ocular manifestations of the dengue fever virus include bilateral panuveitis that can occur after the acute systemic infection has resolved . in
we report a case of chronic , refractory bilateral panuveitis and uveitic glaucoma that began during the acute phase of the systemic infection and required treatment with oral steroids , multiple steroid - sparing agents , and surgical therapy for glaucoma .
a 22-year - old male with acute systemic dengue fever presented with bilateral pain and decreased vision .
management required oral steroids , mycophenolate mofetil , cyclosporine , and bilateral glaucoma valve implantation .
this case highlights the fact that dengue - associated panuveitis can begin in the acute stage of systemic infection and persist long after convalescence with progression to chronic bilateral panuveitis and uveitic glaucoma .
dengue - associated chronic panuveitis with uveitic glaucoma may be effectively managed with a combination of steroid - sparing oral immunosuppression and glaucoma surgery .
this is , to our knowledge , the first case of bilateral refractory dengue - associated panuveitis from the caribbean treated with combination steroid - sparing oral immunosuppression and bilateral glaucoma valve implantation .
dengue fever is caused by a virus in the flaviviridae family transmitted by the aedes aegypti and aedes albopictus mosquitoes .
the acute systemic phase of the infection is marked by pyrexia , malaise , and joint pain.1 the disease has been seen with increasing frequency in the past decade , particularly in the caribbean and parts of the developing world.2 myriad ocular manifestations have been reported , although the most common involve the posterior segment .
anterior segment involvement most commonly includes subconjunctival hemorrhages from thrombocytopenia during the acute phase of the infection.3 anterior chamber inflammation and iridocyclitis are less common , with ciliary congestion being noticeably absent in the majority of cases .
the time course of ocular involvement is frequently during the acute systemic phase of the infection , but has also been reported in some cases months after the primary infection has resolved.4 bilateral involvement is not common.5
a 22-year - old male of caribbean descent presented to our clinic with complaints of diminished vision , pain , and photosensitivity in the right eye ( od ) for several weeks .
he was currently suffering through the acute phase of dengue fever , which had been diagnosed by his primary care provider and confirmed with serology .
the patient had severe arthralgia , malaise , headache , pyrexia , and severe dehydration .
his dengue infection was confirmed with an elevated dengue fever igm performed at a contract reference laboratory ( labcorp , tampa , fl , usa ) on two separate occasions separated by several weeks .
his visual acuity , unimproved with refraction , was 20/80 od and 20/60 in the left eye ( os ) .
slit - lamp examination was notable for pronounced ciliary flush ; large , nongranulomatous keratic precipitates ; scattered anterior synechiae ; and 3 + anterior chamber cell od , while the slit - lamp exam of the left anterior segment was unremarkable except for mild ciliary flush .
there was an anterior vitritis present in both eyes , with significantly greater vitreous opacity od than os .
dilated fundus examination revealed a dense core vitritis , pars planitis , and significant neuroretinitis od , with a milder vitritis , mild neuroretinal folds , and mild pars planitis os .
both optic nerves appeared to have enlarged cup - to - disc ratios , although examination was limited due to vitreous opacity .
the presumptive diagnosis of bilateral panuveitis was made , and a comprehensive lab workup was initiated to locate any other causative etiology . after a normal chest radiograph , treatment was started with oral prednisone 80 mg orally once a day ( po qd ) , topical timolol , topical acetazolamide , and topical cycloplegia .
response to oral steroid was excellent , and a follow - up examination at 1 week showed nearly complete resolution of the vitritis and neuroretinitis .
the intraocular pressures , however , had risen to over 60 mmhg in both eyes , and there was persistent anterior chamber cell and flare od .
topical timolol was continued along with the initiation of an oral prednisone taper , and oral acetazolamide was added .
after another week with no change in oral prednisone dosage at 60 mg po qd , the vitritis and retinitis returned ou with worsening vision to cf od , 20/100 os , and persistently elevated pressures . while increasing the oral and topical steroid over the following 2 weeks was effective at resolving the inflammation , oral acetazolamide and maximal topical hypotensives were inadequate to control the rising intraocular pressures .
it was presumed that there was both an inflammatory glaucoma and a steroid - induced glaucoma response .
steroid - sparing therapy was a primary goal and , for this reason , mycophenolate mofetil was added and raised to 3 g per day.6,7 it was decided that the complete cessation of oral steroid was an important treatment goal given what we believed to be a mixed - mechanism glaucoma with some contribution from a hypertensive steroid response in a very young patient .
as the oral steroids were tapered , every time the dose was decreased to 60 mg po qd or lower , the inflammation again returned , and oral cyclosporine a was added in addition to the mycophenolate mofetil .
combination treatment with both mycophenolate mofetil and cyclosporine a allowed us to completely taper off oral prednisone and topical prednisolone without the recurrence of any inflammation .
the intraocular pressures decreased from the sixties to the forties , but still could not be medically managed to an acceptable range . in our practice , we generally prefer ahmed glaucoma valve implants as first - line drainage procedures in inflammatory glaucomas due to their long - term lower incidence of postoperative hypotony compared to baerveldt implants.8 bilateral ahmed implants ( fp7 ) were placed 4 days apart od and os .
the intraocular pressure was stabilized in the low teens without the need for topical or oral hypotensives .
visual acuity returned to 20/25 od and 20/20 os within 1 month of ahmed glaucoma implantation .
all anterior and posterior inflammation has to date been controlled without the need for further topical or systemic corticosteroid therapy .
dengue - associated uveitis with onset during the acute systemic phase of the infection can have long - term ocular effects including bilateral panuveitis . despite symptoms being reported in only one eye
multiple steroid - sparing agents can be used to control anterior and posterior inflammation when cessation of oral steroids is of primary importance .
early surgical intervention for mixed inflammatory and steroid - induced ocular hypertension can be a useful tool for managing high intraocular pressures and need not be delayed until the cessation of all inflammation .
management of these complicated cases benefits from an aggressive surgical approach , diligent pursuit of steroid - sparing agents , and collaboration with an experienced medical team to help guide and manage the careful use of multiple immunomodulatory agents .
 backgroundocular manifestations of the dengue fever virus include bilateral panuveitis that can occur after the acute systemic infection has resolved . in 
 most reported cases , the inflammation resolves with topical or systemic steroid therapy . 
 we report a case of chronic , refractory bilateral panuveitis and uveitic glaucoma that began during the acute phase of the systemic infection and required treatment with oral steroids , multiple steroid - sparing agents , and surgical therapy for glaucoma.findingsa 22-year - old male with acute systemic dengue fever presented with bilateral pain and decreased vision . 
 clinical examination revealed bilateral panuveitis with elevated intraocular pressures . 
 management required oral steroids , mycophenolate mofetil , cyclosporine , and bilateral glaucoma valve implantation.conclusionthis case highlights the fact that dengue - associated panuveitis can begin in the acute stage of systemic infection and persist long after convalescence with progression to chronic bilateral panuveitis and uveitic glaucoma . 
 dengue - associated chronic panuveitis with uveitic glaucoma may be effectively managed with a combination of steroid - sparing oral immunosuppression and glaucoma surgery . 
 this is , to our knowledge , the first case of bilateral refractory dengue - associated panuveitis from the caribbean treated with combination steroid - sparing oral immunosuppression and bilateral glaucoma valve implantation . 
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Introduction
Case report and discussion
Conclusion