A CASE OF CYSTICERCUS OF THE VITREOUS. BY W. CHEATHAM, A. IE, M. D., OF LOUIS VIELE, KY. REPRINTED FROM ANNALS OF OPHTHALMOLOGY AND OTOLOGY, Vol, HI, No. 2. . April, 1894. A CASE OF CYSTICERCUS OF THE VITREOUS. By W. Cheatham, A. B., M. D., OF LOtflSVILLE, KY. THIS affection being so rare in America, England, France, and countries other than Northern Germany, I feel justified in reporting a case that came under my observation. Mrs. F., aged 42, of Irish parentage, consulted me May 22, 1893, con- cerning her left eye. January, 1893, she had some severe acute inflammation of her left eye in which there was intense pain and edema of the lids, which lasted for some weeks. She now has vision of left eye ls/4o with no improve- ment by glasses. She has some scars of upper part of cornea simulating those found in trachoma, with slight pannus. I was surprised on everting the lid to find no indication of her ever having had trachoma. Vision, right eye 2/aoo and eccentric. She said her right eye had been blind-following a spell of sickness-since she was fifteen years old, or twenty-seven years. She did not come to consult me concerning her right eye, yet as a matter of routine, I examined it. I found all the media perfectly clear. Just at or over right macula I discovered a sac or cyst, pedunculated, the pedicle being attached to the retina above and external to the macula, the body of the sac extending down and in, over the region of the macula. The sac with its pedicle appeared a bluish gray, and opaque, except a part of the wall toward me about the size and shape of the optic nerve entrance, which was trans- parent and through which the deeper or other wall could be seen. The eye was emmetropic with the ophthalmoscope. The highest or most prominent part of the sac, just at the transparent part referred to, could be seen best with a -- 10 T). showing an elevation of about 2.3 mm.: The other cyst wall could be seen through this transparent portion best with about a 2. D. showing an elevation of about .52 mm. The sac was ovoid in shape with the edges at some points serrated, and at one point, down and in there was quite a projection. Over this sac small blood vessels could be seen, o.ne up and in, which could be traced to a larger retinal vessel close by. No motion could be discovered in this opaque cyst. Forming something of a crescent from the lower and outer part of this sac was a transparent, reddish cyst; at the upper part of this cyst could be seen two spots looking like air bubbles, which were no doubt the parasite's suckers. This cyst, when watched closely, could be seen to have a distinct rythmical motion; a spot of pigment beneath it would appear and disappear; the motion was perfect. Above the attachment of the pedicle of the cyst could be seen two white crescent-shaped spots, no doubt the points of entrance of the parasite. The retina between the cyst and optic nerve presented the appearance of a recent detachment. Several large vessels run from the nerve direct to the sac, some of them disappearing under, and reappearing 2 on the other side. There were many more large vessels taking this course than usual. This would probably indicate that the trouble is of long standing. The vitreous seemed to be detached over the optic nerve entrance. Mrs. F. gave a history of several serious attacks of what she called con- gestion of heart and lungs several years ago. For six or seven years, up to January, 1893, when her left eye was so badly inflamed, her health had been very good. She thinks she is going through her "change." Left eye usually inflamed some every four weeks. This case, besides being the second so far as I know of reported in America, presents other points of interest. Could this parasite possibly have been the original cause of the loss of vision of right eye twenty-seven years ago ? I think this possible and probable. The vitreous is clear and but little damaged ; but a small part of the retina and choroid are damaged. The parasite, from the ap- pearance of the parts, seems to have left its old bed, and is migrat- ing. Airs. F. does not remember of ever having had any pain in her right eye. Could the disease she has had in her left eye be sympathetic ? Sympathetic affections have their exacerbations and their times of quiet, as we all know. Foster, Encyclopedic Medical Dictionary, page 1237, says: "Cysticercus cellulosae is the larval stage of tenia solium. It has a quadrangular head, a long cylindrical body, and an elliptical caudal vesicle, and is from ten to fifteen mm. in length." Manthiier describes the animal as follows: "The worm is pro- vided at its posterior end with a round cyst-like formation which acts as the receptaculum scoliocis, into which the animal can with- draw, presenting when in this position the appearance of a round, whitish body. A small hole marks the mouth of this small recep- tacle. When the animal protrudes its head and neck out of the receptacle its body appears to be sprinkled here and there with calcareous deposits, and presents sometimes a smooth and some- times a wrinkled surface. The body decreases in size towards the neck, to which is attached the head, with its four flattened down, but angular projections. A round-shaped snout can be projected by the animal from the center of its head, and this latter is pro- vided at its base with a double row of hook-like tenacles which are capable of retraction. Each of the angular projections of the head is, moreover, provided with a rounded sucking apparatus." Schmidt-Rimpler, page 276, says: "The embryo enters the stomach of the suitable host, in the food or water, loses its cover- ing through the action of the gastric juice, bores into the blood vessels with its hooks and begins to wander. Finally it becomes 3 settled and now begins the second stage of its development in which it is known as cysticercus. It is converted into a vesicle with fluid contents." All authors agree that they travel by the blood'current. Cysticer- cus may occur in any part of the eye or orbit. They have been seen in the orbit, lids, conjunctiva, iris, lens, vitreous, choroid and retina. They are found more often in the posterior part of the eyeball than in the anterior. They are quite common in Northern Germany where uncooked meats are eaten; less often in Southern Germany, France and Italy. There have been three cases reported in Austria. Brudenell Carter says none have been seen in Eng- land, but Soelberg Wells reports a case in his book, page 328. In Northern Germany, Graefe saw eighty cases in 80,000 patients, or one in 1,000, in the deeper tissues of the eye; three in the anterior chamber, five beneath the conjunctiva, and one in the orbit. Hirschberg in six months saw 2,100 new patients in five of which he saw cysticercus, or one in 420 cases of eye diseases. Of the one other case seen in this county reported by Dr. Minor, Loring, on page 188, says: "From the ophthalmoscopic appear- ances there was reason to believe that it was a true case of cysti- cercus, although it was not absolutely proved to be so." Yet, from Dr. Minor's description of the case, and the ophthal- moscopic appearances, page 193, (Loring), I do not think there can be any doubt of its having been a case of cysticercus cellulosas. How long a cysticercus can remain in an eye is in doubt. Cases of two and four years standing are common. Von Graefe saw a case in 1856, which was twenty years afterward seen intact by Hirschberg. Others have reported cases of long standing with vision nearly perfect. My case, as I stated before, is possibly of twenty-seven years standing. Usually though in from fifteen to twenty months irido-cyclo-choroiditis follows, and sometimes pan- ophthalmitis with total loss of the eye. Von Graefe and Hirsch- berg state that there is not much danger of sympathetic inflamma- tion, although sympathetic irritation is often present. Jacobsen reports sympathetic amblyopia. Two cysts have been seen in one eye, but none reported of both eyes being involved. Patients with cysticercus do not have tape-worm. The presence of this parasite in the eye is so dangerous to the vitality and the usefulness of the organ, that its removal has been undertaken and with success, but not with very flattering after results, when it is located in the pos- terior part of the organ. When in the iris a section of this mem- brane can be removed that holds the parasite. 303 West Chestnut Street. 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