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Show Journal of Neuro- Ophthalmology 21( 3): 217- 218, 2001. © 2001 Lippincott Williams & Wilkins, Inc., Philadelphia Photo Essay Bilateral Cysticercosis of the Optic Nerve B. P. GuUiani, MS, Subhash Dadeya, MD, K. P. S. Malik, MS, and D. C. Jain, MD Bilateral cysticercosis of the optic nerves affected a man who presented with features suggestive of optic neuritis. Ultrasonography revealed bilateral sonolucent cystic lesions with central echo- dense, highly reflective structures behind the optic nerve heads. A subretinal cyst was present in one eye. Magnetic resonance imaging of the brain and orbit revealed multiple cysticerci in the brain, orbit, and eye. The subretinal cyst was removed by pars plana vitrectomy, and the other cysts resolved on treatment with albendazole. Key Words: Optic nerve- Cysticercosis- Optic neuritis- Albendazole. Cysticercosis is an infestation by the larval form of the pork tapeworm Taenia solium. It can affect any part of the body, including the heart, muscles, liver, brain, orbit, and eyes. In the eye, cysts may lodge in the vitreous, conjunctiva, or extraocular muscles ( 1) but rarely in the optic nerves ( 2). Unilateral, but not bilateral, cysticercosis of the optic nerve has been reported ( 2- 4). We describe a case of bilateral optic nerve cysticercosis, together with subretinal and multiple brain cysts. CASE REPORT A 29- year- old man presented reported sudden loss of vision and floaters in both eyes. Visual acuity was light perception bilaterally. The anterior segments were normal. Eye movements were full but painful. Fundus examination revealed bilateral blurring of disk margins along with swelling of the optic disks and a subretinal cyst in the superonasal equatorial region OD. The cyst showed movement when illuminated by flashes of light Manuscript received May 17, 2001; accepted July 9, 2001. From the Departments of Ophthalmology ( BPG, SD, KPSM) and Neurology ( DCJ), Safdarjung Hospital, New Delhi, India. Address correspondence and reprint requests to Subhash Dadeya, MD, G- 172, Nomak Pyra, Delhi 21, India. E- mail: sdadeya@ freedialin. com, dadeya86@ freedialin. com The authors do not have any financial interest. from the indirect ophthalmoscope. The neurologic examination was normal apart from the ophthalmic findings. Ultrasonography revealed bilateral disk swelling ( Fig. la, b) along with sonolucent well- defined cystic lesions with central echo- dense, highly reflective structures behind the optic nerve heads bilaterally ( Fig. lc, d) as well as subretinally on the right side ( Fig. le, f). Magnetic resonance imaging of the head and orbit revealed bilateral multiple cysticerci of the optic nerves, brain, and orbit ( Fig. 2). Based on these findings, the diagnosis of ocular and neural cysticercosis was made. The patient was treated with 60- mg oral prednisolone once daily along with 200- mg oral albendazole three times daily. The subretinal cysticercosis was removed by pars plana vitrectomy. After four weeks of treatment, the disk edema and blurring of the optic disk margins disappeared, and imaging evidence of neural cysticercosis and optic nerve cysticercosis resolved with visual acuities of 6/ i8 in both eyes. DISCUSSION This report documents a case of bilateral optic nerve cysticercosis. Even unilateral cysticercosis of the optic nerve is rare; only three case reports have been published ( 2^ t). To the best of our knowledge, this is the first case report of bilateral optic nerve cysticercosis. Earlier cases of unilateral optic nerve cysticercosis were initially believed to be optic nerve tumors. Our patient presented with features more suggestive of optic neuritis. On ultrasonography, a cystic lesion typical of cysticercosis was detected, which was further supported by magnetic resonance imaging. Because our patient had bilateral loss of vision, he was treated with oral albendazole along with prednisolone. Albendazole is the currently preferred therapy for neurocysticercosis ( 5,6) and has been reported to produce regression of neurocysticercosis and myocysticercosis ( 5- 8). However, there are reports of complications such as nausea, vomiting, and headache ( 9) as well as optic neuritis owing to lysis of cyst in the vicinity of optic nerve ( 10). Therefore, short courses of albendazole ( 3- 8 days) 217 218 B. P. GULLIANIETAL. Fig. 1. A: A and B ultrasonographic scans show disk swelling ( small arrow) and a well-defined cystic lesion with a central echo-dense area ( large arrow) OD. B: B ultrasonographic scan shows disk swelling OS ( arrow). C: A and B ultrasonographic scans show a well- defined cystic lesion ( long arrow) with a central echo- dense, highly reflective structure ( small arrow) behind the optic nerve head OD. D: B ultrasonographic scan shows a well- defined cystic lesion ( small arrow) with a central echo- dense, highly reflective structure ( large arrow) behind the left optic nerve head. On A scan, 100% spikes suggest a scolex ( broad arrow). E: B ultrasonographic scan shows a subretinal cyst OD ( arrow). were recommended by Sotelo et al. ( 9). Our patient responded well to medical therapy without any toxic effects. Regarding the subretinal cyst, removal by pars plana vitrectomy remains the preferred method ( 11). Fig. 2. Magnetic resonance imaging of the brain and orbit shows bilateral ring lesions at the origin of optic nerve ( upward arrows) and multiple similar lesions in the brain parenchyma ( downward arrow). In cases that suggest bilateral optic neuritis, cysticer-cosis should be kept in the differential diagnosis, especially in endemic areas. Ultrasonography, magnetic resonance imaging, and other hematologic studies are the investigations of choice. Once the diagnosis is confirmed, a course of albendazole and corticosteroid is recommended. l. 10. REFERENCES 6. Malik SRK, Gupta AK, Choudhary S. Ocular cysticercosis. Am J Ophthalmol 1968; 66: 1168- 71. 2. Menon V, Tandon R, Khanna S, et al. Cysticercosis of the optic nerve. J Neuroophthalmol 2000; 20: 59- 60. 3. Madan VS, Dhamija RM, Gill HS, et al. Optic nerve cysticercosis: a case report. J Neurol Neurosurg Psychiatry 1991; 54: 470- 1. 4. Bousquet CF, Dufour TF, Derome PC. Retrobulbar optic nerve cysticercosis. J Neurosurg 1996; 84: 293- 96. 5. Escobedo F, Penagos P, Rodrigues S, et al. Albendazole therapy for neurocysticercosis. Arch Intern Med 1987; 147: 738- 41. Takayangui OM, Jardim E. Therapy for neurocysticercosis: comparison between albendazole and praziquantel. Arch Neurol 1992; 49: 290- 4. Menon V, Kumar G, Prakesh P. Cysticercosis of extraocular muscle. J Pediatr Ophthalmol Strabismus 1994; 31: 126- 8. Sihota R, Honaver SG. Oral albendazole in the management of extra ocular cysticercosis. Br J Ophthalmol 1994; 78: 621- 3. Sotelo J, Penagos P, Escobedo F, et al. Short course of albendazole therapy for neurocysticercosis. Arch Neurol 1988; 45: 1130- 3. Tandon R, Sihota R, Dada T, et al. Optic neuritis following albendazole therapy for orbital cysticercosis. Aust N J Ophthalmol 1998; 26: 339- 41. 11. Segal P, Mrzyglod S, Smolarz- Dudarewicz J. Subretinal cysticercosis in the macular region. Am J Ophthalmol 1964; 57: 655. / Neuro- Ophthalmol, Vol. 21, No. 3, 2001 |
