Rhinosporidiosis is a chronic and localized infection of the mucous membrane caused by the Phycomycete Rhinosporidium seeberi.12Rhinosporidium can cause infections of the nose, eye, throat, ear and even genitalia in both sexes.3 It presents as polypoidal and vascular masses. Ocular involvement occurs in 10% of Rhinosporidium seeberi infections.45 The sites of ocular involvement include conjunctiva, lacrimal sac, sclera and lid.6 This fungus thrives in a hot tropical climate and endemic zones are located in south India and Sri Lanka.7 The ocular manifestation of rhinosporidiosis is rarely encountered outside the coastal areas of Kerala, Tamil Nadu and Pondicherry. However, sporadic occurrence has been reported from West Bengal, Madhya Pradesh, Rajasthan, Orissa, Bihar and Maharashtra. The state of Orissa lies on the eastern coast of India and comes wholly under the tropical zone. The climate in Orissa is moderate. However, in western districts, namely Bolangir, Sambalpur and Sundergarh, extreme climatic conditions are experienced. Summer temperature varies between 20 degrees and 45 degrees celcius, while in winter it varies from 13 degrees to 32 degrees celcius.
The authors present the clinical and histological profile of 54 cases of ocular Rhinosporidium in a tertiary care hospital of Western Orissa. The unilateral manifestation of oculosporidiosis in all our cases prompted us to report this case series.
Materials and Methods
We studied 54 patients presenting with growth in the eye and its adenexal area retrospectively during November 2003 to November 2005 at a tertiary care hospital of Western Orissa. The study staff included four ophthalmologists and two pathologists. The inter-observer variation of our study was minimized by a standard clinical definition to suspect and a standard histological definition to confirm the ocular Rhinosporidium. In our study, all cases presenting with polypoidal, soft, pink growth of conjunctiva with gray white spots on the surface were taken into account to suspect conjunctival rhinosporidiosis. All those who presented with soft, fluctuant swelling of the lacrimal sac were suspected to have rhinosporidiosis of the lacrimal sac [Fig. 1]. However, the diagnosis in all the cases was confirmed histologically by the presence of fibro-cellular elements covered by proliferating stratified epithelium containing innumerable sporangia of all sizes in the sub epithelial layer [Fig. 2]. For each patient entered into the study, detailed clinical features, epidemiology (age, sex) and treatment were studied and analyzed. Total excision of mass was done in all cases. The patients with rhinosporidiosis involving the lacrimal system underwent dacryocystectomy (DCT). Care was taken to avoid spilling of spores during complete excision; however, no special maneuver was used during surgery to ensure complete removal of spores. Special attention was given to collect information regarding the bathing habits of all patients.
Rhinosporidiosis of eye and its adenexa were uniocular in all 54 patients. The right and left eye were affected in almost equal number of cases. The condition was more common in patients below 10 years of age [Table 1].
Rhinosporidiosis of the conjunctiva presented with complaints of polypoidal growth of the conjunctiva protruding through the palpebral aperture. Ninety per cent of the patients (44 out of 49 presenting with conjunctival Rhinosporidium) had a history of taking bath in pond water. The polyps were soft and pink and showed numerous gray white spots on the surface. All the lesions were vascular and they bled on touch.
Three patients had an infection of the lacrimal sac. On opening the sac pink vascularized growth with finger-like extension was seen in all of them. Recurrence was noted during follow-up in two cases who had earlier presented with subcutaneous spread [Fig. 1]. The duration of follow-up was one year in our series.
Ocular rhinosporidiosis is usually suspected in children presenting with conjunctival polyp and chronic dacryocystitis.8 In our study, the proportion of children was high and among them conjunctival polyp and chronic dacrocystitis was found in 26 and two cases respectively [Table 1]. In the present study, the infection was seen most frequently in children less than 10 years of age. This is in contrast to the findings of Kuriakose10 who had reported a higher prevalence in the 15 to 39 years of age group. His disparity may be accounted for by the higher number of children having the habit of bathing in pond water. Males were affected more often than females (3:1) in our study Table 1, which is consistent with the observation by Mohapatra9 and Kuriakose.10 Rhinosporidiosis is a waterborne disease and the fungus is suspected to be present in ponds. The conjunctiva is the commonest site of infection but the lacrimal gland, lid and sclera may also be affected by ocular rhinosporidiosis.7 In this study, 44 out of 49 cases of conjunctival rhinosporidiosis provided a history of taking bath in local ponds. The majority of the infection was confined to the conjunctiva and only three cases had an infection in the lacrimal sac. The association of conjunctival rhinosporidiosis with bathing habit in pond water is explained by the direct exposure of the conjunctiva to water during bathing. Surgical removal of the lesion is the treatment of choice.910 In this study simple total excision of the conjunctival polyp gave excellent results. Excision of lacrimal sac polyp has been reported to be unsatisfactory by Kuriakose.10
It is recognized that surgical removal of polyp in the lacrimal sac is frequently difficult due to severe bleeding during excision. In our series, recurrence was seen in only two cases of oculosporidiosis of the lacrimal sac showing subcutaneous spread [Fig. 1]. The result of this study does not agree with observation of earlier studies.910 Low recurrence in our study may be due to limited follow-up. And this needs further confirmation through study of a larger case series. There are reports that peripheral keratitis is sometimes associated with rhinosporidiosis of the nasal cavity.11 But the association of peripheral keratitis and ocular Rhinosporidium is yet to be reported. Probably this is the reason why we have not found any associated keratitis in our study.
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