dr.

Ni Putu Ngurah Sri Yuliastini SJ

Consultant:
Dr. dr. AA Mas Putrawati T, Sp.M (K)
dr. Ketut Agus Somia, Sp.PD.KPTI
dr. Putu Sriwidyani, Sp.PA

INTRODUCTION
Dengue is a self-limiting, systemic viral infection transmitted by
Aedes aegypti mosquitoes1
It affects a large proportion of the population in tropical and
sub-tropical countries, causing high morbidity and mortality.

The clinical spectrum of disease includes asymptomatic

infection, mild dengue fever (DF), dengue hemorrhagic fever
(DHF), or dengue shock syndrome, which is frequently fatal
because of abnormal capillary permeability and plasma leakage

1. Ralapanawa DMPUK, Kularatne SAM. Current management of dengue in adult: a review. The International Medical Journal of Malaysia 2015;
14(1):1-14.

INTRODUCTION
Ophthalmic manifestations though rare and varied, range from
subconjunctival hemorrhage to optic neuropathy with the posterior
segment, particularly macular involvement, being the most
common2.
Some conditions due to dengue infection can cause irreversible
blindness and bilateral - requires an approach appropriate initial
treatment2.
This report
rare ocular manifestations in patients with DHF
makes us more aware of the possibility of ocular complications in
patients with dengue fever
2. Moreker S. Dengue eye disease. BMJ 2015; 351:4661.

CASE REPORT
Female, 16 years old
Chief complaint : painful and progressive swelling in the
right eye since two days. She admitted in Intensive Care Unit
of another hospital with history of fever, abdominal pain and
vomiting of seven days duration with one episode gum
bleeding and menorrhagia.
History of :
Eye disorder (-)
Using spectacles (-)
Injury (-)
Allergy (-)

CASE REPORT
NLP
VA
Edema, Proptosis
Palpebra
SCB, chemosis, Conjunctiva
CVI, PCVI
Hazy
Cornea
Hypopyon,
hyphema, lens
Cant be
evaluated

n+2/P

COA
Iris
Pupil
Lens
Vitreous
Fundus

IOP

O,1 ph NI
Normal
Normal
Clear
Normal
Round, regular
Reflex (+)
Clear
Clear
ONH WNL; aa/vv
1/3
Retina : normal
Macula reflex (+)
14 mmHg

Figure 1. Courtesy Sri Yuliastini, 2016

CASE REPORT
Ancillary Testing
WBC
Hb
HCT
Platelet
PTT
aPTT
INR
AST
ALT

:
:
:
:
:
:
:
:
:

10.7 x 103/L (4.0-10.0 103/L)

10.6 g/dL (11.0-16.0 g/dL)
29.8% (37.0-54.0%)
90 x 103/L (150-450 103/L),
14.5 (13.1)
37.6 (29.8)
1,24
56.8 U/L (11-27 UL)
23.9 U/L (11.0-34.0 U/L)

Albumin : 2.63 g/dL (3.20-4.50 g/dL)

BUN
: 4 mg/dl (8.00-23.00 mg/dl),
Creatinin : 0,37 mg/dl (0.50-0.90 mg/dl)
Natrium : 137 mmol/L (136-145 mmol/L)
Kalium : 3.3 mmol/L (3.50-5.10 mmol/L)
Dengue serology was positive for IgG dengue

CASE REPORT
Opthalmology Department

Internal Medicine Department

Assessment

Assessment

RE proptosis e.c retrobulbar hemorrhage

Health care associated pneumonia (HCAP)

and dengue hemorrhagic fever grade

Planning:
Consult to Neuro Opthalmology Division
RE pro Canthotomy and Cantholysis
Methylprednisolone 4x250 mg (3 days)
Mecobalamin 3x1 tab
Kalk 1x1 tab
RE pro USG
Other therapy Internal Medicine
Department

Planning:
IVFD RL 20 dpm
Paracetamol (500 mg tablet three times
daily)
Intravenous antibiotic (cefoperazone
sulbactam 2x1 gram)
Ambroxol tablet 2x1.

