Dengue
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dengue induced ophthalmic manifestation, dengue hemorrhagic retinopathy, dengue shock syndrome, OCT images,case history, investigations, CBC, PLATELETS, NS1 - NS2 Antigen, thromobocyytopenia induced ocular manifestations,
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Dengue
- 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)
- 29. OCT Macula(OS)
- 32. FFA(OD)
- 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
- 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
- 45. THANK YOU
Notes de l'éditeur
- 55yrs old farmer hailing from malda india presented to our hospital on 25th jan, 2017 with the chief complaints of
- 1st degree relatives r at high risk
- EOM was full in both duction and version movements Near point of convergence at 10 cm
- As watering was present to exclude
- To rule out phacotopic glaucoma
- As there is no intumescent mature cataract
- Normal ranges- MCHC-32-37 ,WBC count-4000-11000 ,neutrophil-40-75 ,lymphocyte-20-45 ,MPV-7.4-10.4 PLATELET COUNT-150000-450000 ,PDW-10-15
- Normal ranges- MCHC-32-37 ,WBC count-4000-11000 ,neutrophil-40-75 ,lymphocyte-20-45 ,MPV-7.4-10.4 PLATELET COUNT-150000-450000 ,PDW-10-15
- Subretinal fluid accumulation The principle of OCT is white light, or low coherence, interferometry. The optical setup typically consists of an interferometer (Fig. 1, typically Michelson type) with a low coherence, broad bandwidth light source. Light is split into and recombined from reference and sample arm, respectively
- The principle of OCT is white light, or low coherence, interferometry. The optical setup typically consists of an interferometer (Fig. 1, typically Michelson type) with a low coherence, broad bandwidth light source. Light is split into and recombined from reference and sample arm, respectively
- Disruption in IS-OS junction The principle of OCT is white light, or low coherence, interferometry. The optical setup typically consists of an interferometer (Fig. 1, typically Michelson type) with a low coherence, broad bandwidth light source. Light is split into and recombined from reference and sample arm, respectively
- OCT-A technology uses laser light reflectance of the surface of moving red blood cells to accurately depict vessels through different segmented areas of the eye, thus eliminating the need for intravascular dyes.[2] The OCT scan of a patient's retina consists of multiple individual A-scans, which when compiled into a B-scan provides cross-sectional structural information. With OCT-A technology, the same tissue area is repeatedly imaged and differences are analyzed between scans (over time), thus allowing one to detect zones containing high flow rates (i.e. with marked changes between scans) and zones with slower, or no flow at all, which will be similar among scans
- Superficial-FAZ normal Deep-irregular FAZ zone Outer retina and choriocapillaris-reduced signal flow in choroid capillarary OCT-A technology uses laser light reflectance of the surface of moving red blood cells to accurately depict vessels through different segmented areas of the eye, thus eliminating the need for intravascular dyes.[2] The OCT scan of a patient's retina consists of multiple individual A-scans, which when compiled into a B-scan provides cross-sectional structural information. With OCT-A technology, the same tissue area is repeatedly imaged and differences are analyzed between scans (over time), thus allowing one to detect zones containing high flow rates (i.e. with marked changes between scans) and zones with slower, or no flow at all, which will be similar among scans
- Normal scan
- 8 phases of FFA-choroidal phase(dye reached but not enter artery)(10sec) ,arterial phase-1sec after prearterial phase(10-12sec) ,capillary phase or arterovenous phase-complete filling of arteries and capillaries with early lamellar flow of veins(13) venous phase-early,mid and late phase(3-5mins)(14-16sec) late phase(5-15mins)
- Flavivirus genus of the family, Flaviviridae,
- Singapore National Eye Centre between January 1, 2002, and December 31, 2005.