Ocular manifestations of dengue fever in an East Indian epidemic

Microvascular Changes during Viral Infections: A Systematic Review of Studies Using Retinal Vessel Diameter Assessments

Viral infection frequently affects the cardiovascular system, and vascular disturbances in patients can lead to health complications. One essential component of the cardiovascular system that is vulnerable to the inflammatory effects of viral infections is the microcirculatory system. As a suitable and practical non-invasive method to assess the structure and function of the retinal microcirculation, a proxy for the microcirculatory system, retinal fundus imaging can be used. We examined the impact of viral infections on retinal vessel diameters and performed a systematic analysis of the literature. Our search was carried out on PubMed using predefined search queries. After a methodological filtering process, we were able to reduce the corpus of 363 publications to 16 studies that met the search parameters. We used a narrative review style to summarise the observations. Six studies covered COVID-19, seven described HIV, and three were included in the subgroup called others, covering viruses, such as Dengue Fever and Crimean-Congo Haemorrhagic Fever. Analysis of the literature showed that viral infections are associated with alterations in the retinal vessels' vasoactivity. COVID-19 and other infections cause inflammation-associated the vasodilatation of microvasculature as a short-term effect of the infection. Long COVID-19 as well as HIV are the cause of chronic inflammation impacting microvascular morphology via retinal vessel diameter narrowing. The review emphasises the importance of the understudied area of viral infections' effects on retinal microcirculation. Continuous research in this area is needed to further verify retinal fundus imaging as an innovative tool for the optimal diagnosis of microvascular changes. As changes in the microvasculature precede changes in bigger arteries, the early detection of microvascular changes can go a long way in reducing the morbidity and mortality associated with cardiovascular diseases.

Causes of infectious pediatric uveitis: A review

Infectious pediatric uveitis is a rare disease that can cause severe ocular damage if not detected rapidly and treated properly. Additionally, early identification of an infection can protect the child from life-threatening systemic infection. Infectious uveitis can be congenital or acquired and may manifest as a primary ocular infection or as a reactivation. Nevertheless, publications on infectious paediatric uveitis are usually limited to a small number of patients or a case report. So far, most studies on uveitis in children have focused primarily on noninfectious uveitis, and a systematic study on infectious uveitis is lacking. In this review, we summarize the literature on infectious uveitis in pediatric populations and report on the epidemiology, pathophysiology, clinical signs, diagnostic tests, and treatment. We will describe the different possible pathogens causing uveitis in childhood by microbiological group (i.e. parasites, viruses, bacteria, and fungi). We aim to contribute to early diagnosis and management of infectious pediatric uveitis, which in turn might improve not only visual outcome, but also the general health outcome.

Ocular Autoimmune Systemic Inflammatory Infectious Study (OASIS) - Report 6: Dengue Uveitis at a Tertiary Eye Institution in Singapore

OBJECTIVES

To identify the characteristics, treatment, and visual outcomes of dengue uveitis at a tertiary eye care centre in Singapore.

METHODS

Retrospective case record review of all consecutive dengue uveitis patients (2004 to 2015) from the Ocular Autoimmune Systemic Inflammatory and Infectious Study (OASIS) database.

RESULTS

Fifty-four patients were identified from the OASIS database. The most common ocular symptom was blurring of vision (n = 41, 75.9%), followed by floaters (n = 9, 17.0%), scotoma (n = 5, 9.3%), and metamorphopsia (n = 3, 5.7%). Scotoma based on history, Amsler grid, and perimetry accounted for 27 (50%) patients. Majority presented with either a posterior uveitis or retinal vasculitis (n = 51, 94.4%). Treatments ranged from close observation for spontaneous improvement, to the use of high-dose corticosteroids.

CONCLUSIONS

Dengue uveitis may present with a spectrum of disease manifestations including posterior uveitis, vasculitis, and macula edema. Scotoma is significant and may be found on history taking, Amsler charting, and perimetry.

Ocular Manifestations of Flavivirus Infections

Flaviviruses are a group of positive-sense, single-stranded RNA viruses predominantly transmitted by arthropods (mainly mosquitoes) that cause severe endemic infections and epidemics on a global scale. They represent a major cause of systemic morbidity and death and are expanding worldwide. Among this group, dengue fever, the West Nile virus, yellow fever, Japanese Encephalitis, and, recently, the Zika virus have been linked to a spectrum of ocular manifestations. These manifestations encompass subconjunctival hemorrhages and conjunctivitis, anterior and posterior uveitis (inclusive of vitritis, chorioretinitis, and retinal vasculitis), maculopathy, retinal hemorrhages, and optic neuritis. Clinical diagnosis of these infectious diseases is primarily based on epidemiological data, history, systemic symptoms and signs, and the pattern of ocular involvement. Diagnosis confirmation relies on laboratory testing, including RT-PCR and serological testing. Ocular involvement typically follows a self-limited course but can result in irreversible visual impairment. Effective treatments of flavivirus infections are currently unavailable. Prevention remains the mainstay for arthropod vector and zoonotic disease control. Effective vaccines are available only for the yellow fever virus, dengue virus, and Japanese Encephalitis virus. This review comprehensively summarizes the current knowledge regarding the ophthalmic manifestations of the foremost flavivirus-associated human diseases.

Evaluation of choroidal thickness and choroidal vascularity index in patients with Crimean-Congo hemorrhagic fever

PURPOSE

This study aimed to compare choroidal thickness parameters between patients diagnosed with Crimean-Congo hemorrhagic fever (CCHF) and healthy individuals using spectral domain optical coherence tomography.

