external environment.
 The term adnexa denote all of the supporting and protecting
structures around the eye. Infections may affect any adnexal
structure, such as the mucous membrane (conjunctiva), the skin
(eyelids), and the orbital contents (lacrimal gland, extraocular
muscles, fibroadipose tissue, optic nerve, peripheral nerves and
vessels).
 Infections can involve the interior of the globe and its layers
(infectious retinitis, uveitis, scleritis, endophthalmitis of the vitreous
and panophthalmitis of all layers, including the sclera and episclera)
either from internal hematogenous spread (endogenous) or from
external sources (exogenous), such as trauma or surgery.
 The clinical presentations and histopathologic findings are unique for
each of these sites.
MASQUERADE SYNDROMES
There are four conditions in ophthalmology that deserve particular
attention because they can mimic infectious diseases either clinically
or histopathologically.
CHALAZION
 This inflammatory eyelid disorder, the most common of the eyelids
can easily mislead the general pathologist, because of its
granulomatous features, into a diagnosis of a fungal or tuberculous

1
 infection (which are ruled out with negative Gomori methenamine
silver [GMS] staining or acid-fast staining, respectively).
 The chalazion represents a blockage in the ducts of the meibomian
glands, which may be due to hyperparakeratosis near their orifices,
leading to rupture of the glands. Often commencing as an intratarsal
bacterial infection, cytoplasmic lipid is eventually released
extracellularly to elicit the granulomatous response
SEBACEOUS CARCINOMA
 This tumor arises in the meibomian and Zeis glands, most often of
the upper eyelids in older patients.
 Because it is capable of spreading within the conjunctival epithelium
(“pagetoid extension”), it can create a unilateral red eye, mimicking
infectious conjunctivitis. However, bacterial and viral infections are
usually bilateral.
 A biopsy of reddened conjunctiva will reveal large atypical cells with
frothy vacuolated cytoplasm that are androgen receptor and
adipophilin positive.
INTRAOCULAR LYMPHOMA, LEUKEMIA, BEHḈET DISEASE
WITH HYPOPYON
 Lymphoma cells involving the retina, vitreous, or iris may seed
aqueous of the anterior chamber and settle inferiorly to create a
layered pseudohypopyon.
 Vitreous and aqueous aspirations studied cytologically can reveal
the presence of neoplastic cells or polymorphonuclear leukocytes.
 Inflammatory disease (e.g., Behçet) or infections conditions
(bacterial endophthalmitis) are often associated with hypopyon, but
these typically cause an intensely injected and inflamed eye

2
 whereas a lymphomatous pseudohypopyon is usually encountered
in a noninflamed eye
 Retinoblastoma cells also cause pseudohypopyon in some cases,
particularly the diffuse infiltrative form that tends to occur in older
children.
NECROTIC INTRAOCULAR TUMORS SIMULATING
PANOPHTHALMITIS AND ORBITAL CELLULITIS
 Massive necrosis of a retinoblastoma or uveal melanoma can
produce intense periocular inflammation simulating a cellulitis.
 Imaging studies, especially ultrasound, can help to differentiate
these conditions. Histopathology reveals massive spontaneous
tumor necrosis that typically involves other intraocular structures.
CONJUNCTIVAL INFECTIONS
Conjunctivitis is a common ophthalmic condition that is largely
infectious in nature. It is often diagnosed solely based on clinical
examination. Bacterial conjunctivitis is the most frequent culprit in
children; in adults, viral disease predominates.
BACTERIAL INFECTIONS
Common Bacterial Conjunctivitis
 Bacterial conjunctivitis presents with purulent discharge and
conjunctival injection, often bilaterally. The most common causative
organisms are Streptococcus pneumoniae, Haemophilus influenzae,
and Moraxella catarrhalis. In adults, various staphylococcal species
predominate as etiologic agents, followed by streptococci and H.
influenzae.

