dengue induced ophthalmic manifestation, dengue hemorrhagic retinopathy, dengue shock syndrome, OCT images,case history, investigations, CBC, PLATELETS, NS1 - NS2 Antigen, thromobocyytopenia induced ocular manifestations,

1. {
CASE PRESENTATION
Dr. Vinit Kumar ( fellow SCEH Eye hospital, Lahan , Nepal
Dr. Bibek Acharya ( 3red yr M.S Ophthalmology )
17th November 2019

2.  Patient ID : 2019/11/8977
 Age: 37 years
 Gender: Male
 Address: Darbhanga, India
 Occupation: Shopkeeper
 Date of presentation: 9th November 2019
 Date of examination: 9th November 2019
Particulars

3.  Gradual painless diminution of vision of left eye for 14days
Presenting Complaints

4.  Gradual painless diminution of vision on left eye for 14days
which was preceeded by
 Fever
History of present illness

5.  No history of entry of foreign body or trauma
 No history suggestive of aura, photophobia
 No history of flashes, and coloured halos
 No history of metamorphosia and micropsia
History of present illness

6.  H/O fever for 1month for which he was diagnosed with Dengue
and was treated conservatively
History of past illness

7.  No history of diabetes/ hypertension or other systemic
dieases
History of systemic illness

8.  No history of drug and food allergy known till date
Drug and Allergy History

9.  No history of similar problem in the family
Family History

10.  Non vegetarian by diet
 Non smoker
 Doesn’t consume alcohol
Personal History

11.  Well oriented to time, place and person
 Thinly built, average height (height 5feet 7 inches, weight 75kgs, BMI
25kg/m2)
 Vitals
 Temperature = 98◦ F
 Pulse rate = 69/min, Regular
 Blood Pressure = 100/60 mm Hg
 Respiratory rate : 18/min
Anaemia, Jaundice, Clubbing, Cyanosis, Edema: Absent
General Examination

12. • CVS- S1 S2 M0
• Chest- Vesicular breath sound, No added sound
• Abdomen- Soft, Non-tender, No organomegaly
• CNS examination- Grossly intact
Systemic Examination

13. Right Eye Parameters Left Eye
6/6
Visual Acuity
(Snellen’s chart)
HM
No improvement with
Pinhole
Normal Head Posture Normal
Normal Forehead &
Eyebrow
Normal
Ocular examination

14.  Facial Symmetry – Normal
 Globe – Normal in size and position
 Hirschberg test
- Central corneal reflex on both near and distant gaze.
 EOM
 Fixation : central , steady, maintained
+
+
+
+
++ +
++
+
+
++
+
+
+
+
+
+
+
RE
RELE LE

15. Right Eye
Normal in position
Interpalbebral fissure
height –Vertical: 11mm
Horizontal : 30 mm
Left eye
Normal in position
Interpalbebral fissure
height –Vertical: 11mm
Horizontal : 30 mm
Mild upper lid edema
No entropion/trichiasis
Ectropion/lagophthalmos/d
istichiasis/madarosis/polios
is/scales//mass
Eyelids No entropion/trichiasis
Ectropion/lagophthalmo
s/distichiasis/madarosis/
poliosis/scales/swelling/
mass

16. Right Eye Left Eye
Lacrimal gland-normal
Punctum- normal position
Opposed to globe
Lacrimal sac-no swelling,
redness,
tenderness,regurgitation
Lacrimal
apparatus
Lacrimal gland-normal
Punctum- normal position
Opposed to globe
Lacrimal sac-no swelling,
redness,tenderness,regurgitation

17. Right Eye Left Eye
Normal Conjunctiva Normal
No ectasia, no uveal show, no
staphyloma
Sclera No ectasia, no uveal
show,no staphyloma
clear Cornea
Horizontal diameter
11.5mm
Vertical diameter 11 mm
Corneal sensation- present
clear

18. Right Eye Left Eye
Depth: VH-IV
No cells,flare
Anterior Chamber Depth: VH- IV
No cells, flare
Brown colour;
normal pattern
Iris
Brown colour;
normal pattern

19. Right eye Left eye
Round,regular,
central, ~3.0 mm
diameter to direct light
and consensual light
Pupils Round,regular,
central, ~3.0 mm
diameter to direct
light and consensual
light
clear
Lens
clear
Clear Anterior Vitreous Clear

20. Right eye Fundus Left eye
clear Media Clear
Pink, round, well
defined margins
Optic Disc Pink, round, well
defined margins
0.3: 1, NRR
healthy
Cup: Disc Ratio 0.3:1 , NRR healthy
FR+ Macula Multiple retinal
yellowish deposits
at fovea
A:V : 2:3, Blood Vessels A:V : 2:3
Examination of Fundus

