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 Table of Contents  
Year : 2021  |  Volume : 33  |  Issue : 2  |  Page : 142-145

Clinical profile and outcomes of ophthalmia nodosa in South India: A retrospective study

1 Department of Vitreo-Retina, Aravind Eye Hospital, Puducherry, India
2 Department of Cornea, Aravind Eye Hospital, Puducherry, India

Date of Submission05-Jul-2020
Date of Acceptance11-Jul-2020
Date of Web Publication21-Aug-2021

Correspondence Address:
Dr. Kanika Chhabra
Aravind Eye Hospital, Cuddalore Main Road, Thavalakuppam, Puducherry - 605 007
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/kjo.kjo_97_20

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Aim: The aim of the study was to report the clinical presentation, course, and final outcomes of ophthalmia nodosa and create awareness among general ophthalmologists regarding the disease. Materials and Methods: A retrospective analysis of the cases of ophthalmia nodosa was carried out from January 2018 to December 2018. Ninety-eight eyes were included in the study. Results: Patients presented with redness (76.53%), foreign-body sensation (61.91%), pain (48.98%), lacrimation (28.57%), and photophobia (7.14%). Hairs were found in the conjunctiva in 63.26%, cornea in 39.80%, anterior chamber in 4.08%, lens in 3.06%, and vitreous in 8.16%. Patients with anterior segment involvement responded well to treatment, which included caterpillar hair removal, topical steroids, and cycloplegics. Patients with retinal exudates responded to therapy which included systemic antibiotics and steroids. Multiple sittings of hair removal were required in 38.78% of patients. Follow-up of the patients ranged from a minimum of 30 days to a maximum of 180 days. Conclusion: Ophthalmia nodosa is a relatively common condition in this part of the world. It has a good outcome when timely diagnosed and appropriately managed.

Keywords: Caterpillar hair, inflammation, ophthalmia nodosa

How to cite this article:
Chhabra K, Dhoble P, Khanna V. Clinical profile and outcomes of ophthalmia nodosa in South India: A retrospective study. Kerala J Ophthalmol 2021;33:142-5

How to cite this URL:
Chhabra K, Dhoble P, Khanna V. Clinical profile and outcomes of ophthalmia nodosa in South India: A retrospective study. Kerala J Ophthalmol [serial online] 2021 [cited 2021 Nov 30];33:142-5. Available from: http://www.kjophthal.com/text.asp?2021/33/2/142/324206

  Introduction Top

Ophthalmia nodosa is an inflammatory response of ocular tissue due to caterpillar (CP) hair or other insect hair and few plant hair that come in contact with the eye. Ocular inflammation is likely due to locomotion and toxin secreted by the venom gland connected to the hair shaft.[1],[2] Ocular presentation of the disease varies according to the location of the CP hair. It may range from a local toxic reaction, keratoconjunctivitis, or conjunctival nodules, to severe manifestations such as iritis, vitritis, papillitis, and endophthalmitis.[3]

Ophthalmia nodosa is a seasonal disease, and is seen more often in coastal regions. It is usually in an innocuous condition and responds well to conservative management. Intraocular penetration of CP hair is seen in few patients, which might lead to devastating complications, requiring a surgical treatment.

The aim of our study was to report the clinical presentation, course, and final outcomes of ophthalmia nodosa and create awareness among general ophthalmologists for its timely and appropriate management.

  Materials and Methods Top

A retrospective review of hospital records was performed between January 2018 and December 2018. One hundred and twenty-five patients were diagnosed to have ophthalmia nodosa, out of which, 27 had a follow-up of <30 days and, hence, were excluded from the study. Ninety-eight eyes were included in the study. A comprehensive ophthalmic examination, including best-corrected visual acuity, intraocular pressure with applanation tonometry, slit-lamp examination, and indirect ophthalmoscopy, was performed for each case. Pediatric patients were evaluated under general anesthesia.