3
 Neisseria gonorrhoeae is an important cause of conjunctivitis in
sexually active adults or neonates with direct genital-eye or genital-
hand-eye contact.
o An infected maternal birth canal can cause a dramatic discharge in
conjunctivitis neonatorum.
o Conjunctival smears may reveal intracellular gram-negative cocci;
swabs sent for culture and polymerase chain reaction (PCR) are
confirmatory.
 Trachoma (Chlamydia trachomatis serotypes A to C) is a chronic
keratoconjunctivitis that results in severe conjunctival and corneal
scarring and is a leading cause of blindness worldwide.
 Acute chlamydial inclusion conjunctivitis transmitted from direct or
indirect contact with genital secretions (serotypes D to K which
cause genital infections).
Cat-Scratch Disease and Granulomatous Conjunctivitis
 Granulomatous conjunctivitis with follicle formation and regional
lymphadenopathy is known as Parinaud oculoglandular syndrome.
 The clinical syndrome is most commonly caused by severe non-
granulomatous viral conjunctivitis while its granulomatous
counterpart is most often a manifestation of cat-scratch disease due
to Barontella henselae (and less commonly to tularemia,
sporotrichosis, or other Bartonella species) usually transmitted by a
flea-infested kitten, have granulomatous conjunctival involvement.
 Syphilitic conjunctivitis as a manifestation of secondary syphilis can
also rarely cause a granulomatous conjunctivitis
VIRAL INFECTIONS
Adenoviral Conjunctivitis

4
 Various serotypes of adenovirus can cause a simple, self-limited
follicular conjunctivitis for which microbiologic or histopathologic
examination is rarely performed.
 Adenoviral keratoconjunctivitis, especially serotype D, is responsible
for so-called endemic keratoconjunctivitis or pink-eye infections that
spread rapidly through contaminated ocular secretions in
populations living or working together.
 There is prominent accompanying conjunctiva edema (chemosis)
and prominent preauricular adenopathy.
Herpesvirus Conjunctivitis
 Ocular herpetic disease is an important cause of ocular morbidity
and vision loss due to involvement of various ocular and adnexal
sites.
 Primary infection with HSV usually manifests as a unilateral
blepharoconjunctivitis. The conjunctivitis is follicular in nature and
often associated with a palpable preauricular lymph node and
vesicles on the eyelid skin or at the eyelid margin. Watery or slightly
mucoid discharge is observed.
 Herpes viruses may also cause chronic scleritis, with nonspecific
chronic inflammation of the sclera that is sometimes granulomatous.
Human Papillomavirus
 Human papillomavirus (HPV) has been implicated in the
development of conjunctival squamous cell carcinoma. HPV type 16,
as in oropharyngeal and cervical carcinoma, is the most common
strain isolated with PCR.
FUNGAL INFECTIONS
Rhinosporidiosis

5
 Rhinosporidiosis is caused by infection with the fungus
Rhinosporidium seeberi, which leads to the formation of a distinctive
highly vascular, polypoidal, or pedunculated mass of the mucous
membranes studded with white, subepithelial sporangia.
 Infections are acquired by patients in warm, humid climate.
 Infection probably develops as a result of direct exposure to
stagnant water, although inhalation of spores may also play a role.
 As the life cycle of the organism repeats, the characteristic vascular
mass grows. Complete excision of the sessile or pedunculated red
mass is curative
Other Rare Fungal Conjunctivitis
 Ocular cryptococcosis, an infection of predominantly patients with
human immunodeficiency virus/acquired immune deficiency
syndrome (HIV/AIDS), is rare and most commonly manifests in the
posterior segment.
 Coccidiomycosis, which can cause a fulminant endophthalmitis has
rarely been described to cause conjunctival or eyelid granulomas.
PARASITIC INFECTIONS
Loiasis and Onchocerciasis
 Ocular loiasis is caused by Loa loa, a nematode for which the
human is the definitive host. L. loa is endemic in West Africa and is
transmitted to humans by infected mangrove (Chrysops) flies that
are intermediate hosts for microfilaria.
o Adult worm can be visualized moving through the subconjunctival
space, and patients nearly always present with the complaint of a
sensation of something moving in or around the eye, mimicking
common myokymia.