21.  Intraocular pressure
- RE → 14mm Hg
- LE → 13 mm Hg at 10 am (GAT)(2019/11/9)

22.  Central serous choroidoretinpathy
 Dengue maculopathy
Differential Diagnosis

23. Investigations

24.  HB%-13.7gm%
 MCHC-31.8g/dl
 WBC COUNT-3500cells/cumm
 Neutrophill-81%
 Lymphocytes-16%
 Platelet count-186000/cmm
 MPV-6.0fl
 PDW-16.9%
 PERIPHERAL BLOOD SMEAR EXAMINATION
 RBC MORPHOLOGY-NORMOCYTIC NORMOCHROMIC
 WBC MORPHOLOGY-LEUCOPENIA WITH
NEUTROPHILIA
 RANDOM BLOOD GLUCOSE-96.4MG/DL
Blood investigation(2019/8/23)

25.  TEST FOR DENGUE
 NS1 Antigen -REACTIVE
 TEST FOR MALARIA
 TEST FOR ANTIBODIES TO ENZYME-NEGATIVE

26.  HB%-14.1gm%
 MCH-25.6pg
 MCHC-29.7g/dl
 WBC COUNT-560000cells/cumm
 Platelet count-56000/cmm
 MPV-5.7fl
 PDW-18.1%
 PERIPHERAL BLOOD SMEAR EXAMINATION
 RBC MORPHOLOGY-NORMOCYTIC NORMOCHROMIC
 WBC MORPHOLOGY-LEUCOPENIA WITH
NEUTROPHILIA
 RANDOM BLOOD GLUCOSE-96.4mg/dl
Blood investigation(2019/8/25)

27. OCT MACULA(24/10/2019)

28. OCT MACULA(OD)(9/11/2019)

29. OCT Macula(OS)

30. OCT ANGIOGRAM(OD)

31. OCT ANGIOGRAM(OS)

32. FFA(OD)

33. FFA( OS)
00:23 00:26
10:292:40
00:49
5:12

34.  DENGUE MACULOPATHY
Final Diagnosis

35.  TAB PREDNISOLONE 70MG PO OD
60MG PO OD
50MG PO OD
40MG PO OD
30MG PO OD
20MG PO OD
10 MG PO OD
Management
TAPER EVERY
WEEK

36. Reference articles

37.  Vivien Cherng-Hui Yip, Srinivasan Sanjay, and Yan Tong Koh(Ophthalmic
Complications of Dengue Fever: a Systematic Review) Ophthalmol Ther.
2012 Dec; 1(1): 2. doi: 10.1007/s40123-012-0002-z
 Ophthalmic Symptoms of Dengue-Related Complications
Blurring of Vision,Scotoma,Ocular Pain,Metamorphopsia
Floaters
A fundus photo of a patient who had
dengue fever and blurring of vision in the
right eye showed intraretinal hemorrhage,
cotton wool spots, macular edema confined
to the macula, and a yellow-orange spot at
the fovea
 Ocular Complications Involving the Posterior Segment of the Eye
 Maculopathy-Hemorrhages associated with dengue-related
maculopathy are mostly intraretinal and can take the form of dot,
blot, or flame-shaped hemorrhages
 Dengue-related foveolitis refers to the yellow-orange lesion at the
fovea of patients with dengue maculopathy, which corresponds to a
disruption of the outer neurosensory retina in optical coherence
tomography (OCT)

38.  Macular Edema,Optic Neuropathy
 Investigations
 Fundus fluorescein angiography (FFA) demonstrated mainly vascular occlusion or leakage
 OCT imaging of the macula has been employed in a number of studies to evaluate retinal thickness and
morphology. Foveolitis is a term used to describe the presence of a yellow-orange lesion at the fovea,
which corresponds to an area of disruption to the outer retina of the fovea in OCT.
 Treatment
 Steroid Therapy
 Conclusion
 A myriad of ocular complications relate to dengue infection with most of them
confined to the posterior pole of the fundus.
 A proportion of patients with more severe ocular impairment require steroid
treatment with most patients achieving reasonable improvement in vision and
resolution of signs.
Cont…

39.  13 cases of ophthalmic complications resulting from dengue infection in Singapore
 Visual acuity varied from 20/25 to counting fingers only
 Ophthalmologic findings include macular edema and blot hemorrhages (10), cotton
wool spots (1), retinal vasculitis (4), exudative retinal detachment (2), and anterior
uveitis
 Symptoms
 All patients complained of blurring of vision. Nine patients described bilateral
visual symptoms in both eyes; 4 (30.7%) noted unilateral visual impairment
 The onset of visual symptoms closely correlated with the nadir of
thrombocytopenia associated with DF.
Chan D et.al.Ophthalmic Complications of Dengue.Emerg Infect Dis. 2006 Feb; 12(2):
285–289.doi: 10.3201/eid1202.050274

