1. OCULAR CYSTICERCOSIS – A CASE STUDY
Authors :
1. Dr. Mrs. Nilakshi.S.Pradhan, M.S (Shalakyatantra)
Principal, Professor and H.O.D,
Department of Shalakyatantra,
2. Dr. Pravin Madhukar Bhat, M.S (Shalakyatantra),
Assistant Professor, Department of Shalakyatantra,
Sumatibhai Shah Ayurved College, Malwadi Road, Hadapsar, Pune (Maharashtra).

2. CASE Patient’s Name- X.Y.Z Age-28/F Occupation- Nurse
Address- Fursungi,Hadapsar, Pune
K/C/O- Retinitis Pigmentosa having both eyes distant vision 6/9 Partial and underwent ayurvedic treatment for 1 year at the department of Shalakyatantra, Sane Guruji Hospital, Hadapsar, Pune for stability of vision.
Chief complain- She came in OPD on 2/3/2015 with C/O. sudden painless loss of vision in left eye after rubbing of eyes from 2 days. No other significant complain noted by patient
Past history- No any major illness
Full term normal delivery with Episiotomy 6 month back
No family history of Retinitis Pigmentosa or else genetic
disorder noted.

3. O/E- Right eye quiet
Left eye anterior segment is normal but lens shows cataractus changes on slit lamp examination.
Vision – Right eye 6/9partial and left eye <6/60, no pinhole improvement
On mydriasis - Indirect Ophthalmoscopy done and right eye media clear with Retinitis Pigmentosa noted on retina.
Left eye vitreal haemorrhages with cysticercus worm found after fundus photography.
Investigations- B-Scan had done shows posterior vitreous detachment, exudates along coats of nasal and superior aspect, no evidence of retinal detachment.
Systemic profile was normal
Treatment- Patient underwent pars plana vitreactomy under local anaesthesia and removal of worm done intravitreally. Her post op left eye vision is 6/24

4. Image 2. Post op clear media showing retinitis pigmentosa at periphery
Image 1.Left eye-The white cysticercus worm on the top

5. Post op treatment- Started steroid and antihelmintics for 5 days along with local eye drops and oral antibiotics for 5 days.
T. Wysolon 20mg 1 OD
T. Albendazol 1OD
T.Ciprofloxacin 500mg 1BD
T.Enzoflam 1BD
T.Rablet 20mg 1 BD
Milflox –DF eye drop 1 drop QID
Homide eye drop 1 drop BD
Ocupol-D eye ointment HS
Patient was doing well post vitreactomy and there was no need of silicon oil insertation post vitreactomy. Volume of eyeball maintained.

6. Discussion1
Cysticercosis refers to a parasitic infestation by cysticercus cellulosae, the larval form of the Pork tapeworm Taenia Solium.
Pigs are the intermediate host and the humans are the definitive host acquiring the diseases by ingesting cyst of T.Solium from contaminated pork, vegetables or water.
Ocular cysticercosis may affect almost all eye tissues. The vitrous cavity, subretinal space, and subconjunctival spaces are common sites, while involvement of other regions is relatively less common.
Clinically, the cyst appears as well-defined translucent mass with a dense white spot (Scolex) at one region. The site of entry into the eye is most probably the choroidal vasculature, from which the cyst migrates into the subretinal space, bores a hole in the retina and enters the vitreous cavity.
Acquired strabismus, diplopia, recurrent redness, and painful proptosis are some of the clinical signs in patients with orbital cysticercosis. Either eye may be affected, bilateral involvement is rare. Multiple cyst may develop in the same eye. The cysticercus may lead to blindness in 3-5 years.

7. Lab- Positive test results from a serum ELISA for anticysticercal antibodies help confirms the diagnosis; however, negative results do not excludes cysticercosis. A complete blood count may reveal eosinophilia.
Differential diagnosis- Sarcoidosis , Thyroid ophthalmopathy.
Treatment
In treatment part surgical removal of the larvae is important. Complete surgical removal of the intact cyst results in good functional recovery in eyes with intraocular cysticercosis.
Medical therapy with albendazol is not indicated for ocular diseases since dead parasite may induce intense inflammation and irreversible damage to structural components.
Cyst outside the globe can be treated with4 week regimen of antihelmintics (albendazol- 15mg/kg/D) and steroids (1.5mg/kg/D) in a tapering dose.
Infection can be effectively prevented by personal hygiene and sanitation. This includes cooking pork well, proper toilets and improved access to clean water. Neuroconsultation may be required in concurrent neurocysticercosis. Family members should be screened for infections.
Complications include damage to extraocular muscle fibres leading to post operative diplopia and strabismus.