6
o Worms may also rarely be found in the periocular subcutaneous
tissues or in the anterior chamber of the eye.
 Onchocerca volvulus, also has a tropism for ocular tissues and can
rarely be found crawling in the subconjunctival space. Posterior
segment chorioretinitis and scarring also contribute to blindness
from O. volvulus.
CORNEAL INFECTIONS
A variety of infectious diseases can take up residence within the
cornea, especially in susceptible situations with epithelial
breakdown. These include chronic exposure, accidental trauma,
surgery, trichiasis, and increasingly contact lens wear.
BACTERIAL INFECTIONS
Classic Bacterial Keratitis with Corneal Ulcer
 This condition presents acutely, with severe pain, decreased vision,
and photophobia. On examination, an epithelial defect is present
with a white, purulent infiltrate of the corneal stroma.
 Although most bacteria rely on a disruption of the corneal epithelium
to cause disease, exceptions include Neisseria, Corynebacterium,
and Shigella species.
 The epithelial abrasion allows species normally inhabiting the skin,
mucous membranes, upper respiratory, and digestive tracts, such as
grampositive staphylococci, streptococci, and enterococci, to
become pathogenic.
 Gram-negative infections are usually more fulminant, especially
those with the gram-negative rod Pseudomonas aeruginosa, a
common pathogen isolated from corneal ulcers in contact lens
wearers.

7
 Infectious Crystalline Keratopathy
 A unique clinical and histopathologic variant of bacterial keratitis
known as infectious crystalline keratopathy is caused by fastidious
organisms (often Steptococcus viridans) in patients with
compromised corneal immunity (i.e., corneal transplant patients on
chronic topic immunosuppression).
 No true crystals form, but the opacity has a crystalloid appearance
clinically. It is thought that the bacteria are sequestered by a
polysaccharide-rich glycocalyx consistent with a biofilm. The
overlying epithelium is often intact, rendering the precise organismal
diagnosis of the infectious process difficult.
 A repeat corneal transplantation together with long-term
postoperative antibiotic therapy may be necessary for cure.
VIRAL INFECTIONS
Herpetic Keratitis
 In the cornea, HSV manifest with acute hypesthetic epithelial
keratitis in a clinically classic arborizing pattern termed a dendrite.
o Chronic stromal keratitis leads to stromal scarring and
vascularization—the most common cause of corneal transplantation
related to infectious disease.
 Keratitis from varicella zoster virus (VZV) as a manifestation of
herpes zoster ophthalmicus can also be epithelial, immune-stromal,
or endothelial with similar histologic findings as in simplex
conditions.
 In zoster infections, pseudodendrites may occur, usually in the
corneal periphery, and consist of swollen, poorly adherent epithelial

8
 cells. Unlike HSV dendrites, they lack terminal bulbs and
dichotomous branching.
FUNGAL INFECTIONS
Classic Fungal Keratitis with Corneal Ulcer
 Fungal keratitis is almost always associated with local
immunosuppression, often from chronic topical steroid therapy.
 In addition, it often occurs after trauma involving vegetable matter. It
is most often seen in warm, humid climates.
 Fungal keratitis presents more indolently that bacterial keratitis and
clinically displays a nonsuppurative corneal infiltrate with indistinct
“feathery” borders and satellite lesions surrounding the main
infiltrate.
 Common pathogens are Aspergillus and Candida species. Such
organisms as Paecilomyces may cause a fungal keratitis that is
refractory to conventional treatment and requires penetrating
keratoplasty and oral antifungal therapy.
Microspodial Keratitis
 Microsporidia are obligate intracellular, spore-forming organisms
previously thought to be protozoans but now classified as fungi.
 Microsporidial keratoconjunctivitis was initially described in
immunocompromised patients with HIV/AIDS in the early 1990s.
However, many cases have now been reported in contact lens
wearers and overtly healthy individuals.
 Clinically, coarse punctate corneal epithelial erosions are detected
on examination, but many cases can resemble adenoviral or
herpetic keratitis with deep stromal infiltration.