CASE REPORT
Ancillary Testing

retrobulbar hemorrhage extending to retro

orbita and periorbita of the right eye
(Figure 2. Courtesy Sri Yuliastini, 2016)

vitreous and subchoroidal hemorrhage

(Figure 3. Courtesy Sri Yuliastini, 2016)

CASE REPORT
NLP
VA
Edema, Proptosis
Palpebra
SCB, chemosis, Conjunctiva
CVI, PCVI
Hazy
Cornea

Cant be
evaluated

COA
Iris
Pupil
Lens
Vitreous
Fundus

n/P
IOP

O,1 ph NI
Normal
Normal
Clear
Normal
Round, regular
Reflex (+)
Clear
Clear
ONH WNL; aa/vv
1/3
Retina : normal
Macula reflex (+)
14 mmHg
Figure 4. Courtesy Sri Yuliastini, 2016

CASE REPORT
Opthalmology Department

Internal Medicine Department

Assessment

Assessment

RE proptosis e.c retrobulbar hemorrhage

Health care associated pneumonia (HCAP)

and dengue hemorrhagic fever grade

Planning:
Consult to Neuro Opthalmology Division
Methylprednisolone 4x250 mg (3 days)
Mecobalamin 3x1 tab
Kalk 1x1 tab
RE pro USG
Other therapy Internal Medicine
Department

Planning:
IVFD RL 20 dpm
Paracetamol (500 mg tablet three times
daily)
Intravenous antibiotic (cefoperazone
sulbactam 2x1 gram)
Ambroxol tablet 2x1.

CASE REPORT
NLP
VA
Edema, Proptosis
Palpebra
SCB, chemosis, Conjunctiva
CVI, PCVI
Hazy
Cornea

Cant be
evaluated

COA
Iris
Pupil
Lens
Vitreous
Fundus

n/P
IOP

O,1 ph NI
Normal
Normal
Clear
Normal
Round, regular
Reflex (+)
Clear
Clear
ONH WNL; aa/vv
1/3
Retina : normal
Macula reflex (+)
14 mmHg

Figure 5. Courtesy Sri Yuliastini, 2016

INTRODUCTION
Opthalmology Department

Internal Medicine Department

Assessment

Assessment

RE proptosis e.c retrobulbar hemorrhage

Health care associated pneumonia (HCAP)

and dengue hemorrhagic fever grade

Planning:
Methylprednisolone 4x250 mg (3 days)
Mecobalamin 3x1 tab
Kalk 1x1 tab
Other therapy Internal Medicine
Department

Planning:
IVFD RL 20 dpm
Paracetamol (500 mg tablet three times
daily)
Intravenous antibiotic (cefoperazone
sulbactam 2x1 gram)
Ambroxol tablet 2x1.

INTRODUCTION
Pathology Anatomy
Department

A. Large area of necrosis and hemorrhage in cavum vitreous, retina and choroid
(magnified 40x)
B. Inflammatory infiltrate especially neutrophil (*) (magnified 100x)
Figure 6. Courtesy dr. Sriwidyani, Sp.PA, 2016

DISCUSSION
The mechanism pathophysiology of dengue infection is controversial
and as yet unknown6.
Clinical manifestation is believed caused by direct viral invasion or
immune mediated complex process. Direct virus invasion of
endothelial cell, dendritic cell, monocyte and hepatocyte cell cause
apoptosis and cellular dysfunction. This condition causes a transient
immune response which leading to cytokine overproduction.
Overproduction of cytokine may trigger production of autoantibodies
that destroys platelets and endothelial cells6,7.

6Kapoor

K, Bhai S, John M, Xavier J. Ocular manifestation of dengue fever in east indian epidemic. Can J Opthalmology 2006;41(6):741-746.
S, Chan D, Nah G, Rajagopalan R, Laude A, Ang B, Barkham T, Chee C, Lim T, Goh K. A re-look at ocular complication in dengue fever and
dengue haemorrhagic fever. Dengue Bulletin 2006; 30: 184-190.
7Teoh

DISCUSSION
THEORY

CASE

WHO (1997)
undifferentiated fever, dengue fever and
dengue hemorrhagic fever.
Grade
DHF I

DHF II

DHF III

DHF IV

Clinical manifestation
Fever
Torniquet test positive
Non specific symptom
Grade I + spontaneous
bleeding (gum bleeding,
epistaxis, GI tract bleeding)
Grade II + circulatory
failure (hypotension, cold,
weak and rapid pulse)
Grade
II
+
shock
(undetectable
blood
pressure)

Laboratorium
Thrombocytopenia
Hemoconcentration
Thrombocytopenia
Hemoconcentration
Thrombocytopenia
Hemoconcentration
Thrombocytopenia
Hemoconcentration

16-year-old girl presented to Emergency

Room Sanglah Hospital with painful and
progressive swelling in the right eye
since two days. She admitted in
Intensive Care Unit of another hospital
with history of fever since Februari 17th
2015 (days 8), abdominal pain and
vomiting of seven days duration with
one episode gum bleeding and
menorrhagia

DISCUSSION
THEORY
Diagnosis of dengue infection can be made
on symptoms, signs and thrombocytopenia
in endemic area.
A definitive diagnosis of dengue infection
can be made only in the laboratory and
depends on isolating the virus, detecting
viral antigen or RNA in serum or tissues, or
detecting specific antibodies in the patients
serum3. In our patient, the diagnosis of
dengue infection based on history, clinical
examination and laboratory investigation3.

