|Year : 2023 | Volume
| Issue : 1 | Page : 52-54
Topical ivermectin in ophthalmomyiasis: Literature review and a case report
Department of Ophthalmology, Gitam Institute of Medical Sciences and Research, Gitam University, Visakhapatnam, Andhra Pradesh, India
|Date of Submission||20-Jan-2022|
|Date of Decision||05-Sep-2022|
|Date of Acceptance||11-Sep-2022|
|Date of Web Publication||15-Feb-2023|
Dr. Gayatri Dasari
Department of Ophthalmology, Gitam Institute of Medical Sciences and Research, Gitam University Rishikonda, Visakhapatnam - 530 045, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Ocular myiasis is a rare condition affecting orbital and ocular tissues infected by fly larvae of the order Diptera. This clinical case report highlights the importance and requirement of topical ivermectin eye drops for treating external ophthalmomyiasis. A 55-year-old female patient presented to the hospital who had a history of worms in her right eye in the last 6 months and was diagnosed with right eye external ocular myiasis. Mechanical removal of worms done under topical anesthesia and treated with oral tablet ivermectin 12 mg stat, ivermectin topical drops prepared by dissolving ivermectin 12 mg tablet in 10 ml distilled water and advised to instill four times a day, and oral tablet metronidazole 400 mg twice a day for 5 days. The patient effectively responded to the treatment with complete resolution and there was no recurrence. The treatment modality of ophthalmomyiasis depends on the clinical presentation and severity of tissue destruction and is planned on an individual patient basis. Mechanical debridement of worms under topical anesthesia with adjuvant oral ivermectin is recommended. Topical ivermectin eye drops can be used to kill the worms in places where they cannot be manually reached. Further studies are needed to study the efficacy of topical ivermectin.
Keywords: External ophthalmomyiasis, maggots, oral ivermectin, topical ivermectin
|How to cite this article:|
Dasari G. Topical ivermectin in ophthalmomyiasis: Literature review and a case report. J Public Health Prim Care 2023;4:52-4
|How to cite this URL:|
Dasari G. Topical ivermectin in ophthalmomyiasis: Literature review and a case report. J Public Health Prim Care [serial online] 2023 [cited 2023 Mar 25];4:52-4. Available from: http://www.jphpc.org/text.asp?2023/4/1/52/369666
| Introduction|| |
Ocular myiasis is a rare condition affecting orbital and ocular tissues infected by fly larvae of the order Diptera. It is common in tropical and subtropical regions with hot climates. Poor sanitation and hygiene, lower socioeconomic status, decreased host immunity, and trauma are major risk factors.,,
| Case Report|| |
A 55-year-old female jute mill worker from a village in North Andhra complained of worms coming out of her right eye in the last 6 months, associated with defective vision in the right eye. The patient gave a history of previous consultations in nearby hospitals and the use of antibiotic ointments, following which dead worms came out of her right eye, but recurrences were present. There is no history of trauma or surgery. The patient is not a known diabetic or hypertensive.
On examination, vision in the right eye was the perception of the light test was positive, the patient was unable to open her right eye properly and was uncooperative for visual assessment. Uncorrected vision in the left eye is 6/9 in Snellen's chart, with near vision N10. The right eye presented two live worms near the lid margin with hyperemic conjunctiva and spheroidal degeneration of the cornea [Figure 1]. Fundus showed a normal disc with peripapillary atrophy and dull foveal reflex. The left eye presented spheroidal cornea degeneration with similar fundus signs. The patient was uncooperative for syringing, and ROPLAS was negative. The patient was diagnosed with right eye external ocular myiasis with spheroidal degeneration.
|Figure 1: At Presentation, two worms were present at the lower lid margin and on the lower lid of right eye|
Click here to view
Under topical anesthesia, mechanical removal of worms was performed. Conjunctival sac irrigated - the worms sent to histopathology examination. Patient treated oral tablet ivermectin 12 mg stat, ivermectin topical drops prepared by dissolving ivermectin 12 mg tablet in 10 ml distilled water and advised to instill four times a day, oral tablet metronidazole 400 mg twice a day for 5 days, and injection tetanus toxoid 0.5cc intramuscularly. The patient advised computed tomography (CT) scan orbit. The patient visited after 10 days with complete resolution. Histopathological examination revealed maggots belonged to the Musca domestica family. CT scan orbits showed no bony erosions. The patient gave a history of clumps of dead worms coming out of the right eye during treatment and complete resolution after 5 days [Figure 2]. Her right vision recorded at follow-up was 6/9 after treatment.
|Figure 2: After treatment: Multiple dead worms removed from the right eye|
Click here to view
| Discussion|| |
Ocular myiasis is classified as external ophthalmomyiasis (conjunctiva and nasolacrimal ducts), orbital myiasis, and internal/intraocular ophthalmomyiasis (involving the eyeball). Myiasis is commonly caused by dipterous flies with a life cycle consisting of larvae, pupa, and adult flies. Larvae may lay eggs by parthenogenesis which grows into larvae, which destroys tissues.
Ocular manifestations range from mild conjunctivitis to vast orbital or ocular destruction. Treatment of ocular myiasis depends on the severity and extent of involvement, including mechanical removal of maggots to surgical debridement. Previously, treatment options were mechanical extraction of worms done using liquid paraffin and turpentine oil for paralyzing the maggots. Four percent lignocaine topical anesthetic drops/proparacaine 0.5% eye drops can be used to paralyze the worms and facilitate their removal.
