Caterpillar hair-induced ophthalmitis causing exudative retinal detachment
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BMJ Case Rep: first published as 10.1136/bcr-2022-251145 on 12 July 2022. Downloaded from http://casereports.bmj.com/ on August 27, 2022 by guest. Protected by copyright.
Caterpillar hair-induced ophthalmitis causing
exudative retinal detachment
Bijnya Panda, Shilpa Viswanath , Sucheta Parija, Bhumija Bhatt
Ophthalmology, All India DESCRIPTION
Institute of Medical Sciences, A woman in her 50s presented to our ophthalmology
Bhubaneswar, India clinic with a history of accidental fall of caterpillar into
her left eye 20 days back, while gardening, followed by
Correspondence to
Dr Shilpa Viswanath;
vigorous rubbing of the eye. She reported diminution
shilpaputhumana@gmail.com of vision in the left eye for past 7 days associated with
severe swelling, pain, redness and itching. Visual acuity
Accepted 6 July 2022 on presentation was perception of light in left eye with
accurate projection of rays in all quadrants, intraoc-
ular pressure was 6 mm Hg by non-contact tonometry.
Anterior segment evaluation revealed marked eyelid
oedema, conjunctival congestion, multiple foci of Figure 1 (A) Clinical photograph of the left eye
subconjunctival abscesses, embedded caterpillar hairs showing marked inflammation (lid oedema, conjunctival
in the tarsal, bulbar conjunctiva and cornea. Anterior congestion, chemosis, corneal haze, Anterior chamber
chamber evaluation revealed 3+ aqueous cells and 2+ flare with inferotemporal posterior synechiae) inferonasal
aqueous flare. Posterior synechiae was seen involving scleral abscess is seen (blue arrow). (B) Clinical
five clock hours in the superotemporal quadrant photograph (slit lamp biomicroscope image) of the left
(figure 1A). Subconjunctival abscess in the inferonasal eye showing nasal and inferonasal scleral abscess with
quadrant with embedded caterpillar hair is shown caterpillar hair buried within the sclera (black arrow).
in figure 1B. Fundus examination showed bullous
exudative retinal detachment in the inferonasal quad- on USG B-scan and OCT (figure 2B, figure 4). Oral
rant corresponding to the subconjunctival abscess. steroid was slowly tapered over 6 weeks.
Ultrasound B scan confirmed retinal detachment Caterpillar hair-induced ophthalmitis is an inflam-
(figure 2A). Anterior segment and posterior segment matory response of ocular tissue to caterpillar hair,
examination of the right eye was within normal limits. or other insect hair that come in contact with the
Removal of the conjunctival caterpillar setae was eye.1 The term ophthalmia nodosa was first used in
attempted under topical anaesthesia; however, the 1904 to describe the granulomatous nodules formed
setae which had penetrated into deeper stroma of on the conjunctiva and iris in response to caterpillar
cornea could not be removed (figure 3A,B). She was setae.2 The ocular reactions to caterpillar hairs are
advised to use topical loteprednol etabonate 0.5% diverse in nature and location, ranging from a toxic
eyedrops every 6 hours, atropine 1% every 8 hours, reaction to the external foreign bodies, keratocon-
carboxymethylcellulose 0.5% every 6 hours, chlor- junctivitis or the formation of conjunctival nodules,
amphenicol eye- ointment 8 hourly along with oral to intense iritis, vitritis or papillitis and a useful clas-
levocetirizine 10 mg per day for 1 week. Pus from sification has been developed by Cadera et al.3 It is
the subconjunctival abscess was sent for microbiolog- known that caterpillar hair entering the cornea or
ical examination, culture and sensitivity. On subse- conjunctiva gets surrounded by granulation nodule
quent follow- up, the pus culture was suggestive of
Pseudomonas aeruginosa sensitive to tobramycin and
amikacin.
She was started on topical fortified tobramycin(14
mg/mL) and amikacin(40 mg/mL) every 2 hours
along with continued use of topical soft steroids
and lubricants. Subconjunctival injection of tobra-
mycin (20 mg) in 0.25 mL/site was given daily for
7 days. We administered intravenous piperacillin/
© BMJ Publishing Group tazobactam (4 g/0.5 g) every 8 hours for 5 days.
Limited 2022. No commercial
Oral prednisolone (50 mg) was initiated after noting
re-use. See rights and
permissions. Published by BMJ. decrease in size of the subconjunctival abscess.
Once the inflammation was subsiding, caterpillar
To cite: Panda B, hairs embedded in the conjunctiva were removed Figure 2 (A) Ultrasonography demonstrating exudative
Viswanath S, Parija S,
et al. BMJ Case Rep serially. Within 10 days of initiating treatment, the retinal detachment corresponding to the scleral abscess.
2022;15:e251145. scleral abscess resolved, with reduction in anterior (B) 1 month follow-up ultrasonography showing
doi:10.1136/bcr-2022- chamber reaction but the exudative retinal detach- resolution of the exudative retinal detachment on
251145 ment took 1 month for complete resolution as seen treatment.