8. Ayurvedic overview
As this is an ocular emergency where the worm started eating the vessels and so the vitreal hemorrhage are there therefore it needs an urgent surgical intervention so ayurvedic treatment was not given.
But in disease free state we started Apunarbhav chikitsa for krimi. First of all Shodhan chikitsa like Vaman & Virechan2 should be implemented & use of Krimighna dravyas.
As Krimi formation occurs if Kleda is in excess amount so after Shodhan, Tarpan followed by Putpaka can be implemented. If we use Tarpana before shodhan then it may cause doshotklesh like kaphotklesh & it will be favorable conditions for Krimi. So Tarpan, Putpaka can only be done after Shodhan6.
The Cysticercosis kind of worms cannot be directly correlated with Ayurvedic diseases but it can be taken near possibility of diagnosing it as Raktaj krimi.
As the sthana of the Raktaj krimi is given in text are Raktavahinya and Dhamanya7, the site of entry of cysticercus worm into the eye is most probably the choroidal vasculature. The prabhav of Raktaj krimi given in the samhita are Twak, Sira, Snayu, Mamsa bhakshanam7 and same can be seen in cysticercosis affected eye.

9. Samprapti:
The samprapti of krimi is due to doshavaishamya. The main etiological factors for the formation of raktaj krimi are Virudhashan, Ajirnashan, and Shakasevan8. This vitiates rakta dhatu and kapha dosha and will make sthanasanshraya in head region via siras and affect the various parts like eyes and its components.
Sampramptibhang can be achieved with nidanparivarjan9 and apakarshanadi chikitsa.10 Nidanparivarjan like avoidance of ajirnashan and virudhashan will lead to equilibrium state of kapha and rakta and this avoid formation of krimi. After nidanparivarjan and apakarshanadi treatment apunarbhav chikitsa can be given to avoid krimi formation.

10. Scope for further studies
The things came forward from this case is that we have to make a critical study of our samhitas to find out such diseases which can be correlated with modern diseases. Also there is a vast scope to study the retinal diseases in Ayurvedic point of view.

11. References Medscape references.
Charakasamhita vimansthana 7/15 Vyadhitrupiyam, by Brahmananda Tripathi, Choukhamba Surbharati Prakashan, Varanasi.
Aushadhi Gunadharmashastra by vaidya Guneshastri
Bhavprakash Nighantu, by Bhishakratna Shri. Brahmashankar Mishra, Choukhamba Sanskrit Bhavan, Varanasi.
Sushrutsamhita chikitsasthana 24/18,19, Ayurvedtatvasandipika by Kaviraj Dr.Ambikadutta Shastri, Choukhamba Sanskrit Sansthan, Varanasi
Sushrutsamhita Uttartantra 18/5, Ayurvedtatvasandipika by Kaviraj Dr.Ambikadutta Shastri, Choukhamba Sanskrit Sansthan, Varanasi
Charakasamhita vimansthana 7/11 Vyadhitrupiyam, by Brahmananda Tripathi, Choukhamba Surbharati Prakashan, Varanasi.
Madhavnidan Kriminidanam 7/6, Madhukosha Tika by Shri Sudarshan Shastri, Choukhamba Sanskrit Sansthan, Varanasi
Sushrutsamhita Uttartantra 1/25, Ayurvedtatvasandipika by Kaviraj Dr.Ambikadutta Shastri, Choukhamba Sanskrit Sansthan, Varanasi
Charakasamhita vimansthana 7/14 Vyadhitrupiyam, by Brahmananda Tripathi, Choukhamba Surbharati Prakashan, Varanasi.

12. THANK YOU VERY MUCH FOR PATIENCE HEARING