METHODS

The right eyes of 27 individuals diagnosed with CCHF and 27 healthy subjects were included in this study. CCHF cases were assessed based on a history of tick bites and hospitalization. Choroidal thickness was measured using enhanced depth imaging optical coherence tomography. Measurements of choroidal thickness were taken at 5 different points, including the subfoveal quadrant and the fovea up to 2000 μm with 1000 μm intervals in the temporal and nasal quadrants. Choroidal vascular index (CVI) was calculated as the ratio of luminal area (LA) to total choroidal area (TCA) at the macula's total area and at 1500 μm from the center (CVI and CVI1500).

RESULTS

Choroidal thickness in the CCHF group was found to be thicker in each quadrant compared to the control group, with the subfoveal and nasal quadrants showing significantly greater thickness. TCA, stromal area, and LA were significantly higher in the CCHF group, while no significant difference was observed in CVI and CVI1500.

CONCLUSION

The findings of this study suggest that CCHF disease may have an impact on the choroidal structure.

Dengue Uveitis - A Major Review

Dengue fever is a significant global public health concern with increasing incidence over the past two decades. The symptoms range from mild to severe, including fever, headache, rash, and joint pain. Ocular complications are prevalent among hospitalized patients, estimated to be between 10% and 40.3%, with varying incidences based on the serotype and severity of dengue. These complications can be hemorrhagic or inflammatory and typically occur after the onset of fever. Modern diagnostic tools such as Optical Coherence Tomography (OCT) and Fundus Fluorescein Angiography (FFA) have enabled physicians to better understand the extent of ocular involvement and guide treatment. This article provides an updated overview of the various manifestations of dengue uveitis, including their diagnosis and treatment.

Dengue Virus Infection of Human Retinal Müller Glial Cells

Retinopathy is a recently recognized complication of dengue, affecting up to 10% of hospitalized patients. Research on the pathogenesis has focused largely on effects of dengue virus (DENV) at the blood-retinal barrier. Involvement of retinal Müller glial cells has received little attention, although this cell population contributes to the pathology of other intraocular infections. The goal of our work was to establish the susceptibility of Müller cells to infection with DENV and to identify characteristics of the cellular antiviral, inflammatory, and immunomodulatory responses to DENV infection in vitro. Primary human Müller cell isolates and the MIO-M1 human Müller cell line were infected with the laboratory-adapted Mon601 strain and DENV serotype 1 and 2 field isolates, and cell-DENV interactions were investigated by immunolabelling and quantitative real-time polymerase chain reaction. Müller cells were susceptible to DENV infection, but experiments involving primary cell isolates indicated inter-individual variation. Viral infection induced an inflammatory response (including tumour necrosis factor-α, interleukin [IL]-1β, and IL-6) and an immunomodulatory response (including programmed death-ligand [PD-L]1 and PD-L2). The type I interferon response was muted in the Müller cell line compared to primary cell isolates. The highest infectivity and cell responses were observed in the laboratory-adapted strain, and overall, infectivity and cell responses were stronger in DENV2 strains. This work demonstrates that Müller cells mount an antiviral and immune response to DENV infection, and that this response varies across cell isolates and DENV strain. The research provides a direction for future efforts to understand the role of human retinal Müller glial cells in dengue retinopathy.

Ophthalmic manifestations in seropositive dengue fever patients during epidemics caused by predominantly different dengue serotypes

Purpose

Dengue fever (DF) epidemics in Singapore in 2005-2006 and 2007 were caused predominantly by dengue virus serotypes 1 (DENV-1) and 2 (DENV-2) respectively. We investigated the prevalence of ophthalmic manifestations during these consecutive epidemics.

Methods

Seropositive DF patients admitted to the hospital during two separate dengue epidemics were enrolled from June 2005 to December 2007. Demographic, ophthalmic, and laboratory data were collected. The primary outcome measures were differences in ophthalmic and laboratory features across the two epidemics. Factors associated with increased risk of developing various DF-related ophthalmic manifestations were the secondary outcome measures.

Results

Of the 115 patients enrolled, 109 (94.7%; 33 in 2005-2006 and 76 in 2007) completed the eye screening protocol. Majority of patients were Chinese (65, 59.6%) and males (81, 74.3%). The mean age was 40.8 years (range, 18-87). Colour vision impairment (12 vs 14 [36.4% vs 18.7%]; P ​= ​0.04), cotton wool spots (10 vs 3 [30.3% vs 3.9%]; P ​< ​0.001), bleeding diathesis (7 vs 3 [21.2% vs 3.9%]; P ​= ​0.004) and abnormal liver function (mean alanine amino-transferase [150.2 U/L vs 68.28 U/L; P ​= ​0.001], mean aspartate amino-transferase [196.86 U/L vs 99.53 U/L; P ​= ​0.002], total protein [68.43 ​g/L vs 72.27 ​g/L; P ​= ​0.016], serum albumin [36.86 ​g/L vs 40.5 ​g/L; P ​= ​0.001]) were noted more often in DF epidemics predominantly caused by DENV-1 compared to DENV-2.

Conclusions

A higher prevalence of colour vision impairment, cotton wool spots, bleeding diathesis, and abnormal liver function was found in DF epidemics predominantly caused by DENV-1 compared to DENV-2.

Increased Retinal Vessel Tortuosity Associated With Crimean-Congo Hemorrhagic Fever in Children

BACKGROUND

To evaluate the ocular symptoms and findings of children diagnosed with Crimean-Congo hemorrhagic fever (CCHF).

METHODS

In this prospective study, children diagnosed with CCHF who underwent a complete ophthalmologic examination during the hospitalization period were included.

RESULTS

Twenty-four children with a mean age of 12.4 ± 3.6 years were included study. The most common ocular finding was conjunctival hyperemia and was observed in 50% of patients. Nine (37.4%) children had abnormalities in fundus examination. Two (8.3%) of them had dilated retinal veins, and 7 (29.1%) had tortuous retinal vessels. No significant difference was found between mild to moderate and severe disease groups in terms of ocular symptoms and ophthalmologic examination findings (P > 0.05, for all).

