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Dec 16th - 31st 2000            Orbital Cysticercosis 

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A 7-year-old male child presented with the history of right eye swelling, pain and blurring of vision from 7 days. This was associated with headache and vomiting. There was no history of fever. On examination there was 5 mm of proptosis of right eye along with ptosis and conjunctival injection temporally (figure).

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Updates (Based on responses) 
Basal blood counts of the child are Hb 13.5g%, TLC 9,600, DLC N₄₅L₅₁M₁E₃, Platelet Count 3,24,000, ESR 14mm. Blood Pressure of the child is 108/72 mmHg. Ultrasound abdomen is normal. All the movements of right eye were limited with almost absent abduction and adduction. Vision was 6/60 in right eye and ophthalmoscopic examination did not show significant finding other than diffuse hyperemia of disc. Left eye had normal movement of all muscles with vision of 6/6. Ultrasonogram showed central high reflective opacity with peripheral cystic lesion in lateral rectus muscles with no evidence of any intra-ocular cystic lesion. There is no history of contact with pets and no other swelling at any other site on examination. CAT scan of orbit has been planned. C.T. scan of head and orbit showed two cystic swellings in right lateral rectus muscles with no evidence of intra-cranial involvement (figure 2-CECT, 3-NCCT). MRI confirmed the diagnosis of cysticercosis with the presence of scolex. Patient was treated with albendazole(15mg/kg/day) and prednisolone (1.5-2.0mg/kg/day); response to therapy was dramatic with proptosis reducing to 1 mm within 3 days with normal vision and remarkable movement of right eye.

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Introduction
Cysticercosis is the most common ocular platyhelminth infection. Ocular involvement occurs in 16 -46 per cent of the infected adult patients, however it is rare in children as the youngest reported patient was 6 years of age.
Involvement
Ocular cysticercosis can involve the intra-ocular structures (vitreous cavity, sub-retinal space, optic nerve head, anterior segment) and adnexa (sub-conjunctival space, lachrymal gland, extra-ocular muscles). Adnexal cases are more frequently observed in India than in other parts of the world. Sekhar et al (1997) reported association of extra-ocular muscles (EOM) in orbital cysticercosis in 80 per cent of their cases, with 50 per cent cases having only intra-muscular cysts.
Clinical Presentation
Cysticercosis of the EOM presents with recurrent severe inflammation, chemosis, proptosis, diplopia, restricted motility, ptosis and optic neuritis.
Diagnosis
Presence of cystic lesion with scolex on Ultrasonography and C.T. scan is suggestive of cysticercosis. More than 50 per cent of patients with cysticercosis have no quantifiable antibody response. If scolex is not visible, ELISA may be diagnostic. MR imaging produces image of cysts and outlines a scolex within cyst, and thus may be the best method of assessing patients with presumed cysticercosis. C.T./MRI scan to rule out intra-cranial involvement is advisable in all cases.
Treatment
Treatment of intra-ocular cysticercosis should be surgical. Surgical treatment depending on site may consist of vitrectomy, sclerectomy, photocoagulation, or a combination of these. Prognosis of untreated intra-ocular cysticercosis is poor leading to blindness within 3 -5 years. Adnexal cysticercosis is generally benign and may undergo spontaneous extrusion. The EOM (Adenexal) cysts with visible scolex can be treated with albendazole (15 mg/kg/day) for 4 weeks with oral prednisolone (1.5 -2.0 mg/kg/day). Successfully treated cases of EOM cyst may have residual restricted movement of the muscle involved, whereas cases with intra-ocular cysts may have residual effect on visual acuity after therapy.

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