Intended for healthcare professionals

Clinical Review

Dengue fever

BMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h4661 (Published 15 September 2015) Cite this as: BMJ 2015;351:h4661

Dengue Eye Disease

Manifestations of dengue in the eye, though rare in the past, are now more recently noted to be common in some outbreaks. The most common manifestation, besides the expected complication of bleeding on macula, seems to be foveolitis or maculopathy (1) Sometimes the maculopathy may resolve spontaneously (2) The prevalence may vary according to the subtype of the virus but it can be as high as 10% in some outbreaks (3) (4). Optical coherence tomography (OCT) patterns may be used to predict the visual outcomes of maculopathy (5) and function may be assessed with Electroretinography (6), and some authors have stressed the need to look at both structure and function (7). Some authors have correlated visual field changes with OCT (8) and others (9) have demonstrated a parafoveal retinal thickness and subfoveal chorioidal thickness. Dengue can have various manifestations in the eye, (10)(11) and more recently a newer terminology of “dengue eye disease” has emerged (12). Dengue may have presenting features of subconjunctival haemorrhage and ecchymosis (13). It may have unusual presentations like frosted branch angitis (14) or papillodema secondary to cerebral veinous thrombosis (15). It may cause a central retinal artery occlusion (16), a branch retinal artery occlusion (17) or subhyaloid haemorrhage (18). In severe, unusual cases it has been found to cause even proptosis and globe rupture, as seen by Nagaraj et al (19).

It can also cause symptomatic inflammatory manifestations like retinochoroiditis (20) vasculitis, choroidal neovascularisation (21) secondary to immune damage, and even panophthalmitis (22).

One needs to be aware that it has been known to cause both eye involvement with potential to make a person irreversibly bilaterally blind by causing bilateral vitreous haemorrhage (23), bilateral stellar neuroretinitis (24), bilateral choroidal effusion (25) and may be a suspect ethology even for bilateral acute angle closure glaucoma (26), oculomotor paralysis (27) and optic neuropathy (28). The " Seet Quek Lim triad" of flashes of light, floaters and blurring of vision (29) may now warrant an ophthalmic consult and if not requested may be construed as negligence if eventually the patient loses vision, because dengue vision loss can be irreversible and may be seen in up to 10 percent of cases and has potential to cause bilateral irreversible visual impairment or blindness as reported.

Besides this the patient may present with an opsoclonus which may point towards an encephalopathy (30) (31) and so the expected retinal and macular haemorrhages (32) (33) are not the only pathologies that dengue can cause in the eye.

One also needs to remember that in endemic areas recurrence of infection may mean recurrence of bilateral eye involvement (34).

If it is uveitis it may recover well with steroids like some reports suggest (35) but bilateral cases like vasculitis and macular oedema (36) one may need to use newer medications and even 66 years after eye manifestations of dengue were first reported (37) ,dengue continues to blind people and greater awareness and timely referral is important even today.