CONCLUSIONS

The increased retinal vessel tortuosity was detected as a fundus examination finding in children with CCHF. Both ophthalmologists and pediatricians should be aware of the various ocular manifestations of CCHF for rapid diagnosis and management.

Clinical profile and response to steroids in post-fever retinitis: a nine-year experience from a referral institute in the rural hinterland of Central India

PURPOSE

To describe the demographics, clinical features, and treatment outcomes with systemic steroids in eyes presenting with post-fever retinitis (PFR) from Central India.

METHODS

Single-center, retrospective analysis of 147 eyes of 98 PFR cases between 2011 and 2019.

RESULTS

Mean age of the study cohort was 33.46 ± 12.76 years, with 72 males and 26 females. The mean interval between the onset of fever and the diminution of vision was 21.10 ± 13.54 days (range 0-60 days). The number of PFR cases increased over the nine years with 89 cases (90.1%) presenting during winters. Unilateral involvement was seen in 49 cases, while 49 had bilateral involvement. Clinical characteristics included: multifocal retinitis (n = 122; 61.2%), hemorrhages (n = 132; 89.8%), disc edema (n = 57; 38.8%), anterior chamber reaction (n = 28; 19%), and vitritis (n = 103; 70.1%). Treatment included intravenous followed by oral steroids in 70 patients and oral steroids exclusively in 23; five patients denied treatment. The visual acuity improved from 1.09 ± 0.52 LogMAR to 0.29 ± 0.42 LogMAR (p < 0.05).

CONCLUSION

There has been an increase in the prevalence of PFR cases over the last decade with clustering during the winters. Multifocal retinitis, retinal hemorrhages, and vitritis were the most common clinical findings in our series. The retinitis resolved with improvement in vision following steroid therapy in all eyes.

Dengue outbreak 2019: clinical and laboratory profiles of dengue virus infection in Dhaka city

Background

Dengue fever has been one of the most common mosquito-transmitted diseases in the world, affecting more than 128 countries in both tropical and subtropical regions. Bangladesh has been sufferring from dengue outbreaks almost annually since 2000, and in 2019, Bangladesh faced the worst outbreak of dengue to date. This study aimed to provide clinical and biochemical profiles of Bangladesh's dengue-infected patients.

Methods

This cross-sectional study was conducted from August through December 2019 in three tertiary private hospitals in Dhaka, Bangladesh. We collected information on demographic data, clinical characteristics, and laboratory profiles for 542 confirmed hospitalized acute dengue cases using a structured questionnaire.

Results

The average age of the enrolled patients was 26.15 years, and about 50% of patients belonged to the age group of 20–40 years. The most frequent among the prevalent clinical symptoms were fever (93.1%), abdominal pain (29.5%), skin rash (25.3%), and diarrhea (19.7%). 316 patients had some complications, such as breathing problems (41.4%), pleural effusion (38.9%), gum bleeding (11.1%), etc. More than 90% of the patients showed seropositivity for the DENV-NS1 antigen.

Conclusions

Over the last couple of years, dengue fever has become a major health issue for Bangladesh. To reduce the burden of this disease, timely diagnosis and prompt treatment are necessary. This analysis thus yields the clinical features, laboratory profiles, and seropositivity test results of dengue patients from Bangladesh. The research results may help clinicians understand the circumstantial diagnosis of dengue patients and facilitate early intervention.

Ocular manifestations of emerging viral diseases

Emerging infectious diseases (EIDs) are an increasing threat to public health on a global scale. In recent times, the most prominent outbreaks have constituted RNA viruses, spreading via droplets (COVID-19 and Influenza A H1N1), directly between humans (Ebola and Marburg), via arthropod vectors (Dengue, Zika, West Nile, Chikungunya, Crimean Congo) and zoonotically (Lassa fever, Nipah, Rift Valley fever, Hantaviruses). However, specific approved antiviral therapies and vaccine availability are scarce, and public health measures remain critical. Patients can present with a spectrum of ocular manifestations. Emerging infectious diseases should therefore be considered in the differential diagnosis of ocular inflammatory conditions in patients inhabiting or returning from endemic territories, and more general vigilance is advisable in the context of a global pandemic. Eye specialists are in a position to facilitate swift diagnosis, improve clinical outcomes, and contribute to wider public health efforts during outbreaks. This article reviews those emerging viral diseases associated with reports of ocular manifestations and summarizes details pertinent to practicing eye specialists.

Purtscher-like Retinopathy Associated with Crimean-Congo Hemorrhagic Fever: A Case Report

PURPOSE

To describe retinal findings and spectral-domain optical coherence tomographic (SD-OCT) features of a patient with Crimean-Congo hemorrhagic fever (CCHF) presenting as Purtscher-like retinopathy.

CASE REPORT

A 70-year-old woman presented with the emerging bilateral blurring of vision. She had been diagnosed with CCHF one week ago and hospitalized in another hospital for treatment of disease. Fundoscopy of the patient revealed cotton-wool spots, retinal whitening areas, and few retinal hemorrhages in a Purtscher-like configuration in both eyes. Spectral-domain optical coherence tomography revealed inner retinal hyperreflectivity corresponding to the cotton-wool spots in both eyes, and also showed subretinal fluid in the left eye. Without any treatment retinal lesions and inner retinal hyperreflectivity on SD-OCT regressed within one month.

CONCLUSION

Crimean-Congo hemorrhagic fever is known to cause mild ocular disease, and may also cause Purtscher-like retinopathy. It is important to aware of the ocular findings of CCHF.

