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Br J Ophthalmol. 2007 August; 91(8): 1084–1085.
PMCID: PMC1954787

Multifocal electroretinography in dengue fever‐associated maculopathy

Dengue fever is a viral disease transmitted by Aedes mosquitoes and is endemic in the tropics.1 The severity of dengue fever varies from mild non‐specific febrile illness to potentially fatal dengue haemorrhagic fever causing thrombocytopenia and shock. Patients with dengue fever may develop various ophthalmic manifestations causing visual loss, including macular oedema, macular haemorrhage, retinal vasculitis, “cotton‐wool” spots and optic disc swelling.2,3,4,5,6,7,8 We report the use of multifocal electroretinography (mfERG) in the assessment of a patient with dengue fever‐associated maculopathy in whom there were no clinical or angiographic abnormalities.

Case report

A 16‐year‐old girl with serologically confirmed dengue fever presented with left relative scotoma and reduced vision 7 days after the onset of fever. Her visual acuity was 20/20 and 20/40 in the right and left eye, respectively. Anterior segment examination was unremarkable. Fundus examination showed no abnormality and particularly no retinal haemorrhage. Optical coherence tomography demonstrated normal foveal depression and retinal thickness. Fluorescein and indocyanine green angiographies showed no abnormal leakage (fig 11).). Owing to the lack of clinical evidence of maculopathy, mfERG was performed to evaluate the macular function. mfERG demonstrated reductions in both N1 and P1 response amplitudes at the central and nasal macula, corresponding to the scotoma on perimetry (fig 22).). The patient was managed conservatively without treatment. After 1 year, her visual acuity remained at 20/40 with absence of fundus abnormality. Repeat mfERG recording showed persistent response abnormalities.

figure bj104240.f1
Figure 1 (A) Mid‐phase fluorescein angiography and (B) mid‐phase indocyanine green angiography of the left eye showing normal retinal and choroidal vasculature and the absence of abnormal hyperfluorescence, hypofluorescence or ...
figure bj104240.f2
Figure 2 (A) 30–2 Humphrey visual field of the left eye showing a centrocoecal scotoma. (B) Trace array of multifocal electroretinography showing reduction in the retinal responses at the central and nasal macula (grey area) corresponding ...

Comment

Ocular manifestations in dengue fever have been reported in several case series, and the commonest fundus findings are retinal haemorrhage and macular oedema.2,3,4,5,6,7,8 The onset of visual symptoms usually coincides with the resolution of fever and the lowest point of thrombocytopenia.6,7,8 In our patient and in previous reports, the interval between fever onset and ophthalmic symptoms was around 7 days.2,6,7,8 It has been postulated that this time interval corresponds to the time of antibody formation, deposition of immune complexes or production of autoantibodies.6

Visual disturbances in dengue fever‐associated maculopathy were suggested to be because of retinal haemorrhages, or retinal and choroidal vasculopathy.6,7,8,9 In our patient, visual loss developed in the absence of fundus abnormality including retinal haemorrhages or oedema, and without any angiographic abnormality. With the use of mfERG, retinal dysfunction in the central and nasal macula corresponding to the scotoma was detected. As both the N1 and P1 responses were reduced, the findings suggested that dengue fever‐associated maculopathy might be due to damage to the photoreceptors or bipolar cells. After 1 year, the mfERG abnormalities were found to be persisting in the absence of any visible fundus changes.

Our mfERG and clinical findings support the hypothesis that formation of autoantibodies against the retina could cause visual loss in dengue fever‐associated maculopathy, and that the functional changes could be irreversible. A similar clinical picture and mfERG findings may also occur in acute zonal occult outer retinopathy,10 and dengue fever‐related maculopathy could therefore be an acute zonal occult outer retinopathy‐like disorder. The use of mfERG enabled the diagnosis of dengue fever‐associated maculopathy, which would otherwise be difficult to confirm in the absence of clinical or angiographic abnormalities.

Footnotes

Competing interests: None declared

References

1. Rigau‐Perez J G, Clark G G, Gubler D J. et al Dengue and dengue haemorrhagic fever. Lancet 1998. 352971–977.977 [PubMed]
2. Wen K H, Sheu M M, Chung C B. et al The ocular fundus findings in dengue fever. Gaoxiong Yi Xue Ke Xue Za Zhi 1989. 524–30.30 [PubMed]
3. Haritoglou C, Dotse S D, Rudolph G. et al A tourist with dengue fever and visual loss. Lancet 2002. 3601070
4. Cruz‐Villegas V, Berrocal A M, Davis J L. et al Bilateral choroidal effusions associated with dengue fever. Retina 2003. 23576–578.578 [PubMed]
5. Sinqueira R C, Vitral N P, Campos W R. et al Ocular manifestations in dengue fever. Ocul Immunol Inflamm 2004. 12323–327.327 [PubMed]
6. Lim W K, Mathur R, Koh A. et al Ocular manifestations of dengue fever. Ophthalmology 2004. 1112057–2064.2064 [PubMed]
7. Chlebicki M P, Ang B, Barkham T. et al Retinal haemorrhages in four patients with dengue fever. Emerg Infect Dis 2005. 11770–772.772 [PubMed]
8. Chan D P, Teoh S C, Tan C S. et al Ophthalmic complications of dengue. Emerg Infect Dis 2006. 12285–289.289 [PubMed]
9. Su D H, Chee S P. Maculopathy in dengue fever. Emerg Infect Dis 2006. 12707
10. Yasuda K, Shimura M, Noro M. et al Clinical course of acute retinal zonal occult outer retinopathy in visual field and multifocal electroretinogram. Br J Ophthalmol 1999. 831089–1090.1090 [PMC free article] [PubMed]

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