9
 PARASITIC KERATITIS
Acanthamoeba Keratitis
 Acanthamoeba keratitis is the classic example of corneal protozoal
infection in contact lens wearers who are exposed to stagnant water
and/or do not take appropriate sterilization precautions with their
lenses
 Patients complain of severe pain, often out of proportion to the initial
clinical examination findings (due to a perineuritis).
 The corneal infiltrate is classically ring shaped or circular and a
hypopyon is often seen. As the disease progresses, marked corneal
stromal necrosis can occur.
 Large keratoplasty specimens are often received because the
organisms spread toward the limbus and pathologists are asked to
comment upon the presence of organisms at the graft-host junction,
which serves to guide postoperative antimicrobial therapy.

INTRAOCULAR INFECTIONS (INCLUDING ENDOPHTHALMITIS

AND INFECTIOUS RETINITIS AND CHOROIDITIS)
A variety of pathogens can affect the uveal tract, often posteriorly,
causing inflammation of the retina and choroid.

BACTERIAL INFECTIONS
Acute Bacterial Endophthalmitis
 Bacterial endophthalmitis occurs acutely (several days) after
intraocular surgery or after traumatic rupture of the eye wall. It is
rare and one of the most dreaded complications of cataract or
glaucoma-filtering surgery (bleb-related endophthalmitis)

10
 Patients develop pain, markedly decreased vision, and a hypopyon
several days after surgery. The view of the fundus is commonly hazy
due to the inflammatory response and ultrasonography reveals
debris in the vitreous cavity.
 Diagnosis and treatment are often provided concurrently with
sampling of the vitreous cavity by aspirating a sample of the vitreous
for Gram stain and culture followed by injection of intravitreal
antibiotics on an empiric basis.
 Overall, common sources for hematologic dissemination are the
liver, lung, and heart valves. Subretinal abscesses are known to
occur with bacterial endophthalmitis, especially in endogenous
Klebsiella infections.

Chronic postoperative endophthalmitis

 Chronic postoperative endophthalmitis has an indolent onset with
multiple, recurrent bouts of inflammation beginning weeks to months
after surgery. Less virulent organisms are causative, most
commonly Propionibacterium acnes, a commensal organism
normally found on the eyelid skin and conjunctiva.
 Clinically patients are often misdiagnosed with chronic,
noninfectious iridiocyclitis and treated with topical steroid therapy
until a whitish plaque develops on the intraocular lens
 Treatment often requires removal of the lens and/or capsular bag.

Whipple disease
 Although rare, it most commonly appears as a chronic uveitis or
optic disc swelling (in addition to a variety of other neuro-

11
 ophthalmologic findings). Aspirated vitreous cytologic specimens
may demonstrate PAS-positive macrophages, but molecular
diagnosis performed on vitreous or cerebrospinal specimens is often
required for accurate diagnosis.

VIRAL CHORIORETINITIS
Herpes Family Chorioretinitis
 herpetic disease can affect all aspects of the eye and ocular adnexa.
The most catastrophic manifestation of these herpetic infections is
posterior segment involvement in the form of acute retinal necrosis
(ARN). Patients with HSV retinitis are typically otherwise healthy
adults presenting with acute unilateral loss of vision, photophobia,
floaters, and pain with significant anterior and posterior segment
inflammation (keratic precipitates on the corneal endothelium and a
dense vitritis) together with the evolution of peripheral retinal
whitening and occlusive vasculitis.63 Cytomegalovirus (CMV) can
cause a very similar clinical picture in immunocompetent patients.
 In all cases of ARN due to the herpesviruses, histopathologic
examination of microsurgical retinal biopsies or enucleation
specimens reveals profound necrosis with occlusive retinal arteritis.
 Large eosinophilic intranuclear and intracytoplasmic inclusions are
noted within the retina, along with a mononuclear cell infiltration and
sloughing of the inner retina