CP hairs from conjunctiva were removed using a suture tying forceps, and those in deep conjunctiva, or corneal stroma, were removed with a 26G hypodermic needle under topical anesthesia. The deep stromal hairs were not removed, as removal would have caused significant corneal scarring and that these hairs are often inert.

Medical treatment included topical lubricant and antibiotic drops. Steroids and mydriatic eye drops were added in cases with anterior uveitis. Systemic steroids were initiated when the posterior segment was involved. During subsequent follow-up visits, patients were reexamined for hair and their subsequent removal.

The study was approved by the institutional review board and adhered to the tenets of the Declaration of Helsinki.

  Results Top

A total of 98 patients with ophthalmia nodosa were included in the study, out of these, 53 (54.08%) were male and 45 (45.92%) were female. The age of the patients ranged from 7 months to 67 years. All the cases were unilateral. Majority of the patients (76) had a history suggesting contact with an insect, and the rest of the patients (22) had a history of dust fall. Among them, 28 patients (28.57%) were working in fields, 20 patients (20.41%) were driving a two-wheeler, and 7 patients (7.14%) were sitting under trees and the rest could not give a specific history.

Majority of the cases in our study occurred in the month of March (14), closely followed by April (12). Month-wise distribution is shown in bar graph [Figure 1].
Figure 1: A bar graph illustrating month-wise distribution of cases in our study

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Majority of the patients presented with redness (76.53%), foreign-body sensation (61.91%), pain (48.98%), lacrimation (28.57%), and photophobia (7.14%). The duration of symptoms varied from 1 day to 60 days. At presentation, visual acuity ranged from 20/20 to 20/30 in 69 patients (70.41%), 20/40 to 20/120 in 18 patients (18.37%), and <20/120 in 2 patients (2.04%).

CP hairs were seen in the anterior segment in the majority of the patients, whereas vitreous involvement was seen only in eight eyes (8.16%). Hairs were found in the conjunctiva in 62 eyes (63.26%), cornea in 39 eyes (39.80%), and anterior chamber (AC) in 4 eyes (4.08%). Lens involvement was seen in three patients (3.06%) where the CP hair was lodged in the anterior lens capsule.

The conjunctival signs included congestion in 75 patients (76.53%), CP hair in the upper tarsal conjunctiva in 35 patients (35.71%), hair in the lower tarsal conjunctiva in 27 patients (27.55%), papillary reaction in 11 patients (11.22%), and membrane on the upper tarsal conjunctiva in 3 patients (3.06%). Pattern abrasions were seen in 84 patients (85.71%), superficial punctate keratopathy was seen in 17 patients (17.35%), epithelial defect was seen in 21 patients (21.43%), and infiltrates were seen in 3 patients (3.06%). AC reaction or iridocyclitis was seen in 12 patients (12.24%) and iris granulomas were seen in five patients (5.10%). Vitreous haze was seen in three patients (3.06%) and snowballs and retinal exudates were seen in two patients (2.04%), wherein systemic antibiotics were given in addition to systemic and topical steroids.

Multiple sittings of hair removal (range: 2–5 sittings) were required in 38 patients (38.78%). The follow-up of the patients ranged from a minimum of 30 days to a maximum follow-up of 180 days. At the last follow-up, minimal conjunctival congestion was seen in 19 patients (19.39%), corneal scarring in eight patients (8.16%), CP hair in the deep stroma in 22 patients (22.45%) [Figure 2], and punctate epithelial erosions in 16 patients (16.33%). AC reaction in the form of occasional cells and 1+ flare was seen in four patients (4.08%). The vitreous cavity showed CP hair in eight patients (8.16%) without any signs of inflammation. Visual acuity was 20/20–20/30 in all except six patients, out of which, five had cataracts and the remaining patient had leukomatous corneal scar.
Figure 2: Slit-lamp image showing retained deep stromal setae with minimal surrounding congestion

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Hair isolated from the conjunctiva was studied randomly under a light microscope at ×4 and ×40 magnification, which revealed a smooth shaft without spines [Figure 3]a and [Figure 3]b.
Figure 3: Light microscopic image of setae with no spine along the shaft at, (a) (×4) (b) (×40)

