ACUTE LOSS OF VISION FOLLOWING DENGUE FEVER: AN UNUSUAL CASE OF MACULAR NEURORETINOPATHY. A SYSTEMATIC REVIEW
DOI:
https://doi.org/10.48047/HM.V8.2.2022.896-909Abstract
Purpose: Dengue fever (DF), caused by the dengue virus (DENV), is a rapidly expanding global health threat. While systemic features dominate its presentation, ocular manifestations are increasingly recognized, occurring in up to 10% of hospitalized patients. Among these, Acute Macular Neuroretinopathy (AMN) represents a rare, sight-threatening presentation characterized by acute-onset central or paracentral scotomas and distinct outer retinal changes. This review synthesizes the current literature on DENV-associated AMN, focusing on its immune-mediated microvascular pathophysiology, characteristic multimodal imaging findings, and therapeutic strategies.
Methods: A comprehensive literature search was conducted across major electronic databases (PubMed, Google Scholar, and Scopus) using keywords including "Dengue", "Dengue Maculopathy", "Acute Macular Neuroretinopathy", "Spectral-Domain Optical Coherence Tomography (SD-OCT)", and "Deep Capillary Plexus". Peer-reviewed case reports, retrospective cohort studies, and systematic reviews were analyzed.
Results: DENV-associated AMN primarily affects young to middle-aged adults, typically presenting 7 to 10 days after the onset of fever, closely mirroring the nadir of thrombocytopenia and the rise of the secondary immune response. The pathogenesis is driven by a combination of viral-induced endothelial activation (via non-structural protein 1, NS1), immune-complex deposition, and subsequent microvascular ischemia of the deep capillary plexus (DCP). Spectral-domain optical coherence tomography (SD-OCT) classically reveals hyperreflectivity at the level of the outer plexiform layer (OPL) and outer nuclear layer (ONL), followed by long-term disruption of the ellipsoid zone (EZ) and interdigitation zone (IZ). Optical coherence tomography angiography (OCTA) confirms a corresponding flow deficit in the DCP. While conservative management is suitable for mild cases, severe or progressive visual loss frequently warrants systemic, local, or intravitreal corticosteroid therapy.
Conclusions: DENV-associated AMN is an underdiagnosed, ischemic outer-retinopathy driven by post-viral hyperinflammation and microvascular impairment. Clinicians must maintain a high index of suspicion in dengue-endemic regions or in returning travelers presenting with acute visual symptoms. Early multimodal imaging is essential for diagnosis and prognosis.
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References
Li M, Zhang X, Ji Y, Ye B, Wen F. Acute macular neuroretinopathy in dengue fever: short-term prospectively followed up case series. JAMA Ophthalmol. 2015;133(11):1329–1333. doi:10.1001/jamaophthalmol.2015.2687.
Aggarwal K, Agarwal A, Katoch D, Sharma M, Gupta V. Optical coherence tomography angiography features of acute macular neuroretinopathy in dengue fever. Indian J Ophthalmol. 2017;65(11):1235–1238. doi:10.4103/ijo.IJO_969_18.
Bacsal KE, Chee SP, Cheng CL, Flores JV. Dengue-associated maculopathy. Arch Ophthalmol. 2007;125(4):501–510. doi:10.1001/archopht.125.4.501.
Teoh SC, Chee CK, Laude A, et al. Optical coherence tomography patterns as predictors of visual outcome in dengue-related maculopathy. Retina. 2010;30(3):390–398. doi:10.1097/IAE.0b013e3181bd2fc6.
Tavassoli S, Carreño E, Teoh SC, et al. Optical coherence tomography angiography findings in dengue-related maculopathy: A Case report. Ophthalmic Surg Lasers Imaging Retina. 2016;47(11):1057–1060. doi:10.3928/23258160-20161031-12.
Fang PP, Pfau M, Holz FG, Finger RP. Persistent visual loss in dengue fever due to outer retinal damage. Clin Exp Ophthalmol. 2017;45(7):747–749. doi:10.1111/ceo.12960.
Agarwal A, Aggarwal K, Dogra M, et al. Dengue-induced inflammatory, ischemic foveolitis and outer maculopathy: a swept-source imaging evaluation. Ophthalmol Retina. 2019;3(2):170–177. doi:10.1016/j.oret.2018.09.008.
Su DH, Bacsal K, Chee SP, et al. Prevalence of dengue maculopathy in patients hospitalized for dengue fever. Ophthalmology. 2007;114(9):1743–1747. doi:10.1016/j.ophtha.2007.03.054.
Rajurkar K, Thakar M. Optical coherence tomography angiography features of dengue retinopathy manifesting as acute macular neuroretinopathy, branch vein vasculitis and neurosensory detachment. Oman J Ophthalmol. 2021;14(3):179–182. doi:10.4103/ojo.ojo_210_21.
Ooi KG, Inglis H, Paramanathan N, Downie JA, Hennessy MP. Dengue fever-associated maculopathy and panuveitis in Australia. Case Rep Ophthalmol Med. 2016;2016:5704695. doi:10.1155/2016/5704695.
Bos PJ, Deutman AF. Acute macular neuroretinopathy. Am J Ophthalmol. 1975;80(4):573–584. doi:10.1016/0002-9394(75)90387-6.
Bhavsar KV, Lin S, Rahimy E, et al. Acute macular neuroretinopathy: a comprehensive review of the literature. Surv Ophthalmol. 2016;61(5):538–565. doi:10.1016/j.survophthal.2016.03.003.
Munk MR, Jampol LM, Cunha Souza E, de Andrade GC, Esmaili DD, Sarraf D, Fawzi AA. New associations of classic acute macular neuroretinopathy. Br J Ophthalmol. 2016;100(3):389–394. doi:10.1136/bjophthalmol-2015-306845.
Fawzi AA, Pappuru RR, Sarraf D, et al. Acute macular neuroretinopathy: long-term insights revealed by multimodal imaging. Retina. 2012;32(8):1500–1513. doi:10.1097/iae.0b013e318263d0c3.
Lee SY, Cheng JL, Gehrs KM, et al. Choroidal features of acute macular neuroretinopathy via optical coherence tomography angiography and correlation with serial multimodal imaging. JAMA Ophthalmol. 2017;135(11):1177–1183. doi:10.1001/jamaophthalmol.2017.3790.
Thanos A, Faia LJ, Yonekawa Y, Randhawa S. Optical coherence tomographic angiography in acute macular neuroretinopathy. JAMA Ophthalmol. 2016;134(11):1310–1314. doi:10.1001/jamaophthalmol.2016.3513.
Lim WK, Mathur R, Koh A, Yeoh R, Chee SP. Ocular manifestations of dengue fever. Ophthalmology. 2004;111(11):2057–2064. doi:10.1016/j.ophtha.2004.03.038.
Yip VC-H, Sanjay S, Koh YT. Ophthalmic complications of dengue fever: a systematic review. Ophthalmol Ther. 2012;1(1):2. doi:10.1007/s40123-012-0002-z.
Ng AW, Teoh SC. Dengue eye disease. Surv Ophthalmol. 2015;60(2):106–114. doi:10.1016/j.survophthal.2014.07.003.
Gupta A, Srinivasan R, Setia S, Soundravally R, Pandian DG. Uveitis following dengue fever. Eye (Lond). 2009;23(4):873–876. doi:10.1038/eye.2008.124.
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