Manifestaciones Oculares Posterior a Infecciones por Arbovirus

Introducción: Las infecciones por virus del Dengue, Chikungunya y Zika se han asociado a manifestaciones oculares como neurorretinitis, vasculitis, coroiditis, coriorretinitis, obstrucción venosa, edema macular, foveolitis, entre otras. Objetivo: El propósito del estudio es presentar una serie de casos de pacientes con afección ocular causada por infecciones por arbovirus. Metodología: Estudio es de carácter descriptivo, retrospectivo, en formato de reporte de serie de casos, describiendo los hallazgos de manifestaciones oculares secundarias a infecciones de arbovirus. Resultados: Se presentaron 13 pacientes con Dengue, 5 con Chikungunya y 4 con Zika. Doce de sexo masculino y diez femenino, con edades que oscilan entre 18 y 62 años. Conclusión: El Dengue es la infección con mayor recurrencia de manifestaciones oculares. El tratamiento con esteroides y anti-VEGF utilizado en base a la evidencia disponible demostró un impacto positivo en la evolución de la agudeza visual. El tratamiento conservador en pacientes con obstrucción de vena central de retina fue efectivo en aquellos que no presentaron la variante isquémica. La atrofia óptica fue la complicación más frecuente y presentó mejoría una vez el cuadro inflamatorio ha sido resuelto.

A Case Report on Dengue Encephalitis With Optic Neuropathy

The dengue virus is a type of Flavivirus, responsible for causing dengue fever. It mostly prevails in tropical and subtropical countries, with Southeast Asia reporting the greatest disease burden. The virus can affect a multitude of organ systems and the disease spectrum varies from a mild flu-like illness to severe dengue hemorrhagic fever or dengue shock syndrome. Two serotypes, DENV-2 and DENV-3, have been most frequently associated with neurological complications. We report a case of a 19-year-old male presented with signs and symptoms of encephalitis and optic neuropathy, following a diagnosis of dengue fever. Our diagnosis was supported by findings from brain MRI, electroencephalogram, fundoscopy, and a visual evoked potential test. A high-dose intravenous steroid therapy was given in pulses, which resulted in complete visual and neurological recovery. Dengue fever can present with atypical findings due to its propensity to affect multiple organ systems throughout the body. Neurological involvement is not uncommon and hence, clinicians should be aware of such systemic manifestations in order to diagnose promptly. Effective and timely treatment can reduce associated morbidity and result in complete recovery.

Ocular manifestations of dengue

PURPOSE OF REVIEW

There are an increasing number of publications related to dengue ophthalmic manifestations and multimodality imaging related to dengue. This review summarizes the current literature, describe ocular manifestations, current using of ocular imaging/investigations, and management of ocular dengue.

RECENT FINDINGS

Ocular manifestations of dengue can be present in many stages of dengue fever including after the resolution of systemic disease. Most cases of ocular dengue will exhibit an improvement in vision spontaneously over time. Multimodal imaging such as optical coherence tomography, optical coherence tomography angiography, near-infrared imaging, and microperimetry plays an important role in the diagnosis, follow-up, quantitative measure, and help to understand the disease progression.

SUMMARY

Dengue fever can lead to a variety of ocular manifestations. The mechanisms underlying dengue-related ocular complications remain unclear. Immune-mediated mechanisms and direct viral invasion are thought to play an important role. Ophthalmologists should carefully assess patients with dengue-related ophthalmic disease because some patients may have poor visual acuity and exhibit refractoriness to treatment. Treatment with systemic corticosteroids may benefit those patients with poor presenting visual acuity, progressive ocular symptoms, and lesions involving the optic nerve and/or threatening the macula.

Emerging Viral Infections Causing Anterior Uveitis

PURPOSE

To review the systemic and ocular manifestations of specific emergent viral infectious diseases relevant to the ophthalmologist with particular emphasis on anterior uveitis Methods: Review of literature.

RESULTS

Arboviral diseases are among the most important emergent and resurgent human infections, occurring mostly in tropical and subtropical zones, but appearing in virtually all regions of the world as a result of climate change, travel, and globalization. Arboviral infections are transmitted to humans by the bite of hematophagous arthropods, mainly mosquitoes. Systemic disease may range from asymptomatic to life-threatening. A wide variety of ocular manifestations, including uveitis, has been reported in association with these emerging viral diseases. Numerous viruses other than arboviruses also have been recently recognized as a potential cause of uveitis.

CONCLUSIONS

Proper clinical diagnosis of any emerging infectious disease is based on epidemiological data, history, systemic symptoms and signs, and the pattern of ocular involvement. The diagnosis is usually confirmed by detection of virus-specific DNA or antivirus antibodies in serum.

An unusual occurrence of stromal keratitis in dengue fever

Dengue is a mosquito-borne infection endemic in the tropical and subtropical regions of the world. Classic dengue fever is a self-limiting, influenza-like illness transmitted by Aedes aegypti mosquito. Ophthalmic manifestations though rare can involve both the anterior and posterior segments and are usually associated with the thrombocytopenic state. However, ophthalmic complications such as anterior uveitis and vasculitis suggest immune-mediated pathogenesis. Herein, we report a rare case of stromal keratitis and an unusual occurrence of simultaneous bilateral blindness following dengue fever in a young girl.

Clinical markers associated with acute laboratory-confirmed Dengue infection: results of a national epidemiological surveillance system

OBJECTIVE

To evaluate the association of several clinical markers with acute laboratory-positive Dengue Virus infection.

METHODS

A hospital-based case-control study was conducted in the state of Colima, Mexico, by using information from the National System of Epidemiological Surveillance (Sistema Nacional de Vigilancia Epidemiológica [SINAVE]) for Dengue. Data from 2 732 cases and 2 775 frequency-matched controls were analyzed. Odds Ratio (OR) and the 95 % Confidence Interval (CI), estimated by means of logistic regression models, were used.

RESULTS

The presence of skin rash (OR=1,7; 95 % CI 1,5-2,1), persisting vomiting (OR=1,8; 95 % CI 1,5-2,3) and increased capillary fragility (petechiae, ecchymosis, hematoma or positive tourniquet test; OR=1,8; 95 % CI 1,2-2,6) were associated with laboratory-positive infection.