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  Discussion Top

Schon published the first report of this condition in 1861.[4] The spectrum of clinical manifestations was designated as “ophthalmia nodosa” by Pagenstecher in 1883.[5] It was referred to as “pseudotuberculoma” by Wagenmann in 1890 and “pseudotrachoma” by Schmidt Rimpler in 1899. Saemisch coined the term “ophthalmia nodosa” in 1904.[6]

The first case reported from India was as late as 1968,[7] and is still underdiagnosed due to lack of awareness among general ophthalmologists. Hence, this study was conducted to highlight the clinical manifestations of ophthalmia nodosa, its management, and creating awareness among ophthalmologists for a timely diagnosis and immediate CP hair removal, avoiding untoward complication.

A seasonal variation was found in the presentation of ophthalmia nodosa in our study, as a majority of cases occurred from February to May. This finding is in contrast to other Indian studies where a majority of cases are reported to occur from July to September,[8] whereas, in the Western world, most of the cases are reported in December and January, as it is the time for harvesting of hay and the time of greatest CP activity.[5]

Caterpillar setae can be found in the eye due to contact with caterpillars, exposure to larval cocoon having shed setae or direct entry of wind-borne setae.[9] The various manifestations of ophthalmia nodosa include toxicity and locomotory effects of the setae. Toxin originates in the venom gland connected to the hair shaft, which is transferred through the hollow shaft. Penetration of lids and ocular surface by setae is aided by muscular contraction of the lid muscles and rubbing of lids in response to irritation caused by the toxin. Intraocular penetration is very rare. Gundersen et al. postulated that setae do not have a propulsive power and are propelled further as a result of globe movements and iris pulsations.[10] Ashcher observed that the inflammatory exudates against the broken end of the hair pushed it to move along the path of least resistance.[11]

Duke-Elder and MacFaul described that after the initial symptoms of trauma, there was a quiescent interval of usually 3–5 days, followed by a recurrence of symptoms.[12] However, we found a latent period of <24 h in all our cases, as in other Indian case reports. This difference has been attributed to the type of CP hair by Sethi and Dwivedi.[8] Most of the Western articles reported barbed hair in their cases in contrast to the smooth and nonbarbed hair in India.

CP setae-incited inflammatory reaction has been classified into the following five types by Cadera et al.:[3]

  • Type 1: An acute reaction to the hair consisting of chemosis and inflammation. This begins immediately and lasts for some weeks
  • Type 2: Chronic mechanical keratoconjunctivitis caused by hair lodged in the bulbar or palpebral conjunctiva. Foreign-body sensation occurs, and linear corneal abrasions are seen
  • Type 3: Formation of gray–yellow nodules in the conjunctiva (granulomas). Setae may be subconjunctival or intracorneal and may be asymptomatic
  • Type 4: Iritis secondary to hair penetration of the anterior segment
  • Type 5: Vitreoretinal involvement (10%–20%) after hair penetrates the posterior segment through the AC or transscleral route. This may occur early or some years later. Mild vitritis or vitreous haze is commonly reported as seen in three patients in our series, whereas frank endophthalmitis is very rare.

There are different schools of thought regarding the management of deep-seated CP hair; one school of thought opines that they should be observed as manipulation leads to inflammation and scarring,[13] while the other imparts that these might penetrate deeper and inflammation is more likely and difficult to control.[14],[15],[16] We followed the first school of thought, and CP hairs in deep stroma, AC, or vitreous were left untreated without any inflammation at a later date.

Fraser et al. suggested argon or Nd-YAG laser as the modality of treatment of ophthalmia nodosa as it neutralizes the toxic effects of intraocular setae.[17] However, there is limited evidence to support it as a treatment modality.