References:-
1) Juanarita, Jaafar et al. "Dengue Related Maculopathy and Foveolitis." Asian Pacific Journal of Tropical Biomedicine 2.9 (2012): 755-756.
2) Luk F, O, Chan C, K, Lai T, Y, A Case of Dengue Maculopathy with Spontaneous Recovery. Case Rep Ophthalmol 2013;4:28-33
3) Su DH, Bacsal K, Chee SP, Flores JV, Lim WK, Cheng BC, Jap AH; Dengue Maculopathy Study Group. Prevalence of dengue maculopathy in patients hospitalized for dengue fever. Ophthalmology. 2007 Sep;114(9):1743-7.
4) Chee E, Sims JL, Jap A, Tan BH, Oh H, Chee SP. Comparison of prevalence of dengue maculopathy during two epidemics with differing predominant serotypes. Am J Ophthalmol. 2009 Dec;148(6):910-3. doi: 10.1016/j.ajo.2009.06.030.
5) Teoh SC, Chee CK, Laude A, Goh KY, Barkham T, Ang BS; Eye Institute Dengue-related Ophthalmic Complications Workgroup. Optical coherence tomography patterns as predictors of visual outcome in dengue-related maculopathy. Retina. 2010 Mar;30(3):390-8. doi: 10.1097/IAE.0b013e3181bd2fc6.
6) Mendes TS, Sobrinho EF, Rosa AA, dos Anjos LM, da Costa GM, Souza Gda S, Gomes BD, Saito CA, da Silva Filho M, Silveira LC. Dengue maculopathy: visual electrophysiology and optical coherence tomography. Doc Ophthalmol. 2009 Oct;119(2):145-55. doi: 10.1007/s10633-009-9178-5.
7) Tan MH, Tan PE, Wong EN, Chen FK. Structure and function correlation in a patient with dengue-associated maculopathy. Clin Experiment Ophthalmol. 2014Jul;42(5):504-7. doi: 10.1111/ceo.12269.
8) Rhee TK, Han JI. Use of optical coherence tomography to evaluate visual acuity and visual field changes in dengue fever. Korean J Ophthalmol. 2014Feb;28(1):96-9. doi: 10.3341/kjo.2014.28.1.96.
9) Yamamoto K, Takahashi H, Kanno M, Noda Y, Fujino Y. Changes in parafoveal retinal thickness and subfoveal choroidal thickness in a patient with dengue fever-associated maculopathy. J Ophthalmic Inflamm Infect. 2013 Oct 31;3(1):63.doi: 10.1186/1869-5760-3-63.
10) Chan, David P.L. et al. "Ophthalmic Complications of Dengue." Emerging Infectious Diseases 12.2 (2006): 285-289.
11)Lim WK, Mathur R, Koh A, Yeoh R, Chee SP. Ocular manifestations of dengue fever. Ophthalmology. 2004 Nov;111(11):2057-64. PubMed PMID: 15522372.
12)Ng AW, Teoh SC. Dengue eye disease. Surv Ophthalmol. 2015 Mar-Apr;60(2):106-14. doi: 10.1016/j.survophthal.2014.07.003. Epub 2014 Aug 12.
13) Jain S, Goswami A, Singh N, Kaur S. Bilateral eyelid ecchymosis and sub conjunctival haemorrhage manifesting as presenting feature in a case of dengue haemorrhagic fever. Trop Doct. 2014 Dec 24. pii: 0049475514565429.
14) Rani PK, Chhablani J, Bhargava A. Frosted Branch Angiitis in a Patient Co Infected With Dengue Hemorrhagic Fever and Malaria. JAMA Ophthalmol. 2015 Jun;133(6):e1568. doi: 10.1001/jamaophthalmol.2015.68.
15) Vasanthi N, Vairamon PM, Gowtham T, Das AK. Unusual Presentation of Dengue Fever-Cerebral Venous Thrombosis. J Clin Diagn Res. 2015 Jun;9(6):OD09-10. doi: 10.7860/JCDR/2015/13132.6068.
16) Sadiq N, Naqaish T, Arif A, Mohammad K, Jalis M. Central retinal artery occlusion secondary to dengue fever. J Ayub Med Coll Abbottabad. 2014 Jan-Mar;26(1):98-9.
17) Kanungo S, Shukla D, Kim R. Branch retinal artery occlusion secondary to dengue fever. Indian J Ophthalmol. 2008 Jan-Feb;56(1):73-4.
18)Gupta S, Das D. Subhyaloid haemorrhage in dengue fever. J Indian Med Assoc. 2013 Sep;111(9):623-4.