CONCLUSIONS

Three clinical markers were significantly associated with an increased risk of acute laboratory-confirmed dengue infection. These findings would support accurate and timely diagnosis of dengue in laboratory-limited settings.

[Ocular manifestations of emerging arboviruses: Dengue fever, Chikungunya, Zika virus, West Nile virus, and yellow fever (French translation of the article)]

Arboviruses are viral diseases transmitted by mosquitoes and tics bites. They are a major cause of morbidity and sometimes mortality. Their expansion is constant and due in part to climate change and globalization. Mostly found in tropical regions, arboviruses are sometimes the source of epidemics in Europe. Recently, the Chikungunya virus and the Zika virus were responsible for very large epidemics impacting populations that had never been in contact with those viruses. There are currently no effective antiviral treatments or vaccines. Ocular manifestations due to those infections are thus more frequent and increasingly better described. They are sometimes, as with Zika, complicated by a congenital ocular syndrome. The goal of this review is to describe the ophthalmological manifestations of Dengue fever, Chikungunya virus, Zika virus, West Nile virus, and yellow fever.

Ocular manifestations of emerging arboviruses: Dengue fever, Chikungunya, Zika virus, West Nile virus, and yellow fever

Arboviruses are viral diseases transmitted by mosquitoes and tick bites. They are a major cause of morbidity and sometimes mortality. Their expansion is constant and due in part to climate change and globalization. Mostly found in tropical regions, arboviruses are sometimes the source of epidemics in Europe. Recently, the Chikungunya virus and the Zika virus were responsible for very large epidemics impacting populations that had never been in contact with those viruses. There are currently no effective antiviral treatments or vaccines. Ocular manifestations due to those infections are thus more frequent and increasingly better described. They are sometimes, as with Zika, complicated by a congenital ocular syndrome. The goal of this review is to describe the ophthalmological manifestations of Dengue fever, Chikungunya virus, Zika virus, West Nile virus, and yellow fever.

Case series of ocular involvement due to dengue. First reported cases in Guatemala

OBJECTIVE

Describe the ocular findings of a case series of 8 patients with a diagnosis of dengue.

MATERIALS AND METHODS

Review of clinical records and interviews with patients during outpatient visits, after informed consent was obtained and following the ethical standards of the Helsinki declaration. The patients were diagnosed with diagnosis by IgM / IgG dengue serology in whom ocular involvement was identified, between January and October 2017 in Retinal-vascular clinic of the "Dr. Rodolfo Robles Valverde Hospital", Guatemala.

RESULTS

The 8 patients, 5 men and 3 women from rural areas in Guatemala, were diagnosed with dengue by IgM / IgG serology with associated ocular involvement. The mean age was 32.3 years, with the oldest being 45 years old and the youngest being 20 years old. The ocular manifestations identified were, 4 neuroretinitis, 3 venous obstructions, 3 maculopathies, 2 serous detachments, 1 episcleritis, and 1 vasculitis. Two patients developed optic atrophy after resolving the neuroretinitis, and 1 developed peri-foveal scarring after the maculopathy. The ocular involvement was resolved in all patients after treatment, with an improvement in visual acuity, although in some cases damage to the visual field developed as a sequela of neuroretinitis.

CONCLUSION

It is necessary to consider dengue as an important differential diagnosis in an endemic country such as Guatemala. There are a large number of ocular manifestations due to direct involvement, as well as by an immune system reaction, and thus avoid considering the different ocular manifestations as idiopathic, or due to a different condition.

Molecular Responses of Human Retinal Cells to Infection with Dengue Virus

Recent clinical reports indicate that infection with dengue virus (DENV) commonly has ocular manifestations. The most serious threat to vision is dengue retinopathy, including retinal vasculopathy and macular edema. Mechanisms of retinopathy are unstudied, but observations in patients implicate retinal pigment epithelial cells and retinal endothelial cells. Human retinal cells were inoculated with DENV-2 and monitored for up to 72 hours. Epithelial and endothelial cells supported DENV replication and release, but epithelial cells alone demonstrated clear cytopathic effect, and infection was more productive in those cells. Infection induced type I interferon responses from both cells, but this was stronger in epithelial cells. Endothelial cells increased expression of adhesion molecules, with sustained overexpression of vascular adhesion molecule-1. Transcellular impedance decreased for epithelial monolayers, but not endothelial monolayers, coinciding with cytopathic effect. This reduction was accompanied by disorganization of intracellular filamentous-actin and decreased expression of junctional molecules, zonula occludens 1, and catenin-β1. Changes in endothelial expression of adhesion molecules are consistent with the retinal vasculopathy seen in patients infected with DENV; decreases in epithelial junctional protein expression, paralleling loss of integrity of the epithelium, provide a molecular basis for DENV-associated macular edema. These molecular processes present potential therapeutic targets for vision-threatening dengue retinopathy.

Neurological Manifestations of Dengue Infection

Dengue counts among the most commonly encountered arboviral diseases, representing the fastest spreading tropical illness in the world. It is prevalent in 128 countries, and each year >2.5 billion people are at risk of dengue virus infection worldwide. Neurological signs of dengue infection are increasingly reported. In this review, the main neurological complications of dengue virus infection, such as central nervous system (CNS), peripheral nervous system, and ophthalmic complications were discussed according to clinical features, treatment and possible pathogenesis. In addition, neurological complications in children were assessed due to their atypical clinical features. Finally, dengue infection and Japanese encephalitis were compared for pathogenesis and main clinical manifestations.

Multimodal Imaging in Dengue-Fever-Associated Maculopathy

Dengue fever can cause ocular complications that may not be easily identified during a regular eye examination. A high degree of suspicion and multimodal imaging will help characterize the lesions during acute stages of the infection.

