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Chapter 9 : Ocular Microsporidiosis
Authors:
Dorothy Nahm Friedberg1,
David C. Ritterband2
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Affiliations:
1: Department of Ophthalmology, New York University School of Medicine, New York, NY 10016;
2: Department of Ophthalmology, New York Eye and Ear Infirmary, New York, NY 10003
Content Type: Monograph
Publication Year:
1999
Category: Fungi and Fungal Pathogenesis
Book DOI:
10.1128/9781555818227
Chapter DOI:
10.1128/9781555818227.ch9
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Abstract:
One of the difficulties in understanding the epidemiology of ocular microsporidiosis is the constantly changing nomenclature and the difficulty in speciation. The clinical and histopathologic appearance of ocular microsporidiosis can be divided into two distinct patterns of infection, one involving the deep corneal stroma and seen in immunocompetent patients, and the other a superficial epithelial keratopathy infection seen in immunodeficient individuals. Both deep stromal and superficial epithelial keratitides due to ocular microsporidiosis are rare but must be considered in situations where these entities do not respond to conventional therapy. Ocular microsporidiosis has emerged as the cause of bilateral keratoconjunctivitis in immunosuppressed individuals. The differential diagnosis of microsporidial infection causing stromal disease is broader; diagnosis is unlikely based on clinical examination. Microsporidia are sufficiently unique to be classified as a separate phylum. The early light microscopy (LM) findings of ocular microsporidiosis were instrumental in localizing and recognizing these organisms in other tissues. Both isolated, deep stromal keratitis and superficial epithelial keratitis caused by microsporidia are rare. However, superficial keratitis is important, as it may be the initial manifestation of systemic microsporidia infection. Therapy, either topical or systemic, can be visually and pathologically evaluated with minimal morbidity.
Citation:
Friedberg D, Ritterband D.
1999.
Ocular Microsporidiosis,
p 293-314.
In
Wittner M, Weiss L (ed),
The Microsporidia and Microsporidiosis.
ASM Press, Washington, DC.
doi: 10.1128/9781555818227.ch9
Figures
Ocular Microsporidiosis
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Citation:
Friedberg D, Ritterband D.
1999.
Ocular Microsporidiosis,
p 293-314.
In
Wittner M, Weiss L (ed),
The Microsporidia and Microsporidiosis.
ASM Press, Washington, DC.
doi: 10.1128/9781555818227.ch9
/content/10.1128/9781555818227.chap9.fig9-1
FIGURE 1
Several keratocytes with ill-defined basophilic spores of V. corneae.The sample was stained with hematoxylin and eosin. Original magnification, Xl60.) (Reprinted with permission from Ophthalmology[ Davis et al., 1990 ].)
10.1128/9781555818227/fig9-1_thmb.gif
10.1128/9781555818227/fig9-1.gif
FIGURE 1
Several keratocytes with ill-defined basophilic spores of V. corneae.The sample was stained with hematoxylin and eosin. Original magnification, Xl60.) (Reprinted with permission from Ophthalmology[ Davis et al., 1990 ].)
Citation:
Friedberg D, Ritterband D.
1999.
Ocular Microsporidiosis,
p 293-314.
In
Wittner M, Weiss L (ed),
The Microsporidia and Microsporidiosis.
ASM Press, Washington, DC.
doi: 10.1128/9781555818227.ch9
/content/10.1128/9781555818227.chap9.fig9-2
FIGURE 2
Same field as Fig. 1 with numerous birefringent linear structures probably corresponding to portions of polar filament. The sample was viewed by polarized light. Original magnification, x160. (Reprinted with permission from Ophthalmology[ Davis et al., 1990 ].)
10.1128/9781555818227/fig9-2_thmb.gif
10.1128/9781555818227/fig9-2.gif
FIGURE 2
Same field as Fig. 1 with numerous birefringent linear structures probably corresponding to portions of polar filament. The sample was viewed by polarized light. Original magnification, x160. (Reprinted with permission from Ophthalmology[ Davis et al., 1990 ].)
Citation:
Friedberg D, Ritterband D.
1999.
Ocular Microsporidiosis,
p 293-314.
In
Wittner M, Weiss L (ed),
The Microsporidia and Microsporidiosis.