19) Nagaraj KB, Jayadev C, Yajmaan S, Prakash S. An unusual ocular emergency in severe dengue. Middle East Afr J Ophthalmol. 2014 Oct-Dec;21(4):347-9. doi:10.4103/0974-9233.142276.
20) Tabbara K. Dengue retinochoroiditis. Ann Saudi Med. 2012 Sep-Oct;32(5):530-3. doi: 10.5144/0256-4947.2012.30.4.1105.
21) Veloso CE, Schmidt-Erfurth U, Nehemy MB. Choroidal neovascularization induced by immunogenic alteration of the retinal pigment epithelium in dengue Fever. Case Rep Ophthalmol. 2015 Jan 17;6(1):18-23. doi: 10.1159/000371791.
22) Saranappa S B S, Sowbhagya HN. Panophthalmitis in dengue fever. Indian Pediatr. 2012 Sep;49(9):760.
23) Sanjay S, Au Eong KG. Bilateral vitreous haemorrhage associated with dengue fever. Eye (Lond). 2007 Jan;21(1):144-5.
24) de Amorim Garcia CA, Gomes AH, de Oliveira AG. Bilateral stellar neuroretinitis in a patient with dengue fever. Eye (Lond). 2006Dec;20(12):1382-3.
25) Cruz-Villegas V, Berrocal AM, Davis JL. Bilateral choroidal effusions associated with dengue fever. Retina. 2003 Aug;23(4):576-8.
26) Pierre Filho Pde T, Carvalho Filho JP, Pierre ET. Bilateral acute angle closure glaucoma in a patient with dengue fever: case report. Arq Bras Oftalmol. 2008 Mar-Apr;71(2):265-8.
27) Donnio A, B?ral L, Olindo S, Cabie A, Merle H. [Dengue, a new etiology in oculomotor paralysis]. Can J Ophthalmol. 2010 Apr;45(2):183-4. doi: 10.1139/i09-207.
28) Sanjay S, Wagle AM, Au Eong KG. Dengue optic neuropathy. Ophthalmology. 2009Jan;116(1):170; author reply 170. doi: 10.1016/j.ophtha.2008.08.015.
29) Seet RC, Quek AM, Lim EC. Symptoms and risk factors of ocular complications following dengue infection. J Clin Virol. 2007 Feb;38(2):101-5.
30) Wiwanitkit V.Opsoclonus Myoclonus Ataxia associated with Dengue.Parkinsonism Relat Disord. 2015 Feb;21(2):159. doi: 10.1016/j.parkreldis.2014.11.008.
31) Tan AH, Linn K, Sam IC, Tan CT, Lim SY.Opsoclonus Myoclonus Ataxia associated with dengue virus disease.Parkinsonism Relat Disord. 2015 Feb;21(2):160-1. doi: 10.1016/j.parkreldis.2014.11.009.
32) Gupta P, Jain C, Aggarwal A, Gupta SC. Dengue Fever presenting with macular
hemorrhages. Retin Cases Brief Rep. 2011 Summer;5(3):213-8. doi:
10.1097/ICB.0b013e3181e72348. PubMed PMID: 25390167.
33) Sumardi U, Nelwan EJ. Retinal hemorrhage in dengue hemorrhagic fever. Acta Med Indones. 2011 Jan;43(1):66-7. PubMed PMID: 21339548.
34) Quek DT, Barkham T, Teoh SC. Recurrent bilateral dengue maculopathy following sequential infections with two serotypes of dengue virus. Eye (Lond). 2009
Jun;23(6):1471-2. doi: 10.1038/eye.2008.149. Epub 2008 Jun 6. PubMed PMID:
18535604.
35) Gupta A, Srinivasan R, Setia S, Soundravally R, Pandian DG. Uveitis following
dengue fever. Eye (Lond). 2009 Apr;23(4):873-6. doi: 10.1038/eye.2008.124.
36) 1: Tan CS, Teoh SC, Chan DP, Wong IB, Lim TH. Dengue retinopathy manifesting with bilateral vasculitis and macular oedema. Eye (Lond). 2007 Jun;21(6):875-7.
37) 1: KUNITOMO N, CH'IU LY. [Eye-troubles with dengue; changes in the fundus oculi? Nippon Ganka Gakkai Zasshi. 1948 Feb;52(1-2):6.

Competing interests: No competing interests

19 September 2015
Sunil R Moreker
Consultant Eye Surgeon
Nanavati Superspeciality, Seven hills, Fortis Hiranandani, Apollo, Cumballa Hill, MGM , Eyeris and Conwest Jain Hospitals
A132 Palash towers, Veera Desai Road, Andheri West, Mumbai, India