Ivermectin is a synthetic drug derived from avermectins and is an anthelmintic with an off-label use as antiparasitic.
Neelam Puthran et al. treated orbital myiasis with a single oral dose of 12 mg ivermectin and 1% ivermectin eye drops eliminating the need for exploratory surgery. Johanna Osorio et al. treated two patients of orbital myiasis with skin carcinomas with oral ivermectin and debridement. Kamlesh Thakur et al. described the acute presentation of a case of external ophthalmomyiasis, which was treated promptly by removal of larvae mechanically followed by the instillation of antibiotic and steroid eye drops to prevent serious complications.
Ricci GD et al. assessed the in vitro larvicidal activity of ivermectin and povidone-iodine (PVP-I) against Oestrus ovis. They concluded that ivermectin 1% solution in propylene glycol, ivermectin 1% solution +0.6% PVP-I, and propylene glycol alone showed a good, relatively rapid larvicidal activity against O. ovis larvae.
In this case, along with mechanical removal of worms and oral ivermectin 12 mg and metronidazole 400 mg tablets, topical 1% ivermectin eye drops were prepared by dissolving 12 mg tablet in distilled water and advised the patient to use four times a day and refrigerate the reconstituted medication. Oral ivermectin can be used only as a stat dosage and not daily, and to provide adequate antiparasitic medication at the site of infestation, and for the drug to reach the places where manually removal of worms is not possible; topical ivermectin has advantages. Metronidazole or albendazole is an antihelminthic antibiotic to prevent secondary bacterial infection.
Limited data are available regarding topical ivermectin. The topical dosage of the drug, duration of action, and ocular surface side effects should be determined by further studies.
| Conclusions|| |
Dipterous flies cause ophthalmomyiasis in hot climates, poor hygiene states, and low immunity persons. Mechanical removal under anesthesia of all worms is the mainstay of treatment. The treatment protocol depends on the severity and extent of involvement and destruction of ocular tissues and is decided on a case-by-case basis. Early diagnosis and treatment help to retain vision and prevent destructive surgical explorations. Enucleation remains the only option for massive orbital involvement with no vision potential.
Adjuvant antiparasitic therapy with oral ivermectin stat and topical ivermectin is recommended to kill the worms. Topical ivermectin has the advantage of providing medication at the site of infestation when it is beyond manual reach. It also prevents the extension of worms into surrounding tissues. Ivermectin also deters the need for surgical debridement and facilitates a timely and complete cure for the patient. Further studies are needed to determine the efficacy, dosage, duration of action, and side effects of topical ivermectin.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Khataminia G, Aghajanzadeh R, Vazirianzadeh B, Rahdar M. Orbital myiasis. J Ophthalmic Vis Res 2011;6:199-203. [Full text]
Nene AS, Mishra A, Dhand P. Ocular myiasis caused by Chrysomya bezziana
– A case report. Clin Ophthalmol 2015;9:423-7.
Ayalon A, Yehezkeli V, Paitan Y, Szpila K, Mumcuoglu KY, Moisseiev E. Massive orbital myiasis caused by Sarcophaga argyrostoma
complicating eyelid malignancy. Case Rep Ophthalmol Med 2020;2020:5618924.
Anderson GS. Minimum and maximum development rates of some forensically important Calliphoridae
(Diptera). J Forensic Sci 2000;45:824-32.
Sivaramasubramanyam P, Sadanand AV. Ophthalmomyiasis. Br J Ophthalmol 1968;52:64-5.
Chandra DB, Agrawal TN. Ocular myiasis caused by Oestrus ovis
. (A case report). Indian J Ophthalmol 1981;29:199-200.
] [Full text]
Thakur K, Singh G, Chauhan S, Sood A. Vidi, vini, vinci: External ophthalmomyiasis infection that occurred, and was diagnosed and treated in a single day: A rare case report. Oman J Ophthalmol 2009;2:130-2.
] [Full text]
Dourmishev AL, Dourmishev LA, Schwartz RA. Ivermectin: Pharmacology and application in dermatology. Int J Dermatol 2005;44:981-8.
De Tarso P, Pierre-Filho P, Minguini N, Pierre LM, Pierre AM. Use of ivermectin in the treatment of orbital myiasis caused by Cochliomyia hominivorax
. Scand J Infect Dis 2004;36:503-5.
Puthran N, Hegde V, Anupama B, Andrew S. Ivermectin treatment for massive orbital myiasis in an empty socket with concomitant scalp pediculosis. Indian J Ophthalmol 2012;60:225-7. [Full text]
Osorio J, Moncada L, Molano A, Valderrama S, Gualtero S, Franco-Paredes C. Role of ivermectin in the treatment of severe orbital myiasis due to Cochliomyia hominivorax
. Clin Infect Dis 2006;43:e57-9.
Ricci GD, Garippa G, Cortese S, Serra R, Boscia F, Dore S, et al. In vitro
larvicidal activity of ivermectin and povidone-iodine against Oestrus ovis
. PLoS One 2021;16:e0259044.
[Figure 1], [Figure 2]