ASM Press, Washington, DC.
doi: 10.1128/9781555818227.ch9
/content/10.1128/9781555818227.chap9.fig9-3
FIGURE 3
Anterior corneal stroma. Many keratocytes contain gram positive spores, and some are extracellular. Corneal epithelium appears slightly thinned, and Bowman's layer appears intact. The sample was treated with Brown and Hopps stain. Original magnification, x100. (Reprinted with permission from Ophthalmology[ Davis e t al., 1990 ].)
10.1128/9781555818227/fig9-3_thmb.gif
10.1128/9781555818227/fig9-3.gif
FIGURE 3
Anterior corneal stroma. Many keratocytes contain gram positive spores, and some are extracellular. Corneal epithelium appears slightly thinned, and Bowman's layer appears intact. The sample was treated with Brown and Hopps stain. Original magnification, x100. (Reprinted with permission from Ophthalmology[ Davis e t al., 1990 ].)
Citation:
Friedberg D, Ritterband D.
1999.
Ocular Microsporidiosis,
p 293-314.
In
Wittner M, Weiss L (ed),
The Microsporidia and Microsporidiosis.
ASM Press, Washington, DC.
doi: 10.1128/9781555818227.ch9
/content/10.1128/9781555818227.chap9.fig9-4
FIGURE 4
High-power view of area in Fig. 3 showing both intracellular and extracellular organisms. The sample was treated with Brown and Hopps stain. Original magnification, x252. (Reprinted with permission from Ophthalmology[ Davis et al., 1990 ].)
10.1128/9781555818227/fig9-4_thmb.gif
10.1128/9781555818227/fig9-4.gif
FIGURE 4
High-power view of area in Fig. 3 showing both intracellular and extracellular organisms. The sample was treated with Brown and Hopps stain. Original magnification, x252. (Reprinted with permission from Ophthalmology[ Davis et al., 1990 ].)
Citation:
Friedberg D, Ritterband D.
1999.
Ocular Microsporidiosis,
p 293-314.
In
Wittner M, Weiss L (ed),
The Microsporidia and Microsporidiosis.
ASM Press, Washington, DC.
doi: 10.1128/9781555818227.ch9
/content/10.1128/9781555818227.chap9.fig9-5
FIGURE 5
Organisms are acid fast variable. The sample was treated with Ziehl- Neelsen stain. Original magnification ×252. (Reprinted with permission from Ophthalmology [ Davis et al., 1990 ].)
10.1128/9781555818227/fig9-5_thmb.gif
10.1128/9781555818227/fig9-5.gif
FIGURE 5
Organisms are acid fast variable. The sample was treated with Ziehl- Neelsen stain. Original magnification ×252. (Reprinted with permission from Ophthalmology [ Davis et al., 1990 ].)
Citation:
Friedberg D, Ritterband D.
1999.
Ocular Microsporidiosis,
p 293-314.
In
Wittner M, Weiss L (ed),
The Microsporidia and Microsporidiosis.
ASM Press, Washington, DC.
doi: 10.1128/9781555818227.ch9
/content/10.1128/9781555818227.chap9.fig9-6
FIGURE 6
Oval to elongated extracellular spores are outlined within the corneal stroma.The sample was treated with Grocott methenamine-silver stain. Original magnification, ×403. (Reprinted with permission from Ophthalmology [ Davis et al., 1990 ])
10.1128/9781555818227/fig9-6_thmb.gif
10.1128/9781555818227/fig9-6.gif
FIGURE 6
Oval to elongated extracellular spores are outlined within the corneal stroma.The sample was treated with Grocott methenamine-silver stain. Original magnification, ×403. (Reprinted with permission from Ophthalmology [ Davis et al., 1990 ])
Citation:
Friedberg D, Ritterband D.
1999.
Ocular Microsporidiosis,
p 293-314.
In
Wittner M, Weiss L (ed),
The Microsporidia and Microsporidiosis.
ASM Press, Washington, DC.
doi: 10.1128/9781555818227.ch9
/content/10.1128/9781555818227.chap9.fig9-7
FIGURE 7
Conjunctival scraping with numerous large ovoid gram positive organisms within conjunctival epithelial cells. Original magnification, ×500. (Reprinted with permission from Archives of Ophthalmology [ Friedberg et al., 1990 ]. Figure copyright 1990, American Medical Association.)
10.1128/9781555818227/fig9-7_thmb.gif
10.1128/9781555818227/fig9-7.gif
FIGURE 7
Conjunctival scraping with numerous large ovoid gram positive organisms within conjunctival epithelial cells. Original magnification, ×500. (Reprinted with permission from Archives of Ophthalmology [ Friedberg et al., 1990 ]. Figure copyright 1990, American Medical Association.)
