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A Pruritic Eyelid Lesion Followed by Conjunctival Swelling

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

An otherwise healthy 54-year-old woman presented with an erythematous right lower eyelid lesion with a vermiform appearance, accompanied by pruritus and pain (Figure 1A). The lesion resolved after 1 month, but she developed redness and swelling of the inner part of her right conjunctiva the next day (Figure 1B). She denied any vision changes, eye pain, eye discharge, or systemic symptoms, such as fevers, chills, night sweats, weight loss, or diarrhea. The patient had recently immigrated from rural Moldova 1 month prior to presentation, where she had exposure to farm animals, including dogs and cats. She had not traveled to any other countries.

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Ocular dirofilariasis

B. Injection of subconjunctival lidocaine followed by surgical removal of the lesion

The patient presented with a pruritic eyelid lesion for 1 month, followed by conjunctival swelling. Careful slitlamp examination showed a slowly mobile nematode coiled under the bulbar conjunctiva. No nematode was visible in the anterior chamber, vitreous, or retina. The organism was suspected to have migrated from the eyelid, likely the site of inoculation, into the subconjunctival space. Combined with the patient’s recent travel from Moldova, these findings raised suspicion for a parasitic infection with Dirofilaria species endemic in Moldova.1 After injection of subconjunctival lidocaine, 1%, with epinephrine to paralyze the nematode, a small conjunctival incision was made, and the worm was removed intact using forceps.2 Pathological examination demonstrated an 11.8-cm-long nematode with a maximum diameter of 0.5 mm and tapered ends (Figure 2). Transverse sections showed a multilayered cuticle with external longitudinal ridges approximately 7 μm wide with 11 μm between ridges, morphological features characteristic of Dirofilaria repens.3

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Article Information

Corresponding Author: Kyle Kirkland, DO, Marr Eye Center, 3030 University Dr E, College Station, TX 77845 (kylekirklanddo@gmail.com).

Published Online: August 4, 2022. doi:10.1001/jamaophthalmol.2022.2147

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
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2.
Tse  BC , Siatkowski  R , Tse  DT .  A technique for capturing migratory periocular worms: a case series and review of literature.   Ophthalmic Plast Reconstr Surg. 2010;26(5):323-326. doi:10.1097/IOP.0b013e3181c563e9PubMedGoogle ScholarCrossref
3.
Portnoy  LG . Dirofilariasis. In: Connor  DH , Chandler  FW , Schwartz  DA , Manz  HJ , Lack  EE , eds.  Pathology of Infectious Diseases. Vol II. Appleton & Lange; 1997:1391-1396.
4.
Kalogeropoulos  CD , Stefaniotou  MI , Gorgoli  KE , Papadopoulou  CV , Pappa  CN , Paschidis  CA .  Ocular dirofilariasis: a case series of 8 patients.   Middle East Afr J Ophthalmol. 2014;21(4):312-316. doi:10.4103/0974-9233.142267PubMedGoogle ScholarCrossref
5.
Capelli  G , Genchi  C , Baneth  G ,  et al.  Recent advances on Dirofilaria repens in dogs and humans in Europe.   Parasit Vectors. 2018;11(1):663. doi:10.1186/s13071-018-3205-xGoogle ScholarCrossref
6.
Ruiz-Moreno  JM , Bornay-Llinares  FJ , Prieto Maza  G , Medrano  M , Simón  F , Eberhard  ML .  Subconjunctival infection with Dirofilaria repens: serological confirmation of cure following surgery.   Arch Ophthalmol. 1998;116(10):1370-1372. doi:10.1001/archopht.116.10.1370PubMedGoogle ScholarCrossref
7.
Pampiglione  S , Rivasi  F , Angeli  G ,  et al.  Dirofilariasis due to Dirofilaria repens in Italy, an emergent zoonosis: report of 60 new cases.   Histopathology. 2001;38(4):344-354. doi:10.1046/j.1365-2559.2001.01099.xPubMedGoogle ScholarCrossref
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Khoramnia  R , Wegner  A .  Images in clinical medicine: subconjunctival Dirofilaria repens.   N Engl J Med. 2010;363(25):e37. doi:10.1056/NEJMicm1003006PubMedGoogle ScholarCrossref
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Arvanitis  PG , Vakalis  NC , Damanakis  AG , Theodossiadis  GP .  Ophthalmic dirofilariasis.   Am J Ophthalmol. 1997;123(5):689-691. doi:10.1016/S0002-9394(14)71083-9PubMedGoogle ScholarCrossref
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Boss  JD , Sosne  G , Tewari  A .  Ocular dirofilariasis: ophthalmic implication of climate change on vector-borne parasites.   Am J Ophthalmol Case Rep. 2017;7:9-10. doi:10.1016/j.ajoc.2017.04.004PubMedGoogle ScholarCrossref
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