40.  Signs
 The most common ophthalmic signs were found on the macular region of the retina.
Macular edema was the most common pathology; The second most common finding
on ophthalmoscopy was macular hemorrhage
 less common fundus findings include perifoveal telangectasia and cotton wool spots,
both at the macula and peripheral retina
 All but 2patients were treated conservatively(oral prednisolone at 1 mg/kg/day for 1
week, tailed off over the next 2 months)
 Conclusion-DF and DHF can cause ophthalmic symptoms that were not previously
well-described in the medical literature. Blurring of vision typically coincides with
the nadir of thrombocytopenia and occurs ≈1 week after onset of fever. Clinical
features include retinal edema, blot hemorrhages, and vasculitis. Less common
features include exudative retinal detachment, cotton wool spots, and anterior
uveitis.
Cont…

41.  41 patients with serological evidence of dengue fever who had ocular signs and symptoms not
attributable to other diseases within 1 month after onset of symptoms of dengue.
 Seventy-one eyes had maculopathy. Mean best-corrected visual acuity in the affected eye was 20/40
(range, hand motions to 20/20)
 Fundus fluorescein angiography demonstrated venular occlusion in 25% or arteriolar and/or
venular leakage in 3% and 13%, respectively. Yellow subretinal dots were an unusual finding in
28%. Of these, 50% showed corresponding hypofluorescent spots on indocyanine green
angiography.
 Twenty-eight patients received steroid treatment. Mean visual acuity showed significant
improvement between weeks 2 and 4, with an increasing proportion of eyes achieving a best-
corrected visual acuity of 20/40 or better across time.
 Conclusion-Fundus fluorescein and indocyanine green angiography, optical coherence
tomography, and visual field testing are useful tools in the diagnosis of dengue maculopathy.
Kristine Enrile Bacsal E.Ket.al.Dengue-Associated Maculopathy.Arch
Ophthalmol. 2007;125(4):501-510. doi:10.1001/archopht.125.4.501

42. Luk F.O.Chan ,C.K,Lai T.Y.A Case of Dengue Maculopathy with
Spontaneous Recovery, : Case Rep Ophthalmol 2013;4:28-33
 25-year-old female patient with diagnosis of dengue fever.
 patient developed dengue maculopathy mainly affecting the vision of her left eye
 Results: As there is no proven treatment for dengue maculopathy, the patient opted for
observation
 vision returned to normal within 3 weeks.
 Conclusion: Dengue maculopathy can cause severe visual loss and may resolve
without treatment

43. Siqueira et al
Case report
BOV BE;
VA: RE 6/30 LE 6/60
CWS at macula;
FFA: areas of capillary nonperfusion in
both the equator and macula.
Su et al.
Case series
197/M:F 119:78
Maculopathy (27 eyes);
white spots at macula
(15 eyes);
yellow spots at macula
(3 eyes);
FFA: mild arteriolar and/or
venular leakage in some eyes
- ICG: hypofluorescence in mid
and late phases in some areas
- OCT: outer neurosensory
retina/RPE thickening at fovea

44. Teoh et al. 2010
Case series
41/M:F 22:19
- OCT
• Diffuse oedema (44.6%)
• Macular oedema (21.6%)
• Cystic foveolitis (33.8%)
PanelWee-KiakLim
Ocular manifestations of dengue fever
Presented at: The Annual Retina Club Meeting, Wills Eye
Hospital, Oct 10 2003; Philadelphia, Pennsylvania.
Purpose
To evaluate ocular manifestations associated with dengue
fever.
Results
Six patients, 5 females and 1 male
The presenting best-corrected visual acuity ranged from 20/30 to
counting fingers and ocular involvement was bilateral but
asymmetric in 5 cases and unilateral in 1 case
Fundus findings included small, intraretinal, whitish lesions, with localized
retinal and retinal pigment epithelium (RPE) disturbance, small dot hemorrhages,
and vascular sheathing around the macula and the papillomacular bundle.
Fluorescein angiography showed arteriolar focal knobby hyperfluorescence at the
macula with mild staining of the vascular walls and leakage at the level of the
RPE. All 5 cases that had indocyanine green angiography done showed early
diffuse choroidal hyperfluorescence with late silhouetting of the larger choroidal
vessels

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