Optical Coherence Tomography Angiography Findings in Dengue-Related Maculopathy: A Case Report

The ophthalmic manifestations of dengue fever include a visually impairing maculopathy, where patients are left with a central or paracentral relative scotoma. The authors present a case of a 26-year-old female patient returning from Thailand with unilateral reduction in visual acuity and a central scotoma associated with dengue fever. The authors report the use of the optical coherence tomography angiography (OCTA) as a noninvasive imaging platform to demonstrate its value in showing the persistent changes corresponding to the functional central scotoma in dengue-related maculopathy, which often cannot be visualized clinically or by standard OCT and fundus fluorescein angiography. [Ophthalmic Surg Lasers Imaging Retina. 2016;47:1057-1060.].

New associations of classic acute macular neuroretinopathy

PURPOSE

To describe novel underlying associations of classic acute macular neuroretinopathy (AMN).

METHODS

Multimodal imaging case series evaluating patients with classic AMN lesions and previously unreported underlying aetiologies.

RESULTS

Six patients were included (five women, one man, mean age 30±7 years). Mean distance best corrected visual acuity at initial presentation was 0.21±0.3 logMAR (mean Snellen acuity: 20/30, range 20/15-20/100) and at last follow-up visit 0.09±0.17 logMAR (Snellen acuity: 20/20, range 20/15-20/60). All cases but one had bilateral lesions and showed typical parafoveal hyporeflective lesions on infrared imaging, which corresponded to the hyper-reflectivity in the Henle's layer with attenuation of the external limiting membrane, the ellipsoid zone and interdigitation zone. Underlying diseases included thrombocytopenia and anaemia associated with dengue fever, acute lymphoblastic leukaemia, chronic kidney disease and ulcerative colitis, while Valsalva-like manoeuvre was found to be a potential trigger. Other novel associations included the use of lisdexamphetamine.

CONCLUSIONS

Classic AMN may be associated with leukaemia, dengue fever, ulcerative colitis and chronic kidney disease, probably as a result of chorioretinal hypoxia in the setting of thrombocytopenia and anaemia. Adrenergic agonists such as lisdexamphetamine may also contribute to the manifestation of AMN.

Ocular Pathology: Role of Emerging Viruses in the Asia-Pacific Region-A Review

The role of viral infections in ocular pathology varies greatly, involving all the components of the eye. Some viruses like herpes simplex, herpes zoster, adenovirus, enterovirus 70, influenza virus, human immunodeficiency virus, and cytomegalovirus are well-known for their role in ocular pathology. In recent years, emerging and resurging viral infections represent an important public health problem. The Asia-Pacific region has witnessed a number of pandemic and epidemic outbreaks caused by these viruses during the last 2 decades. The number of ocular complications being reported in patients of these viral infections has also increased significantly during this period. Ophthalmologists and physicians should be aware of ocular manifestations of newly emerging or resurging viral diseases. We conducted a review of the literature published during the last 20 years with the objectives of finding out outbreaks of emerging and reemerging viruses in the Asia-Pacific region and finding out any ocular involvement in these viral infections. An iterative search of the MEDLINE and the Google databases was made using the search terms emerging virus, ocular manifestations, ocular complications, Chikungunya, Dengue, Japanese encephalitis, West Nile fever, Kyasanur forest disease, Rift valley fever, Hantavirus, Henipavirus, Influenza virus, Enterovirus 71, and Asia-Pacific region, separately and with reported ocular involvement in combination. This review article discusses the epidemiology and the systemic and ocular manifestations of all emerging viral infections with reported ocular involvement in the Asia-Pacific region.

Retinal profile: a clinical indicator of severity in dengue fever in a suburban Indian environment

Purpose

To study the retinal changes in subjects suffering from dengue fever and check if these changes can be taken as sufficient indicator of severity and progression of the disease.

Patients/Methods

A detailed history was recorded of 118 patients on whom ocular examination, including direct ophthalmoscopy, indirect ophthalmoscopy and coloured fundus photography, was performed.

Results

Forty-seven percent of patients were found to have posterior segment abnormalities. Retinal vein dilatation or tortuosity was the most common finding followed by changes in the optic disc (8.4% of patients) and background haemorrhage (6.7% of patients). With increasing severity of thrombocytopenia, the proportion of patients with retinal abnormalities increased. In patients with grade I thrombocytopenia, no fundal abnormality was found. In those with grade II thrombocytopenia, fundal abnormality was found in 13.63% patients, whereas in the grade III category it was 27.90%.

Conclusions

Severity of thrombocytopenia had a significant association with retinal abnormalities. Occurrence of fundus changes increases with an increase in severity of thrombocytopenia. Fundus changes were found in all patients with grade IV thrombocytopenia.

Dengue: Moving from Current Standard of Care to State-of-the-Art Treatment

Treatment of dengue remains supportive in the absence of targeted antiviral therapy or approved vaccines. Responsive fluid management is key to preventing progression to shock or other severe manifestations. The dynamic natural history of dengue infection and its influence on hemodynamic homeostasis needs to be carefully considered in the planning of individualized therapy. Though largely self-limiting, the sheer burden of dengue disease on the global population will result in atypical manifestations especially in children, older adults, and comorbid patients. Management of these has not yet been systematized. The failure of recent randomized controlled trials to show utility for antiviral and immunomodulatory agents in dengue is disappointing. Vaccine candidates hold promise, but growing outbreaks require more robust, evidence-based management guidelines to inform clinicians, especially in novel epidemic situations.

Neurological complications of dengue virus infection

Dengue is the second most common mosquito-borne disease affecting human beings. In 2009, WHO endorsed new guidelines that, for the first time, consider neurological manifestations in the clinical case classification for severe dengue. Dengue can manifest with a wide range of neurological features, which have been noted--depending on the clinical setting--in 0·5-21% of patients with dengue admitted to hospital. Furthermore, dengue was identified in 4-47% of admissions with encephalitis-like illness in endemic areas. Neurological complications can be categorised into dengue encephalopathy (eg, caused by hepatic failure or metabolic disorders), encephalitis (caused by direct virus invasion), neuromuscular complications (eg, Guillain-Barré syndrome or transient muscle dysfunctions), and neuro-ophthalmic involvement. However, overlap of these categories is possible. In endemic countries and after travel to these regions, dengue should be considered in patients presenting with fever and acute neurological manifestations.