CASE

She admitted in Intensive Care Unit of

another hospital with history of fever,
abdominal pain and vomiting of seven
days duration with one episode gum
bleeding and menorrhagia
Laboratory
examination
showed
thrombocytopenia with platelet count
was 90.000 microliter and IgG dengue
was positive.

3.Ranjan S, Ranjan R. Dengue related ocular pathology: a review. International Journal of Biomedical Research 2013;04: 451-460.

DISCUSSION
THEORY
Proptosis in dengue patients can
secondary to panopthalmitis or due to
retrobulbar hemorrhage4,5.
Vitreous, choroid and retrobulbar
hemorrhage can occur spontaneously
because of thrombocytopenia with
coagulation defect, capillary fragility
and platelet dysfunction 4.

CASE

CT scan showed:
retrobulbar hemorrhage extending to
retro orbita and periorbita of the right
eye
Laboratory
examination
showed
thrombocytopenia with platelet count
was 90.000 microliter and IgG dengue
was positive.

4.Nagaraj K, Jayadev C, Yajmann S, Prakash S. Case report : an unusual ocular emergency in severe dengue. Middle East Affrican Journal of
Opthalmology 2014; 21(4):347-350.
5. Hussain I, Afzal F, Shabbir A, Adil A, Zahid A, Tayib M. Opthalmic manifestation of dengue fever. Opthalmology update 2012; 10(1):93-96

DISCUSSION
THEORY

CASE

Hemorrhagic manifestation in dengue infection can cause

by multifactorial factors. Thrombocytopenia and

abnormality of coagulation profile (PT, APTT)

have predictive value for spontaneous hemorrhage6,7.
Kapoor et al studies showed 90.7 % of patients with
ocular hemorrhage had significant thrombocytopenia

(<50.000/microliters).
There was no significance of spontaneous
hemorrhages

with

other

parameters

such

as

leucopenia, prolonged PTT and aPTT and

abnormality of liver function6.
Husein et al reported the patient with ocular
hemorrhage have platelet count range within
13.000-40.000/microliters5.

Anterior segment revealed proptosis, bloody

discharge,
lid
edema,
chemosis,
subconjunctival bleeding, partial thickness
rupture of conjunctiva, corneal edema, hypopion,

hyphema

and lens at anterior chamber. The rest

of the details were difficult to evaluate

B scan ultrasonography : vitreous and

subchoroidal hemorrhage
Computed tomography (CT): retrobulbar
hemorrhage extending to retro orbita
and periorbita.
Laboratory
examination
showed
thrombocytopenia with platelet count
was 90.000 microliter.

5. Hussain I, Afzal F, Shabbir A, Adil A, Zahid A, Tayib M. Opthalmic manifestation of dengue fever. Opthalmology update 2012; 10(1):93-96.
6. Kapoor K, Bhai S, John M, Xavier J. Ocular manifestation of dengue fever in east indian epidemic. Can J Opthalmology 2006;41(6):741-746.
7. Teoh S, Chan D, Nah G, Rajagopalan R, Laude A, Ang B, Barkham T, Chee C, Lim T, Goh K. A re-look at ocular complication in dengue fever and dengue
haemorrhagic fever. Dengue Bulletin 2006; 30: 184-190.

DISCUSSION
THEORY

Proptosis in dengue patients can secondary to

panopthalmitis or due to retrobulbar
hemorrhage4,5.
Vitreous, choroid and retrobulbar hemorrhage
can occur spontaneously because of
thrombocytopenia with coagulation defect,
capillary fragility and platelet dysfunction .

CASE
Anterior segment revealed proptosis, bloody
discharge, lid edema, chemosis, subconjunctival
bleeding, partial thickness rupture of conjunctiva,
corneal edema, hypopion, hyphema and lens at
anterior chamber. The rest of the details were
difficult to evaluate
Computed

tomography

hemorrhage

(CT):

retrobulbar

extending to retro orbita and

periorbita.
Histopathological analysis represented proliferation
and dilatation of vessels with infiltration of
polimorphonuclear cell with a large area of necrosis
and hemorrhage - panopthalmitis.