Citation:
Friedberg D, Ritterband D.
1999.
Ocular Microsporidiosis,
p 293-314.
In
Wittner M, Weiss L (ed),
The Microsporidia and Microsporidiosis.
ASM Press, Washington, DC.
doi: 10.1128/9781555818227.ch9
/content/10.1128/9781555818227.chap9.fig9-8
FIGURE 8
Conjunctival scraping showing organisms staining with Giemsa stain. Original magnification, ×500.
10.1128/9781555818227/fig9-8_thmb.gif
10.1128/9781555818227/fig9-8.gif
FIGURE 8
Conjunctival scraping showing organisms staining with Giemsa stain. Original magnification, ×500.
Citation:
Friedberg D, Ritterband D.
1999.
Ocular Microsporidiosis,
p 293-314.
In
Wittner M, Weiss L (ed),
The Microsporidia and Microsporidiosis.
ASM Press, Washington, DC.
doi: 10.1128/9781555818227.ch9
/content/10.1128/9781555818227.chap9.fig9-9
FIGURE 9
Plastic section of conjunctival biopsy specimen. Sloughing superficial cells contain parasite-laden vacuoles. Mature spores stain densely. The sample was treated with methylene blue-azure II-basic fuchsin stain. Original magnification, ×360. (Reprinted with permission from Archives of Ophthalmology [ Friedberg et al., 1990 ]. Figure copyright 1990, American Medical Association.)
10.1128/9781555818227/fig9-9_thmb.gif
10.1128/9781555818227/fig9-9.gif
FIGURE 9
Plastic section of conjunctival biopsy specimen. Sloughing superficial cells contain parasite-laden vacuoles. Mature spores stain densely. The sample was treated with methylene blue-azure II-basic fuchsin stain. Original magnification, ×360. (Reprinted with permission from Archives of Ophthalmology [ Friedberg et al., 1990 ]. Figure copyright 1990, American Medical Association.)
Citation:
Friedberg D, Ritterband D.
1999.
Ocular Microsporidiosis,
p 293-314.
In
Wittner M, Weiss L (ed),
The Microsporidia and Microsporidiosis.
ASM Press, Washington, DC.
doi: 10.1128/9781555818227.ch9
/content/10.1128/9781555818227.chap9.fig9-10
FIGURE 10
Electron micrograph from conjunctival biopsy. A mature electron-dense uninucleate spore has seven turns of the polar tubule. Original magnification, ×46,000. (Reprinted with permission from Archives of Ophthalmology [ Friedberg et al., 1990 ). Figure copyright 1990, American Medical Association.)
10.1128/9781555818227/fig9-10_thmb.gif
10.1128/9781555818227/fig9-10.gif
FIGURE 10
Electron micrograph from conjunctival biopsy. A mature electron-dense uninucleate spore has seven turns of the polar tubule. Original magnification, ×46,000. (Reprinted with permission from Archives of Ophthalmology [ Friedberg et al., 1990 ). Figure copyright 1990, American Medical Association.)
Citation:
Friedberg D, Ritterband D.
1999.
Ocular Microsporidiosis,
p 293-314.
In
Wittner M, Weiss L (ed),
The Microsporidia and Microsporidiosis.
ASM Press, Washington, DC.
doi: 10.1128/9781555818227.ch9
/content/10.1128/9781555818227.chap9.fig9-11
FIGURE 11
Electron micrograph from conjunctival biopsy. The superficial cell has clear parasitophorous vacuoles with parasites at various stages of development. Deeper cells show meronts in vacuole indenting the nucleus (lower right). Original magnification, ×2,700. (Reprinted with permission from Archives of Ophthalmology [ Friedberg et al., 1990 ]. Figure copyright 1990, American Medical Association.)
10.1128/9781555818227/fig9-11_thmb.gif
10.1128/9781555818227/fig9-11.gif
FIGURE 11
Electron micrograph from conjunctival biopsy. The superficial cell has clear parasitophorous vacuoles with parasites at various stages of development. Deeper cells show meronts in vacuole indenting the nucleus (lower right). Original magnification, ×2,700. (Reprinted with permission from Archives of Ophthalmology [ Friedberg et al., 1990 ]. Figure copyright 1990, American Medical Association.)
Citation:
Friedberg D, Ritterband D.
1999.
Ocular Microsporidiosis,
p 293-314.