Clinical and laboratory features that discriminate dengue from other febrile illnesses: a diagnostic accuracy study in Rio de Janeiro, Brazil

BACKGROUND

Dengue is an acute febrile illness caused by an arbovirus that is endemic in more than 100 countries. Early diagnosis and adequate management are critical to reduce mortality. This study aims to identify clinical and hematological features that could be useful to discriminate dengue from other febrile illnesses (OFI) up to the third day of disease.

METHODS

We conducted a sectional diagnostic study with patients aged 12 years or older who reported fever lasting up to three days, without any evident focus of infection, attending an outpatient clinic in the city of Rio de Janeiro, Brazil, between the years 2005 and 2008. Logistic regression analysis was used to identify symptoms, physical signs, and hematological features valid for dengue diagnosis. Receiver-operating characteristic (ROC) curve analyses were used to define the best cut-off and to compare the accuracy of generated models with the World Health Organization (WHO) criteria for probable dengue.

RESULTS

Based on serological tests and virus genome detection by polymerase chain reaction (PCR), 69 patients were classified as dengue and 73 as non-dengue. Among clinical features, conjunctival redness and history of rash were independent predictors of dengue infection. A model including clinical and laboratory features (conjunctival redness and leukocyte counts) achieved a sensitivity of 81% and specificity of 71% and showed greater accuracy than the WHO criteria for probable dengue.

CONCLUSIONS

We constructed a predictive model for early dengue diagnosis that was moderately accurate and performed better than the current WHO criteria for suspected dengue. Validation of this model in larger samples and in other sites should be attempted before it can be applied in endemic areas.

Dengue retinochoroiditis

Dengue is a mosquito-borne infection caused by a flavivirus. I describe the ocular findings observed in two patients infected with dengue virus who presented with acute onset of loss of vision preceded by febrile illness, malaise, generalized fatigue headache, and maculopapular rash. Ophthalmologic evaluation in each patient revealed a normal anterior segment. Vitreous cells were noted in one patient. Ophthalmoscopy revealed multiple foci of retinochoroiditis, vasculitis, cotton-wool spots, and retinal hemorrhages. The healing of the lesion showed discrete atrophic and pigmented retinochoroiditic scars. Fluorescein angiography displayed early hypofluorescence and late hyperfluorescence suggestive of leakage. The healed scars showed late staining. The serologic testing showed elevated IgG antibodies, and one had high IgM antibodies to dengue virus. Ocular findings of dengue fever consist of multifocal areas of retinochoroiditis and may lead to loss of vision. In Saudi Arabia, dengue fever should be considered in the differential diagnosis of multifocal chorioretinal lesions and retinal vasculitis.

Ophthalmic complications of dengue Fever: a systematic review

Introduction

In recent years there has been a spurt of peer-reviewed publications on the ophthalmic complications of dengue fever. The authors aim to review the ocular manifestations, utility of relevant diagnostic tests, management, prognosis, and sequelae of dengue-related ocular complications.

Methods

A comprehensive literature search was conducted on Medline, PubMed, and Google Scholar databases. Only articles published or translated into the English language were considered, and key data from the full article of each paper was extracted and evaluated.

Results

The authors’ search yielded 29 articles. A total of 686 patients with a mean age of 33.4 years (range 14–73 years) were included. Blurring of vision was the most common presenting symptom followed by scotoma. Ocular findings were mostly seen in the posterior pole of the fundus, manifesting as retinal hemorrhages, macular edema, foveolitis, vasculitis, and optic neuropathy. Most patients with dengue-related ophthalmic complications recover spontaneously without any treatment. Patients with severe visual loss or bilateral involvement were treated with systemic steroids and occasionally immunoglobulins. Prognosis of dengue-related ophthalmic complications is favorable; almost all patients had normal or showed improvement in visual acuity and complete resolution of dengue ophthalmic complications was noted in almost all cases.

Conclusion

The pathological process of dengue ophthalmic complications is complex and clinical manifestations varied. Ophthalmic complications are usually seen in young adults who often present at the nadir of thrombocytopenia. Despite good recovery of vision and resolution of clinical signs in most patients, ophthalmologists and physicians should be aware and vigilant as isolated reports of cases of dengue ophthalmic complications with poor visual acuity refractory to treatment have been reported.

Prevalence of retinal hemorrhages in critically ill children

BACKGROUND

Retinal hemorrhages (RHs) with encephalopathy and subdural bleeding are considered suggestive of abusive head trauma (AHT). Existing studies describing RH focus on AHT and have potential selection bias. We undertook a prospective observational study to define the prevalence, distribution, and extent of RH in critically ill children.

METHODS

From February 2008 to December 2009, emergency intensive care admissions ≥ 6 weeks of age underwent dilated retinal examination by either a pediatric ophthalmologist or RetCam (retinal photograph) imaging after written informed consent. Patients with suspected or proven AHT, penetrating eye trauma, and elective admissions were excluded.

RESULTS

The prevalence of RH was 15.1% (24/159; 95% confidence interval [CI]: 9.5%-21%); 16/24 (66%) mild, and 2/24 (8%) moderate. Severe multilayered RH were seen in only 6 patients (3.7%), 3 with myeloid leukemia and sepsis, 2 with severe accidental head injury, and 1 with severe coagulopathy secondary to late onset hemorrhagic disease of newborn. There was no detectable impact of age, gender, seizures, coagulopathy or cardiopulmonary resuscitation on prevalence of severe multilayered RH; however, sepsis (odds ratio: 3.2; 95% CI: 1.3-8.0, P = .018) and coagulopathy (odds ratio: 2.8; 95% CI: 1.2-7.0, P = .025) were significantly associated with any RH. Only admission diagnosis was independently associated with severe multilayered RH on logistic regression.