FUNGAL INFECTIONS
Classic Fungal Endophthalmitis

12
 As opposed to bacterial endophthalmitis, which is largely exogenous
in nature, many cases of fungal endophthalmitis are endogenous
 Such cases occur in chronically immunosuppressed patients on
long-term steroid therapy, patients receiving parenteral nutrition or
with central venous catheters, intravenous drug users, and solid
organ transplant patients (especially of the liver).
 The most common organisms isolated are Candida albicans and
other Candida species, Aspergillus species, and Cryptococcus
 Classically, fundoscopic examination reveals a fluffy white,
circumscribed vitreous “fungus ball” or “string of pearls”

CRYPTOCOCCAL ENDOPHTHALMITIS AND OTHER UNUSUAL

CAUSES OF FUNGAL ENDOPHTHALMITIS
 It preferentially affects the lungs and central nervous system in
immunocompromised adults
 Intra-ocular infection, largely in the form of multifocal choroiditis, is
due to either hematogenous dissemination or direct extension
through the leptomeninges via the optic nerve sheath.
 Chorioretinitis, endophthalmitis, papilledema, and cranial nerve
palsies are other ophthalmic findings associated with the disease.
 Endophthalmitis is rare but cata-strophic and usually is associated
with disseminated disease, although cases are being reported
without concomitant systemic involvement
 Histopathologic examination of enucleated eyes demonstrates
intraocular granulomas on the iris, in the retina, and within the
vitreous cavity, which can appear sarcoidal but contain the fungal
organisms.

13
 Such chronic granulomatous endophthalmitis leads to tissue
destruction and disorganization of the intraocular contents.

Ocular Histoplasmosis
 The most common manifestation of histoplasmosis is known as the
“presumed ocular histoplasmosis syndrome,” a multifocal
chorioretinitis that is often asymptomatic (as is the primary
pulmonary infection) and occurs in immune competent patients.
 Patients have peripapillary (surrounding the optic nerve) atrophy and
pigment changes and multiple atrophic choroidal scars (“histo
spots”) without vitreous inflammation.
 Histoplasmosis can cause an unusual focal retinochoroiditis or a
fulminant endophthalmitis in either immunosuppressed
 Clusters of oval yeast forms within macrophages can be seen
histopathologically within the choroid in focal choroiditis. The
organisms can also appear in the vitreous cavity.

Pneumocystitis Choroiditis
 Prior to the development of highly active antiretroviral therapy,
Pneumocystis jirovecii manifested frequently in HIV/AIDS patients
as a bilateral multifocal choroiditis
 The organism has also been seen histopathologically in the
ganglionic and plexiform layers of the retina.

PARASITIC INFECTIONS
Toxoplasma gondii

14
 Toxoplasmosis can be acquired congenitally and encountered in the
neonate as characteristic bilateral, pigmented macular scars along
with brain lesion.
 It is the most common cause of infectious posterior uveitis in adults
and children, with a very characteristic fundus appearance.
 Immunocompetent patients, usually in their second to fourth
decades of life, exhibit a focal, white retinitis with overlying vitreous
inflammation (so-called headlight in a fog) often adjacent to a
pigmented, healed chorioretinal scar from prior disease episodes.
The diagnosis is usually made clinically from the classic
appearance, although antibody titers and PCR of the aqueous or
vitreous fluid aspirates can be useful.

DIFFUSE UNILATERAL SUBACUTE NEURORETINITIS AND

OTHER NEMATODE INFECTIONS
 Diffuse unilateral subacute neuroretinitis (DUSN) is caused by
migration of a nematode (thought to be either Ancylostoma caninum,
the dog hookworm, or Baylisascaris procyonis, the raccoon
roundworm) through the subretinal space often in adolescent and
otherwise healthy patients
 Recurrent inflammatory episodes of the retina, retinal pigment
epithelium, and optic nerve have been seen due to migration of the
worm, which can be visualized on fundoscopy in the subretinal
space and treated with photocoagulation.