To summarize, ophthalmia nodosa is a common entity in the southern part of India. It has a varied presentation, ranging from mild conjunctivitis to rarely frank endophthalmitis. It could be easily missed by an ophthalmologist unless he/she is aware of the disease entity. Timely diagnosis and appropriate treatment, including CP hair removal, results in a good prognosis. Importance of follow-ups should be stressed upon to the patients as many of them require multiple sittings of hair removal. Awareness should be raised regarding the wearing of protective glasses/helmets while driving a two-wheeler or working in fields.

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Conflicts of interest

There are no conflicts of interest.

  References Top

D'Hermies F, Parent de Curzon H, Mathieu L, Furia M, Campinchi R. Chorioretinopathy caused by migration of caterpillar hairs. J Fr Ophtalmol 1985;8:471-8.  Back to cited text no. 1
Lamy M, Pastureaud MH, Novak F, Ducombs G, Vincendeau P, Maleville J, et al. Thaumetopoein: An urticating protein from the hairs and integument of the pine processionary caterpillar (Thaumetopoea pityocampa Schiff., Lepidoptera, Thaumetopoeidae). Toxicon 1986;24:347-56.  Back to cited text no. 2
Cadera W, Pachtman MA, Fountain JA, Ellis FD, Wilson FM 2nd. Ocular lesions caused by caterpillar hairs (ophthalmia nodosa). Can J Ophthalmol 1984;19:40-4.  Back to cited text no. 3
Schön J. Application for practical ophthalmology Hamburg, Germany: Hoffman & Campe; 1861; p 183.  Back to cited text no. 4
Bishop JW, Morton MR. Caterpillar-hair keratoconjunctivitis. Am J Ophthalmol 1967;64:778-9.  Back to cited text no. 5
Saemisch T. Graefe-Saemisch Handbook of entire Ophthalmology, 2nd ed., vol. 5, pt 1; 1904; p.548.  Back to cited text no. 6
Gupta JS, Gopal H. Orient arch. Ophthalmologia 1968;6:306-7.  Back to cited text no. 7
Sethi PK, Dwivedi N. Ophthalmia nodosa. Indian J Ophthalmol 1982;30:11-4.  Back to cited text no. 8
[PUBMED]  [Full text]  
Sridhar MS, Ramakrishnan M. Ocular lesions caused by caterpillar hairs. Eye (Lond) 2004;18:540-3.  Back to cited text no. 9
Gundersen T, Heath P, Garron LK. Ophthalmia nodosa. Trans Am 17 Ophthalmol Soc 1950;48:151-69..  Back to cited text no. 10
Ascher KW. Mechanism of locomotion observed on caterpillar hairs. Br J Ophthalmol 1968;52:210.  Back to cited text no. 11
Duke-Elder SS, MacFaul PA. System of ophthalmology. Vol. XIV. London: Henry Kimpton; 1972.  Back to cited text no. 12
Joshi D. Ophthalmia nodosa with intraocular caterpillar setae. Med J Armed Forces India 2011;67:167-8.  Back to cited text no. 13
Sengupta S, Reddy PR, Gyatsho J, Ravindran RD, Thiruvengadakrishnan K, Vaidee V. Risk factors for intraocular penetration of caterpillar hair in Ophthalmia Nodosa: A retrospective analysis. Indian J Ophthalmol 2010;58:540-3.  Back to cited text no. 14
[PUBMED]  [Full text]  
Rishi P, Agarwal M, Mahajan S, Rishi E. Management of intralenticular caterpillar setae. Indian J Ophthalmol 2008;56:437-8.  Back to cited text no. 15
[PUBMED]  [Full text]  
Imaizumi A, Koike N, Kimu M, Shirota Y, Takahashi H, Inatomi M. A case of intractable uveitis induced by urticating hair of caterpillar. Jpn J Clin Ophthalmol 2003;57:471-5.  Back to cited text no. 16
Fraser SG, Dowd TC, Bosanquet RC, Cottrell DG. Argon and YAG lasers in the treatment of ophthalmia nodosa. Eye (Lond) 1995;9 (Pt 5):638-40.  Back to cited text no. 17


  [Figure 1], [Figure 2], [Figure 3]


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