Bob Ching Li Cheng, FRCS, 1, Kristine Bacsal, MD, 1, Soon-Phaik Chee, FRCOphth, 1, 2 – 1 Singapore Eye Research Institute, Singapore Eye Centre, 2 National University of Singapore

Purpose:

To describe an unusual case of severe visual loss secondary to dengue maculopathy.

Case Report:

A previously healthy 31 year-old Chinese woman presented with high fever and thrombocytopenia. 7 days after the onset of fever, she developed bilateral simultaneous and severe loss of vision with counting fingers visual acuity. There was severe arteriorlar sheathing, intra-retinal hemorrhages, disc hyperemia and marked macular swelling bilaterally. Fundus fluorescein angiography demonstrated diffuse and marked macular arteriolar staining and leakage of dye. Optical coherent tomography showed bilateral exudative macular detachment. Multifocal electro-retinography revealed markedly delayed foveal responses. Investigations showed a positive IgM level to dengue, mildly depressed C4 level, normal C3 level and negative results for anti-nuclear antibody, antidouble- stranded DNA, ANCA, anti-cardiolipin antibody, lupus anticoagulant and rheumatoid factor. Dengue virus DNA was not detected in blood by polymerase chain reaction on day 8.

Management:

Intravenous methylprednisolone instituted on day 7 resulted in initial visual improvement. This was reversed on day 9 when the visual acuity deteriorated again to pretreatment levels. Intravenous immunoglobulin together with intravenous hydrocortisone was given from day 9 to 14 with limited visual recovery.

Discussion:

As ocular symptoms presented only at day 7, ocular signs are more likely mediated by immune mechanisms than direct viral invasion. Antibodies generated against endothelial cells or immune complex deposition could lead to pathological changes observed in this patient.

Take-home message:

Patients with travel history to South East Asia may develop severe visual loss secondary to dengue maculopathy.