In
Wittner M, Weiss L (ed),
The Microsporidia and Microsporidiosis.
ASM Press, Washington, DC.
doi: 10.1128/9781555818227.ch9
/content/10.1128/9781555818227.chap9.fig9-12
FIGURE 12
Stromal keratitis from Vittaforma corneae.(Reprinted with permission from Ophthalmology [ Davis etal.,1990 ].)
10.1128/9781555818227/fig9-12_thmb.gif
10.1128/9781555818227/fig9-12.gif
FIGURE 12
Stromal keratitis from Vittaforma corneae.(Reprinted with permission from Ophthalmology [ Davis etal.,1990 ].)
Citation:
Friedberg D, Ritterband D.
1999.
Ocular Microsporidiosis,
p 293-314.
In
Wittner M, Weiss L (ed),
The Microsporidia and Microsporidiosis.
ASM Press, Washington, DC.
doi: 10.1128/9781555818227.ch9
/content/10.1128/9781555818227.chap9.fig9-13
FIGURE 13
Eye in Fig. 12 six months after corneal transplantation. There is no evidence of recurrent microsporidial keratitis. ( Reprinted with permission from Ophthalmology [ Davis et al., 1990 ].)
10.1128/9781555818227/fig9-13_thmb.gif
10.1128/9781555818227/fig9-13.gif
FIGURE 13
Eye in Fig. 12 six months after corneal transplantation. There is no evidence of recurrent microsporidial keratitis. ( Reprinted with permission from Ophthalmology [ Davis et al., 1990 ].)
Citation:
Friedberg D, Ritterband D.
1999.
Ocular Microsporidiosis,
p 293-314.
In
Wittner M, Weiss L (ed),
The Microsporidia and Microsporidiosis.
ASM Press, Washington, DC.
doi: 10.1128/9781555818227.ch9
/content/10.1128/9781555818227.chap9.fig9-14
FIGURE 14
Minimal bulbar conjunctival reaction with moderate hyperemia of inferior palpebral conjunctiva with erythema and fusiform edema in the inferior fornix of an AIDS patient infected with Encephalitozoon hellem.(Reprinted with permission from Archives of Ophthalmology [ Friedberg et al., 1990 ]. Figure copyright 1990, American Medical Association.)
10.1128/9781555818227/fig9-14_thmb.gif
10.1128/9781555818227/fig9-14.gif
FIGURE 14
Minimal bulbar conjunctival reaction with moderate hyperemia of inferior palpebral conjunctiva with erythema and fusiform edema in the inferior fornix of an AIDS patient infected with Encephalitozoon hellem.(Reprinted with permission from Archives of Ophthalmology [ Friedberg et al., 1990 ]. Figure copyright 1990, American Medical Association.)
Citation:
Friedberg D, Ritterband D.
1999.
Ocular Microsporidiosis,
p 293-314.
In
Wittner M, Weiss L (ed),
The Microsporidia and Microsporidiosis.
ASM Press, Washington, DC.
doi: 10.1128/9781555818227.ch9
/content/10.1128/9781555818227.chap9.fig9-15
FIGURE 15
Mild superficial epithelial keratitis in AIDS patient infected with E. hellem. (Reprinted with permission from Archives of Ophthalmology [ Friedberg et al., 1990 ]. Figure copyright 1990, American Medical Association.)
10.1128/9781555818227/fig9-15_thmb.gif
10.1128/9781555818227/fig9-15.gif
FIGURE 15
Mild superficial epithelial keratitis in AIDS patient infected with E. hellem. (Reprinted with permission from Archives of Ophthalmology [ Friedberg et al., 1990 ]. Figure copyright 1990, American Medical Association.)
Citation:
Friedberg D, Ritterband D.
1999.
Ocular Microsporidiosis,
p 293-314.
In
Wittner M, Weiss L (ed),
The Microsporidia and Microsporidiosis.
ASM Press, Washington, DC.
doi: 10.1128/9781555818227.ch9
/content/10.1128/9781555818227.chap9.fig9-16
FIGURE 16
Diffuse, coarse, superficial epithelial keratitis in an AIDS patient infected with E. hellem. (Reprinted with permission from Archives of Ophthalmology [ Friedberg et al., 1990 ]. Figure copyright 1990, American Medical Association.)
10.1128/9781555818227/fig9-16_thmb.gif
10.1128/9781555818227/fig9-16.gif
FIGURE 16
Diffuse, coarse, superficial epithelial keratitis in an AIDS patient infected with E. hellem. (Reprinted with permission from Archives of Ophthalmology [ Friedberg et al., 1990 ]. Figure copyright 1990, American Medical Association.)
