Intraocular Pressure Changes in Long-term Presumed Trematode induced Granulomatous Anterior Uveitis

: Introduction : There are several reasons for pediatric anterior chamber granulomas. Presumptive parasite infection is cited as a recently identified cause of AC granuloma. This condition is more common in children's eyes in rural areas who have been exposed to canal water. It is characterized by one or more anterior chamber (AC) nodules that resemble pearls. It can also be linked to subconjunctival nodules, corneal opacity, keratic precipitates, or anterior chamber reaction. Aim of the study: To outline the long-term intra-ocular pressure sequelae in children diagnosed with presumed parasitic anterior chamber granuloma and received treatment. Subjects and Methods: A retrospective study that included 84 patients (87 eyes) diagnosed with granulomatous anterior uveitis attributed to being caused by presumed treamtode infection and received the appropriate treatment, separated into three groups: A) Medical treatment. B) Treated with periocular steroids. C) Surgical treatment. Involvement of anterior and posterior segment complications has been documented and reported. Results : The median age of the patients was 11±1 year with an average of 7-12 years. The median IOP measurement was 15+/-1. There was no statistically significant difference regarding IOP. Conclusions: Even after obtaining the proper therapy, presumed trematode-induced anterior chamber granuloma has long-term consequences on the anterior and posterior segments that jeopardize visual acuity. So, we should observe all patients after perceiving appropriate treatment including IOP measurement.


Pediatric
anterior chamber granulomas have various causes.A newly described cause of AC granuloma is attributed to presumed parasitic infection.
Once exposed to canal water, children's eyes in rural settings are more susceptible to this condition, which is characterized by one or more anterior chamber (AC) nodules that resemble pearls, it may be associated with subconjunctival nodules, corneal opacity, keratic precipitates or Anterior chamber reaction [1,2].
It looks like the illness is endemic to disappearance of granuloma better than medical treatment [3].
Despite increasing reports on characterization, pattern, and treatment of the disease, there are scarce publications on its complications and sequelae that may affect the visual outcome.Some cases developed complications such as a rise in intraocular pressure, complicated cataracts and posterior synechiae [4].One of the most common causes of uveitis diminution of vision is macular edema, which may be missed due to media haze secondary to posterior synechiae, virtutis or cataract formation [5].Also, cases left with unresolved granuloma for a long duration showed permanent corneal scars with significant visual acuity affection.Diffuse thickening and edema of the ciliary body were found in UBM in many cases as same as a hyperreflective lesion (granuloma) was found in some cases [6].

Subjects
Our retrospective case series study included 83 patients (87 eyes) between 5 and 12 years old consecutively selected (every subject meeting the criteria of inclusion is selected until the sample size is achieved).Included patients had been collected from the outpatient clinic at the Ophthalmology Department of Fayoum University.The study was conducted from 1st of January 2022 till 1st of January 2023.

Inclusion criteria
Patients diagnosed with granulomatous anterior uveitis attributed to being caused by presumed trematode infections and received either medical or surgical treatment  Patients with inadequate data.

Methods
These patients were separated into three groups by treatment modality: Group C: Patients who underwent anterior chamber wash surgery did so under general anesthesia, with utmost aseptic precaution.A micro-surgical knife (keratome 3.2mm) was used to make the corneal incision, which was then followed by the injection of visco-elastic to reform the anterior chamber, the removal of the granuloma from its attachment to the root of the iris and cornea using either OVD dissection or capsule-rhexis forceps, vannis, or retina 23g curved scissor, or by OVD dissection.

Evaluation
The patients who were recruited had their medical records examined.Age, gender, location of residence, and the moment the eye symptoms started were all recorded along with demographic information, with a focus on prior river swimming, if it was done.