4. Nagaraj K, Jayadev C, Yajmann S, Prakash S. Case report : an unusual ocular emergency in severe dengue. Middle East Affrican Journal of
Opthalmology 2014; 21(4):347-350.
5. Hussain I, Afzal F, Shabbir A, Adil A, Zahid A, Tayib M. Opthalmic manifestation of dengue fever. Opthalmology update 2012; 10(1):93-96

DISCUSSION
THEORY

Ocular manifestation in dengue infection - rare.

Ocular manifestations reported to be associated with dengue infection are
mostly posterior segment, such as macular edema, vascular occlusion, vitreous
hemorrhage, optic neuropathy, chorioretinitis, vasculitis with retinal
hemorrhages, and cotton wool spots
Anterior segment manifestation has been mostly reported in the form of
subconjunctival hemorrhages and anterior uveitis.
Other very rare associations are ptosis and periorbital ecchymosis and globe
rupture, proptosis.

DISCUSSION
THEORY

DISCUSSION
THEORY

CASE

Retrobulbar hemorrhage is an ocular

emergency which is sight threatening8
The
goal of
treatment is
orbital
decompression to reduce the pressure on
important orbital contents like optic nerve and
vessels with performing digital massage,
osmosis agent intravenous or canthotomy and
cantholysis lateral. High dose of corticosteroid
is used to traumatic optic neuropathy caused by
compression9
Therapy
Mannitol intravena

Dose

Frequency

20% 2g/kg

Every 6 hours

Acetazolamide i.v

250 mg

Every 6 hours

Methylprednisolone i.v 250 mg

Timolol topical
0,25%

Every 6 hours

Canthotomy and cantolysis was also

done for orbital decompression. The
patient was managed symptomatically
with high dose steroid 4 x 250 mg
methylprednisolone intravenous for 3
days and lubricants.

Twice daily

8. Shek K, Chung K, Kam C, Yau H. Acute retrobulbar hemorrhage: an ophthalmic emergency. Emergency Medicine Australasia 2006;18:299-301.
9. Ballard C et al. Emergency lateral canthotomy and cantholysis : a simple procedure to preserve vision from sight threatening orbital hemorrhage.
Journal of Special Operations Medicine 2009;9(3):26-32

DISCUSSION
THEORY

CASE

Visual recovery corresponds to platelet

count improvement2.

Figure 7. Saranappa S. 2012.

Figure 9. Sriram S, Kavalakatt JA, Pereira

AL, Murty S. 2015.

Figure 8. Nagaraj K et al. 2014.

In due course of follow up, the

proptosis was reduced and the
vision remained no light
perception

DISCUSSION
THEORY
Povoa et al reported characteristic of histopathological
and structural aspect of the liver, lung, heart, kidney and
spleen of four cases in Brazil13.
Histopathological analysis of liver showed parenchyma and
circulatory damage. The hepatic parenchyma also
presented focal area of necrosis with presence of
mononuclear infiltrate. Histopathological analysis of
the lung showed septum thickening with an increase of

cellularity and the presence of mononuclear

inflammatory with hyperplasia of alveolar
macrophages. All cases showed diffuse area of
hemorrhage and edema. Histopathological analysis of

CASE

Histopathological
analysis
showed
circulatory
damages.
There
was
proliferation and vasodilatation of
vessels
with
polymorphnuclear
infiltration in choroid and sub choroid.
Large area of necrosis found in retina.
Vitreous filled with necrosis mass and
nuclear debris with mononuclear
infiltrated.

the heart showed myocarditis with infiltration of

mononuclear, vessels congestion, edema and extensive
area of hemorrhage. Analysis of kidney and spleen
presented circulatory and parenchyma damage with large
area showed vessel congestion, edema and hemorrhage14.

Other study reported 17 patients with dengue infection

presented edema and large area of hemorrhage of lung,
spleen, kidney, gastrointestinal tract, heart and brain13.

13. Povoa TF, Alves AMB, Oliviera CAB, Nuovo GJ, Chagas LA, Paas
MV. Plos One 2014; 9(4):1-16.
14. Idirisinghe KAP. Journal of Diagnostic Pathology 2013;8(1):50-58.

CONCLUSION
DHF is still a challenge in the medical world for its pathogenesis is
not well known.
Ocular manifestations of dengue infection is very rarely reported ,
but in some cases can cause blindness.

There is no guideline therapy and management of dengue

patients with ocular complications.
So we need the right diagnosis early and aggressive
supportive therapy to reduce the risk of morbidity in ocular
complications.