The twenty children with ocular lesions enrolled in this study are just a sample of patients with similar lesions who frequently attended the ophthalmology clinics. Anti-inflammatory drugs were recommended as the first line of treatment, and the lesions were surgically removed for those not responding to medical therapy or those with recurrent lesions after treatment. The belief that prevailed in the earlier periods and the related research studies indicated a stage of one of the flatworms as the cause of these ocular infections [3–6]. Many Egyptian specialists in collaboration with their scientific teams accepted such assumption and recommended antiparasitic drugs alone, in combination with surgical aspiration, or other interventions in the management of such presumed trematode-induced anterior uveitis in children in different governorates Amin et al.  in Alexandria, El Nokrashy et al.  in Mansoura, Sadek et al.  in Al-Fayoum. The same concept was followed in India [4, 6]. Recently, in the Egyptian governorate, Sohag, Alsmman et al.  applied argon laser to the anterior chamber nodules with or without medical treatment to treat similar ocular lesions.
These preliminary identifications may have come from the fact that these studies relied on traditional methods of examination as histopathology or conventional PCR using universal nonspecific primers. In addition, findings as Splendore–Hoeppli phenomenon, microscopically observed within sections from the removed ocular lesions, may have been used to explain the investigators’ views. Similarly, this phenomenon was also reported in all ocular lesions involved in this study. The reaction is characterized by the presence of dense eosinophilic amorphous material surrounding the causative microorganisms, which may be of fungal, bacterial, or parasitic nature . Moreover, syncytial tissues, which are full of nuclei and cellular organelles, were visualized. This may have increased the belief that it might be the tegument of a parasitic stage related to class Trematoda.
The presence of cellular organelles is a vital feature of eukaryotes. In the present study, the ultrastructure of the ocular specimens revealed the presence of a functioning eukaryotic structure in 5 samples, evident by the characteristic organelles and an active synthesizing process within these organelles. These eukaryotic structures were multinucleated with no distinct cell boundaries, forming a syncytium which was noticed distributed into distal and proximal parts in the active ocular lesions. The syncytium is a tissue characterized by cytoplasmic continuity with a large number of nuclei. Many organisms are distinguished by the presence of this unique structure as protists, plants, fungi, tegument of platyhelminths, and in some organs in animal species including humans . In addition, cytoplasmic inclusions, which are generally diverse intracellular non-living substances, were also seen. These inclusions are possibly stored nutrients, secretory products, or pigment granules .
Ascomycota phylum of the kingdom Fungi was detected within the ocular lesions, with a wide range of bacterial species, applying metagenomic analysis. Fungi are known to have interconnecting syncytium, which is beneficial for colony development, transport of nutrients, and exchange of genetic substances, resulting in enlargement of colony size [13–16]. What is surprising in the results of our metagenomic analysis is the detection of the T. gondii parasite among such communities in this unusual ocular location for this parasite. Toxoplasma infections commonly affect the retina, resulting in retinochoroiditis and may involve the optic nerve, causing blindness [17, 18]. This can occur due to either congenital infection or acquired from the oral route that allows the parasitic stages to reach the ocular tissue via blood .
In this study, TEM examination revealed Toxoplasma tachyzoites among a microbial community enclosed by a hyaline material, possibly secreted by the microorganisms dwelling within the anterior chamber lesion. As demonstrated by the active secretory activity seen, this study suggests that this material is possibly extracellular polymeric substances (EPS) secreted by this microbial community. These EPS have been described as polymers synthesized biologically by numerous types of microorganisms, resulting in the formation of biofilms comprised mainly of polysaccharides, proteins, and DNA . Protection is one of the vital functions of these EPS, which ensure a barrier between microbes and the external environment. This is guarding the community against drought and other factors. These polymeric substances facilitate the setup of nutrients (main carbon), energy source, adhesion, aggregation, communication with variable microorganisms [21, 22]. In the presence of bacteria, as evident in this study, bacterial polymers can act as virulence factors for pathogenicity . Besides, it can protect the microbes against the host inflammatory reaction, as well as reactive oxygen species (ROS) [24, 25]. This may explain the survival of microbial colonies in an active productive status. In this work, the outer zones of the community “distal cytoplasm of the syncytium” showed a relatively large number of variable size mitochondria, which are necessary for metabolic activity and energy needed . Thus, possibly denotes the activity and the absorptive capacity of the distal cytoplasm during the formation of the hyaline layer, by depositing the secretory EPS to this layer, perhaps as a protective covering layer. That was marked by the secretory vesicles and granules within the distal cytoplasm.
The mitochondrial activity, within the outer layer, may help the microbial community to acquire some nutrients from the host and/or to guard against the host's immune response. On the other hand, signs of cellular abnormalities (e.g., variable size or abnormal mitochondria) are seen in some areas, reflecting the overstress condition that faced these communities .
An aquatic transmission of the microbial community to the anterior chamber of the eye of Egyptian children was postulated in the present study. Water is very easily contaminated by cats’ excreta full of the massive number of highly resisting Toxoplasma oocysts , resulting in outbreaks as reported in many developing countries . Environmental changes, absence of host specificity, animal and bird movement, as well as children habitual behavior, may contribute to the aquatic transmission of such divergent microbial communities . Once in the ocular tissues, microorganisms develop several strategies to survive including the production of EPS, yet the underlying procedures and the controlling pathways are still not well known. Many microorganisms produce EPS, and because of the great diversity we are still far from complete understanding, thus several opportunities remain for further explorations and discoveries .
In conclusion, our findings revealed the presence of T. gondii among a microbial community forming a syncytium-like structure, in an atypical lesion in the anterior chamber of the eye. Using TEM, active cellular activity was observed in active lesions. There is an urgent need for an ultimate understanding of the mechanisms behind such ocular illness. Further larger studies are required to obtain solid data, regarding genotype characterization, proteomic analysis, as well as aquatic transmission of these mixed microbial species to the ocular tissues.