Results
This retrospective study included 87 eyes with distinctive AC granulomas, separated according to treatment modality into three groups: -Group A: Included 50 eyes who received medical treatment.
-Group B: Included 12 eyes who received peri-ocular injection.
-Group C: Included 25 eyes who underwent surgery.
Eighty-seven eyes of 83 patients were included in the study as having anterior chamber granuloma, 82 patients were males and 1 patient was female with a median age of 11+1 years in a range of 7-12 years as shown in Table 1.There was no statistically significant difference between the three studied groups for age and sex distribution.The average time to the presentation of recurrence is after a median of 8+/-2 months from treated first attack as 37 eyes of the medical group had recurrent attacks of anterior granulomatous uveitis, 5 eyes of the periocular group had recurrent attacks but only one case of the surgical group had a recurrence.The duration of symptoms was significantly longer in group C. The recurrence rate was significantly higher in group A with a rate of 37 (74%) in group A, 5(41.7%) in group B, and one case (4%) in group C, p <0.001.as shown in Figure 1.molecular testing in 6 of 14 samples, done in Egypt, were positive [1,8].
Given the increasing number of parasite agents being discovered as possible sources of similar outbreaks, it seems that the worldwide prevalence of pediatric waterborne parasitic AC granulomas will only increase [10].
Local observed furthermore that antiparasitic therapy alone (praziquantel+metronidazole) is helpful for small granulomas, whereas surgical aspiration is a useful adjuvant treatment for big granulomas [10].The safety and effectiveness of using argon laser photocoagulation of the pearl-like nodules in the AC by destruction or thermal ablation of the nodules in the AC, which are associated with the trematode larvae or adult worm, were reported previously [11].
This method eliminated the antigenic stimulant of the relapsing granulomatous anterior uveitis.

Ethical approval and consent to participate:
Before commencement, the research was granted clearance by the ethical committee of Fayoum University Hospital at its 90th session on September 1, 2022, under approval number M562.The processes were followed in compliance with the relevant laws and guidelines, and written informed consent was taken from all patients or their guardians before recruitment in the study after explaining the objectives of the work.written informed consent was taken from all patients or their guardians before recruitment in the study after explaining the objectives of the work.

Funding:
The authors have no sources of funding to declare for this manuscript.

Competing interests:
The authors declare no conflicts of interest.
Egypt and has spread far throughout the Nile basin.The precise species of helminths can now be found thanks to molecular diagnostic procedures including real-time PCR, sequencing, and BLAST (Basic Local Alignment Search Tool) analysis.Many different ways of medical and surgical treatment have been tried on those patients, the surgical management showed significant resolution of inflammation and

FUMJ
Patients having active inflammation within three months.Individuals with granulomatous uveitis due to reasons other than suspected trematode infections, or those with a history of ocular trauma.

Group A :
Individuals who underwent medicinal treatment (steroids) in the form of cycloplegics (3 drops/day) and prednisolone eye drops (5 drops/day to be reduced progressively according to improvement) Group B: Patients who received Peri-ocular steroids in the form of posterior sub-Tenon injection of Triamcinolone acetonide under local anesthesia 0.2-0.3ml(two injections with one-week intervals).

Figure 1 :
Figure 1:The granulomas recurrence rate of the studied groups.

Figure 2 :
Figure 2: IOP results of the studied groups.

( 11 )FUMJ
It is necessary to include preventive actions.To prevent the emergence of all these dangers in our children's eyes, public health education and knowledge of the recognized to canal waters should be enhanced, particularly in endemic regions.Conclusion More environmental investigation is to further identify the risk factors for this problematic pathogen identify subtypes of helminths and possible preventive measures in the given endemic areas and outline the best management.Public health education and raising awareness of the recognized risks associated with canal water exposure are important, particularly in endemic regions.

2024, 13(3)133-141 Saif et al., 2024 4
To rule out the possibility of any other related systemic granulomatous illness, a pediatrician was consulted for a comprehensive assessment of each patient.Full blood count, stool sample collection, specialized tests to rule out other granulomatous infections, and radiographic studies in chest radiography were sought as part of the laboratory workup.A rebound system (I care tonometer, ic100, Finland) with a Goldman application tonometer was used to measure intraocular pressure (IOP).FUMJ,

Table 1 : Demographic data of the studied groups
Data are presented as frequency (%) unless otherwise mentioned, Statistical significance at p <0.05.