Citation:
Friedberg D, Ritterband D.
1999.
Ocular Microsporidiosis,
p 293-314.
In
Wittner M, Weiss L (ed),
The Microsporidia and Microsporidiosis.
ASM Press, Washington, DC.
doi: 10.1128/9781555818227.ch9
/content/10.1128/9781555818227.chap9.fig9-17
FIGURE 17
Conjunctival scraping showing microsporidial organisms reacting intensely with species-specific antisera indicating presence of E. hellemin conjunctival epithelial cells. Original magnification, ×1,000.) (Reprinted with permission of the author and publisher from the American Journal of Ophthalmology [ Diesenhouse et al., 1993 ]. Figure copyright, Ophthalmic Publishing Co.)
10.1128/9781555818227/fig9-17_thmb.gif
10.1128/9781555818227/fig9-17.gif
FIGURE 17
Conjunctival scraping showing microsporidial organisms reacting intensely with species-specific antisera indicating presence of E. hellemin conjunctival epithelial cells. Original magnification, ×1,000.) (Reprinted with permission of the author and publisher from the American Journal of Ophthalmology [ Diesenhouse et al., 1993 ]. Figure copyright, Ophthalmic Publishing Co.)
Citation:
Friedberg D, Ritterband D.
1999.
Ocular Microsporidiosis,
p 293-314.
In
Wittner M, Weiss L (ed),
The Microsporidia and Microsporidiosis.
ASM Press, Washington, DC.
doi: 10.1128/9781555818227.ch9
/content/10.1128/9781555818227.chap9.fig9-18
FIGURE 18
In vivo confocal microscopy demonstrates corneal epithelial cells which contain intracellular microsporidial spores. (Inset) Enlargement of the two cells, showing numerous aggregates of small, high contrast intracellular microsporidial spores (arrows). (Micrograph courtesy of Gaurav Shah and Edward Holland.)
10.1128/9781555818227/fig9-18_thmb.gif
10.1128/9781555818227/fig9-18.gif
FIGURE 18
In vivo confocal microscopy demonstrates corneal epithelial cells which contain intracellular microsporidial spores. (Inset) Enlargement of the two cells, showing numerous aggregates of small, high contrast intracellular microsporidial spores (arrows). (Micrograph courtesy of Gaurav Shah and Edward Holland.)
Citation:
Friedberg D, Ritterband D.
1999.
Ocular Microsporidiosis,
p 293-314.
In
Wittner M, Weiss L (ed),
The Microsporidia and Microsporidiosis.
ASM Press, Washington, DC.
doi: 10.1128/9781555818227.ch9
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Tables
Ocular Microsporidiosis
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Citation:
Friedberg D, Ritterband D.
1999.
Ocular Microsporidiosis,
p 293-314.
In
Wittner M, Weiss L (ed),
The Microsporidia and Microsporidiosis.
ASM Press, Washington, DC.
doi: 10.1128/9781555818227.ch9
/content/10.1128/9781555818227.chap9.tab9-1
TABLE 1
Cases of ocular microsporidial infection in immunocompetent patients
10.1128/9781555818227/tab9-1_thmb.gif
10.1128/9781555818227/tab9-1.gif
TABLE 1
Cases of ocular microsporidial infection in immunocompetent patients
Citation:
Friedberg D, Ritterband D.
1999.
Ocular Microsporidiosis,
p 293-314.
In
Wittner M, Weiss L (ed),
The Microsporidia and Microsporidiosis.
ASM Press, Washington, DC.
doi: 10.1128/9781555818227.ch9
/content/10.1128/9781555818227.chap9.tab9-2
TABLE 2
Cases of ocular microsporidial infection in immunosuppressed patients
a N.S.,not stated.
b Number of cases included but previously reported.
10.1128/9781555818227/tab9-2_thmb.gif
10.1128/9781555818227/tab9-2.gif
TABLE 2
Cases of ocular microsporidial infection in immunosuppressed patients
a N.S.,not stated.
b Number of cases included but previously reported.
Citation:
Friedberg D, Ritterband D.
1999.
Ocular Microsporidiosis,
p 293-314.
In
Wittner M, Weiss L (ed),
The Microsporidia and Microsporidiosis.
ASM Press, Washington, DC.
doi: 10.1128/9781555818227.ch9