Dr.Ekta Rishi,Dr.Pukhraj Rishi,Dr.Jyotirmay Biswas
Panophthalmitis in Dengue is Infectious or Immunological?
Introduction
Ocular complications related to Dengue haemorrhagic fever range from 10-40%. Subconjunctival haemorrhage is most common ocular finding but there are reports of uveitis and occlusive vasculitis. Severe vision loss is rarely reported and in a study by Kapoor etal 54% patients had ocular complication and 7.5 % patients also had fundus involvement still there were no sever visual deterioration noted. Panophthalmitis is rarely reported in patients with Dengue haemorrhagic fever and athere are few published case reports. The present study aims to report a series of Dengue fever related panophthalmitis.
Material and methods:
A retrospective interventional case series of patients presenting with panophthalmitisfollowing recently diagnosed Dengue haemorrhagic fever. All patient Presented with Panophthalmitis following serologically proven Dengue fever at a tertiary eye care centre from 2006-2016. Electronic case records were searched and the History, haematological investigations, ultrasound / MRI imaging, histopathology was studied in detail. All these patients underwent a complete evaluation of duration of onset of symptoms from fever and its relation with nadir of thrombocytopenia and packed cell transfusion. All these patients were evaluated to rule out any bacterial infection by doing culture and PCR studies of aqueous tap , corneal scrapping or the eviscerated material. Histopathological studies were done on the eviscerated material to ascertain the cause as infective or immunological.
Results:
Panophthalmitis presentation was seen in 13 eyes of 11 patients Following Dengue fever. The mean age of these patients was 24 years ( SD 5.36). The main complaints of all patients wereredness, painful vision loss and proptosis all developing within few hours of receiving packed RBC following hospitalisation for reduced platelets counts ( 4000-8000/cuml). All the patients were serologically proven to have Dengue fever with DSV or Dengue NS1 antigen positivity and showed symptoms after a mean of 6 days of fever.
Corneal Involvement was seen in all eyes, 12/13 with corneal ringinfiltrate, Corneal melts in 3/13 eyes.
Hyphema and vitreous haemorrhage was seen in all eyes obscuring fundus evaluation, Globe perforation in 7/13 eyes.
On ultrasound examination, mean axial length of these eyes was 19.1 mm. Optic nerve enlargement with T sign was seen in all 13 eyes. Choroid was thickenes with mean choroidal thickness noted to be 3.2mm.Retinal detachment with subretinal haemorrhage was detected in 10/13 eyes.Features of Posterior Scleritiswas noted in 13/13 eyes. All eyes showed proptosis with features of exposure keratitis and 3/13 eyes were eviscerated. Histopathological studies of the the eviscerated material showed features of acute inflammation with necrosis and lymphocytic infiltration of all layers. Culture and PCR for DENV of eviscerated material was negative.
10 eyes managed conservatively with steroids and anti- inflammatory medications.Average follow-up was more than 6 months. All eyes with conservative management ended with phthisis bulbiand no perception of light.AC tap, vitreous biopsy, corneal and scleral scraping, culture of eviscerated material was all negative.
Discussion
Maculopathy, optic disc oedema, occlusive vasculitisare known complications following Dengue fever and can cause visual loss. Panuveitis is a rare manifestation. Panophthalmitis has been reported to present after 1 week of fever and patients with hospitalisation and reduced platelet counts. The vision loss following Dengue fever may be immune mediated as none of the reported cases found an active infection similar to our series. All patients in our series presented after platelet transfusion, we still don’t have an answer whether this is a transfusion reaction or thrombocytopenia sequelae. A study by Lee et al has discussed increased bleeding and slower platelet recovery following prophylactic platelet transfusion. Bleeding is maximum within 48 hours of nadir of thrombocytopenia as was seen in all our patients as well.
All these patients had acute inflammation with a sudden loss of vision and severe inflammation involving all the coats of the eye. None of these eyes were left with any useful vision and conservative management in form of steroids and tarsorraphy may be helpful.
Conclusion
Panophthalmitis following Dengue is vision threatening and non infective. It May be an immunologic response leading to thrombocytopenia or following thrombocytopenia and transfusion. It occurs following extensive thrombocytopenia during the early febrile illness.Steroids help in conservative management.
References
1 Kapoor HK, Bhai S, John M, Xavier J. Ocular manifestations of dengue fever in an East Indian epidemic. Can J Ophthalmol. 2006; 41(6):741-46.
2 Su DH, Bacsal K, Chee SP, Flores JV, Lim WK, Cheng BC et al; Dengue Maculopathy Study Group. Prevalence of dengue maculopathy in patients hospitalized for dengue fever. Ophthalmology 2007; 114 (9):1743-47;
3 Gupta A, Srinivasan R, Setia S, Soundravally R, Pandian DG. Uveitis following dengue fever. Eye (Lond) 2009; 23:873-76.
4 Saranappa SBS, Sowbhagya HN. Panophthalmitis in dengue fever. Indian Pediatr 2012; 49 (9):760.
5 Lee T H et al. Potential Harm of Prophylactic Platelet Transfusion in Adult Dengue Patients. Plos One Mar 2016.
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