EYELID AND ORBITAL (SKIN AND SOFT TISSUE) INFECTIONS

15
 Infection of the periocular skin and soft tissue (eyelids and orbital
contents) is in many cases the consequence of spread from
adjacent sinuses.

BACTERIAL INFECTIONS
Bacterial Orbital Cellulitis
 Bacterial infections of the eyelid skin and orbit originate from an
adjacent sinus, especially in children, or can be from direct
inoculation through the skin. Bacteremic spread from a distant focus
is rare.

Subperiosteal Abscess
 Subperiosteal abscess is a common orbital complication of bacterial
sinusitis and orbital cellulitis. Histopathologic study reveals
liquefactive necrosis surrounded by fibrous periosteal tissue and
orbital fat and associated fibrous septa.

Necrotizing Fasciitis
 This condition rarely affects the eyelids, periocular tissues, and
orbital contents due to group A β-hemolytic streptococci infection.
Necrosis is likely mitigated by the rich vascular supply of the eye
and orbit.
 Histopathologic examination discloses suppurative inflammation with
necrosis that extends from the eyelids into the orbit between the
orbicularis oculi muscle and conjunctiva along the orbital fascial
planes.

16
 Fundoscopic examination may reveal a central retinal artery
occlusion, making the decision to exenterate the orbit easier.

BACTERIAL DACRYOCYSTITIS, CANALICULITIS, AND

DACRYOADENITIS
 Dacryocystitis is produced by obstruction of the nasolacrimal duct
with resultant tear stasis. Clinically, patients display erythema and
swelling of the lacrimal sac, creating a mass in the medial canthal
area, centered below the medial canthal tendon. Infected
dacryocystoceles can become massive.
 Along with antibiotic therapy or external drainage of an abscess
through the skin, definitive treatment consists of
dacryocystorhinostomy (DCR) surgery to create a new passageway
for tears into the nasal cavity, eliminating the predisposing stagnant
tear fluid in the lacrimal sac that is the basis for infection.
 Infection of the canaliculus (a thin canal extending from the puncta
of the eyelid margin to the lacrimal sac) is relatively uncommon and
presents with epiphora (tearing) and edema and reddening of the
puncta (usually lower punctum, seen as a “pouting punctum”.
 Dacryoadenitis (inflammation of the lacrimal gland located in the
anterior superotemporal orbit just beneath the conjunctiva and
behind the orbital rim) is typically idiopathic and noninfectious. Many
infectious cases are viral mediated (Epstein-Barr virus, mumps),
although S. aureus may cause an ascending bacterial
dacryoadenitis via the excretory ducts of the gland that empty into
the conjunctival sac.

17
 MYCOBACTERIAL INFECTIONS AND OTHER UNUSUAL
BACTERIAL INFECTIONS OF THE EYELIDS AND ORBIT
 Tuberculous infections of the orbit are rare but may occur as a
periostitis or orbital soft tissue tuberculoma; disease may also
spread from the paranasal sinuses.
 They can involve the eyelid skin, creating unique clinical and
histopathologic appearances. Patients present weeks after surgery
(usually blepharoplasty) with erythematous, nodular eyelid lesions
along the healing surgical incision, which may be mistaken for a
suture granuloma or chalazion.
 M. leprae has a high rate of ocular involvement. A leonine facies
eventually emerges. Ptosis caused by cranial nerve III palsy and
ectropion and lagopthalmos by CN VII involvement are also noted in
leprosy patients. Biopsy of eyelid lesions reveals acid-fast bacilli
within the dermis
 Malakoplakia is a histiocytic disease most commonly isolated from
the bladder, usually in patients with some underlying
immunosuppressive state or a chronic disease
 Botryomycosis or pseudomycosis, a rare morphologic expression of
infection, which can occur in immunosuppressed patients, is due to
chronic bacterial infection (usually with S. aureus) and displays
histopathologic features similar to that of actinomycosis;
conglutinated colonies of organisms appear to be encapsulated in
granules.
 Infection of the adnexa by Blastomyces dermatitidis may follow
systemic dissemination of a primary pulmonary infection. The
infection causes pseudoepitheliomatous hyperplasia, evident as