Panda B, et al. BMJ Case Rep 2022;15:e251145. doi:10.1136/bcr-2022-251145 1
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BMJ Case Rep: first published as 10.1136/bcr-2022-251145 on 12 July 2022. Downloaded from http://casereports.bmj.com/ on August 27, 2022 by guest. Protected by copyright.
rubbing by the patient, leading to scleral abscess formation and
subsequent exudative retinal detachment.1
Tan MKH et al have described ocular complications of caterpillar
setae in four patients during an outbreak of the exotic oak proces-
sionary caterpillar in Netherlands and have set guidelines for treat-
ment according to the severity of involvement.5 Our patient had a
severe anterior chamber reaction along with multiple infective foci,
which was treated in a tailored approach similar to the above expert
opinion-based guidelines. There are numerous published series of
caterpillar hair-
induced ophthalmitis with varied involvement of
anterior and posterior segments.6–9 Many modalities of treatment
have been described according to the site of involvement, superficial
hairs buried in conjunctiva cornea or sclera can be removed with
a help of forceps. Argon/Nd-YAG laser burns can be applied for
hairs buried deeper in corneal stroma hairs.9 For intralenticular hair,
pars plana removal of hair with fine-gripping forceps can be tried
followed by pars plana lensectomy and vitrectomy. The iatrogenic
retinal breaks could be further managed with laser barrage and sili-
cone oil tamponade.10 Our case was unique in terms of involvement
of retina without associated vitritis, which could be managed conser-
vatively and ultimately led to the resolution of inflammation.
Figure 3 (A) Clinical photograph (2 weeks follow-up) showing
multiple cilia embedded in corneal stroma. (B) Clinical photograph (2
month follow-up) showing few remaining cilia penetrated deep into Learning points
corneal stroma with clear cornea and quiet eye.
► Caterpillar hair(setae) can get deeply buried into the ocular
tissues due to intraocular migration. Combination of a
consisting of epithelioid cells, giant cells and lymphocytes. While mechanical phenomenon (penetration of the hair) and a
the soft conjunctival and episcleral tissues permit the formation chemical phenomenon (discharge of a toxic substance)
of a protruding nodule, the stiffer cornea and sclera do not accounts for the pathological symptomatology induced by the
expand. This mechanical difference along with shape of broken caterpillar.
hair with the cellular infiltrate surrounding it pushes it in the ► Delayed treatment can lead to scleral abscess and exudative
direction of least resistance that is in the direction of broken retinal detachment and carry guarded visual prognosis.
hair.4 Thus, the pathological damage caused by a caterpillar hair ► Early and aggressive treatment with removal of caterpillar
is a function of its direct toxicity and locomotion. The force with hair setae out of the tissue, subconjunctival antibiotics,
which the hair strikes the eye may determine the risk of intraoc- systemic antibiotics and corticosteroids will fasten the
ular penetration. Therefore, the possible mechanism responsible resolution of symptoms.
for the clinical findings in our patient might be the deeper pene-
tration of the sharp hairs into the scleral tissue due to vigorous
Contributors All the authors contributed to the manuscript. BP contributed
to the concept, design of the work, acquired data and revised and reviewed the
manuscript. SV interpreted the data of the work, drafted the manuscript and revised
the manuscript. SP and BB contributed in acquiring data and analysis of the same.
Funding The authors have not declared a specific grant for this research from any
funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent for publication Consent obtained directly from patient(s)
Provenance and peer review Not commissioned; externally peer reviewed.
Case reports provide a valuable learning resource for the scientific community and
can indicate areas of interest for future research. They should not be used in isolation
to guide treatment choices or public health policy.
ORCID iD
Shilpa Viswanath http://orcid.org/0000-0002-7496-8124
REFERENCES
1 Sengupta S, Reddy P, Gyatsho J, et al. Risk factors for intraocular penetration of
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2 Fraser SG, Dowd TC, Bosanquet RC. Intraocular caterpillar hairs (setae): clinical course
and management. Eye 1994;8 (Pt 5:596–8.
3 Cadera W, Pachtman MA, Fountain JA, et al. Ocular lesions caused by caterpillar hairs
(ophthalmia nodosa). Can J Ophthalmol 1984;19:40–4.
Figure 4 1 month follow-up optical coherence tomography image 4 Ascher KW. Mechanism of locomotion observed on caterpillar hairs. Br J Ophthalmol
showing resolution of the exudative retinal detachment on treatment. 1968;52:210.
2 Panda B, et al. BMJ Case Rep 2022;15:e251145. doi:10.1136/bcr-2022-251145
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BMJ Case Rep: first published as 10.1136/bcr-2022-251145 on 12 July 2022. Downloaded from http://casereports.bmj.com/ on August 27, 2022 by guest. Protected by copyright.
5 Tan MKH, Jalink MB, Sint Jago NFM, et al. Ocular complications of oak processionary 8 Sengupta S, Reddy PR, Gyatsho J, et al. Risk factors for intraocular penetration of
caterpillar setae in the Netherlands; case series, literature overview, national survey caterpillar hair in ophthalmia nodosa: a retrospective analysis. Indian J Ophthalmol
and treatment advice. Acta Ophthalmol 2021;99:452–5. 2010;58:540–3.
6 Al Somali AI, Otaif W, Afifi TM, et al. Ophthalmia nodosa secondary to multiple 9 Doshi PY, Usgaonkar U, Kamat P. A hairy affair: ophthalmia nodosa due to caterpillar
intraocular caterpillar hairs in a 2-year-old girl. Saudi J Ophthalmol 2020;34:230–2. hairs. Ocul Immunol Inflamm 2018;26:136–41.
7 Saleh S, Brownstein S, Kapasi M, et al. Ophthalmia nodosa secondary to caterpillar- 10 Agarwal M, Acharya MC, Majumdar S, et al. Managing multiple caterpillar hair in the
hair-induced conjunctivitis in a child. Can J Ophthalmol 2020;55:e56–9. eye. Indian J Ophthalmol 2017;65:248–50.
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