CONCLUSIONS

RHs were seen in critically ill children with a prevalence of 15.1% (24/159); however, most were mild. Severe multilayered RH resembling those described in AHT were rare (6/24) and were only seen in patients with fatal accidental trauma, severe coagulopathy, sepsis with myeloid leukemia, or a combination of these factors.

Measuring the burden of arboviral diseases: the spectrum of morbidity and mortality from four prevalent infections

BACKGROUND

Globally, arthropod-borne virus infections are increasingly common causes of severe febrile disease that can progress to long-term physical or cognitive impairment or result in early death. Because of the large populations at risk, it has been suggested that these outcomes represent a substantial health deficit not captured by current global disease burden assessments.

METHODS

We reviewed newly available data on disease incidence and outcomes to critically evaluate the disease burden (as measured by disability-adjusted life years, or DALYs) caused by yellow fever virus (YFV), Japanese encephalitis virus (JEV), chikungunya virus (CHIKV), and Rift Valley fever virus (RVFV). We searched available literature and official reports on these viruses combined with the terms "outbreak(s)," "complication(s)," "disability," "quality of life," "DALY," and "QALY," focusing on reports since 2000. We screened 210 published studies, with 38 selected for inclusion. Data on average incidence, duration, age at onset, mortality, and severity of acute and chronic outcomes were used to create DALY estimates for 2005, using the approach of the current Global Burden of Disease framework.

RESULTS

Given the limitations of available data, nondiscounted, unweighted DALYs attributable to YFV, JEV, CHIKV, and RVFV were estimated to fall between 300,000 and 5,000,000 for 2005. YFV was the most prevalent infection of the four viruses evaluated, although a higher proportion of the world's population lives in countries at risk for CHIKV and JEV. Early mortality and long-term, related chronic conditions provided the largest DALY components for each disease. The better known, short-term viral febrile syndromes caused by these viruses contributed relatively lower proportions of the overall DALY scores.

CONCLUSIONS

Limitations in health systems in endemic areas undoubtedly lead to underestimation of arbovirus incidence and related complications. However, improving diagnostics and better understanding of the late secondary results of infection now give a first approximation of the current disease burden from these widespread serious infections. Arbovirus control and prevention remains a high priority, both because of the current disease burden and the significant threat of the re-emergence of these viruses among much larger groups of susceptible populations.

Dengue Fever presenting with macular hemorrhages

PURPOSE

To report ocular manifestations in cases of previously undiagnosed dengue fever.

METHODS

A retrospective study was done to evaluate the cause of sudden painless loss of vision in three cases with history of fever. Detailed systemic evaluation and ophthalmologic examination consisting of fundus photographs, fundus fluorescein angiography, and optical coherence tomography were done, where needed.

RESULTS

All three patients tested positive for dengue serology, which had been undiagnosed earlier. Retinal hemorrhages were found in all three patients, while one patient also showed evidence of retinitis-like lesions. He was treated with oral steroids and showed improvement in visual acuity over a period of 6 weeks. Two of the three patients had subhyaloid hemorrhages, which were seen to resolve spontaneously.

CONCLUSION

A significant subset of patients with mild form of dengue fever may go undiagnosed.

Clinical and laboratory features that differentiate dengue from other febrile illnesses in an endemic area--Puerto Rico, 2007-2008

Dengue infection can be challenging to diagnose early in the course of infection before severe manifestations develop, but early diagnosis can improve patient outcomes and promote timely public health interventions. We developed age-based predictive models generated from 2 years of data from an enhanced dengue surveillance system in Puerto Rico. These models were internally validated and were able to differentiate dengue infection from other acute febrile illnesses with moderate accuracy. The accuracy of the models was greater than either the current World Health Organization case definition for dengue fever or a proposed modification to this definition, while requiring the collection of fewer data. In young children, thrombocytopenia and the absence of cough were associated with dengue infection; for adults, rash, leucopenia, and the absence of sore throat were associated with dengue infection; in all age groups, retro-orbital pain was associated with dengue infection.

Optical coherence tomography patterns as predictors of visual outcome in dengue-related maculopathy

PURPOSE

The purpose of this study was to characterize the presentations, long-term outcomes, and visual prognostic factors in dengue-related maculopathy of 41 patients with dengue fever and impaired vision from dengue-related maculopathy in a retrospective noninterventional and observational series.

METHODS

The medical records of patients with dengue-related maculopathy diagnosed over 18 months between July 2004 and December 2005 at The Eye Institute, Tan Tock Seng Hospital and Communicable Disease Center, Singapore, were reviewed and followed up for 24 months. Visual acuity and symptoms (presence of scotoma on automated visual fields and Amsler grid) were correlated with optical coherence tomography evaluation.

RESULTS

Mean age was 28.7 years and there were more men (53.7%). The most common visual complaints were blurring of vision (51.2%) and central scotoma (34.1%). Most patients recovered best-corrected visual acuity >20/40. Optical coherence tomography showed 3 patterns of maculopathy: 1) diffuse retinal thickening; 2) cystoid macular edema; and 3) foveolitis. The visual outcome was independent of the extent of edema, but scotomata persisted longest in patients with foveolitis and shortest with those with diffuse retinal thickening.

CONCLUSION

Dengue-associated ocular inflammation is an emerging ophthalmic condition and often involves the posterior segment. Prognosis is variable. Patients usually regain good vision but may retain persistent scotomata even at 2 years despite clinical resolution of the disease. Optical coherence tomography patterns in dengue maculopathy are useful for characterization, monitoring, and prognostication of the visual defect.