18
 large hyperkeratotic verrucous plaques. Some infected patients
have had contact with beaver dams.

VIRAL INFECTIONS
Eyelid Molluscum Contagiosum
 This affection, caused by a DNA poxvirus, commonly infects the
face, including the eyelid margin. Pale, round smooth papules with a
central umbilication at the eyelid margin may cause a chronic,
unilateral follicular conjunctivitis due to shedding of the viral particles
into the inferior conjunctival sac

Herpesvirus Family
 As discussed in the conjunctival and cornea sections, primary HSV
often manifests as a unilateral vesicular rash with a
blepharoconjunctivitis. Herpes zoster ophthalmicus from reactivation
of the latent VZV in the trigeminal (gasserian) ganglion can present
in a similar fashion, usually in middle-aged, elderly, or
immunocompromised individuals. The painful vesicular rash always
respects the midline. Occasionally, only a single vesicular lesion is
observed.

Fungal Infections
 Invasive orbital fungal infection with Mucor or Rhizopus fungi (class
Zygomycetes), like most cases of bacterial orbital cellulitis, begins in
the nasal cavity or sinuses and extends into the orbit. Patients with
invasive fungal rhinosinusitis are nearly always immunosuppressed
due to hematologic malignancy, diabetes, immunosuppressive

19
 therapy after solid organ transplantation, long-term corticosteroid
use, HIV/AIDS, etc.
 Diagnosis is often suspected from necrotic tissue seen within the
nasopharynx, using nasal endoscopy. Orbital disease presents with
proptosis, ophthalmoplegia, and decreased vision
 Cases were reported in immunocompetent patients following minor
trauma with implantation of soil or decaying vegetable matter; these
infections may be more indolent.

PARASITIC INFECTIONS
Trichinosis
 Infection with Trichinella spiralis and other Trichinella species occurs
after ingestion of contaminated meats containing larvae. The usual
offender is contaminated pork, but a variety of sources, including
horse meat, has been indicted.
 Larvae may rarely migrate into retinal vessels but rather encyst in
the extraocular muscles where they cause pain with eye movement
or paresis with diplopia. Calcification of Trichinella cysts may be
seen on imaging studies of involved extraocular muscles.

Dirofilaria
 Dirofilaria species are zoonotic filariae that are transmitted to
humans through an infected vector (blood-sucking insects) that have
fed on an animal with a filarial infection. The most common
presentation is a periocular subcutaneous nodule filaria that may be
found subconjunctivally or within the eyelid or orbital tissues,

20
 clinically and radiographically mimicking preseptal or orbital cellulitis
or orbital “pseudotumor”

Echinococcosis
 The adult tapeworm of Echinococcus granulosa causes hydatid cyst
of the orbit. Patients (usually children) present with unilateral slowly
progressive proptosis and a quiet eye in areas where the disease is
endemic such as the Middle East.
 The hydatid cyst forms a thick fibrous capsule in the orbit as it
enlarges. Treatment of orbital disease is surgical.

Myiasis
 Ophthalmomyiasis is due to invasion of the ocular and adnexal
tissue by fly larvae and can be classified as external (conjunctiva or
eyelid), internal (subretinal space or vitreous cavity), or orbital. The
larval tracks may be seen in the subretinal space. In the eyelid a
gelatinous head often develops. Larvae may spontaneously appear
or after chemical immobilization may be removed from the eyelid,
orbit, or aqueous/vitreous cavity

21