DENGUE ASSOCIATED ACUTE ANGLE CLOSURE GLAUCOMA

 

Dengue is a mosquito-borne viral disease transmitted by Aedes aegypti. It is caused by one of four dengue virus serotypes (DENV-1 to DENV-4) from the Flavivirus family.

Ophthalmic complications range from subconjunctival hemorrhage and anterior uveitis to severe optic neuritis, retinal vasculitis, maculopathy, and panophthalmitis. Other diverse ocular effects include central retinal artery occlusion, bilateral vitreous hemorrhage, and uncommonly acute angle-closure glaucoma (AACG).

From: Pierre Filho Pde T

Dengue can directly inflame ocular anatomical tissues. The ocular structures have a particularly poor tolerance for inflammatory insult and disruption of vessel regulation due to their rich choroid and ciliary body vasculature. These structures are involved in vascular leakage, which causes forward displacement of the lens-iris diaphragm and narrowing of the anterior chamber angle, potentially leading to AACG. 

Edema in the ciliary body exacerbates the mechanical crowding of the angle structures, increasing outflow resistance through the trabecular meshwork.

AACG can also be precipitated by certain drugs used to treat dengue complications, or by medications that patients may have been taking before hospitalization. For example, sulfonamide-based antibiotics and anti-epileptics, such as topiramate, have been associated with drug-induced AACG due to ciliochoroidal effusion and angle closure. Severe dengue may cause systemic capillary leak syndrome, which acts synergistically with these pharmacologic triggers to worsen anterior segment crowding and precipitate glaucoma. In addition, systemic hypovolemia and electrolyte imbalances may exacerbate vascular instability in ocular tissues, leading to fluid extravasation and segmental edema.

Dengue may have an associated autoimmune-mediated inflammation in the anterior segment. Such immune responses would further augment ciliary body edema, interfere with aqueous production and outflow, and have detrimental effects on IOP regulation. In addition, genetic predispositions associated with human leukocyte antigen (HLA) alleles could participate in the autoimmune eye inflammation induced by the dengue virus and need to be further studied.

Hypothesized Sequence of Events:

Dengue virus infection generates a systemic inflammatory response mediated by cytokines. This, in turn, leads to vascular permeability and extravasation of fluid from the ciliary body, resulting in ocular edema. The resulting anterior segment anatomical changes lead to narrowing or closure of the anterior chamber angle, ultimately leading to AACG. Additionally, the dengue pathophysiology, medications, individual anatomical predispositions, and possibly autoimmune pathways provide a multifactorial basis for AACG development in dengue-affected individuals.

REFERENCE:

Al-Essa A (April 11, 2025) Acute Angle-Closure Glaucoma as an Ocular Complication of Dengue Fever: A Comprehensive Review. Cureus 17(4): e82119. doi:10.7759/cureus.82119.

Pierre Filho Pde T, Carvalho Filho JP, Pierre ET. Bilateral acute angle closure glaucoma in a patient with dengue fever: case report. Arq Bras Oftalmol. 2008 Mar-Apr;71(2):265-8. doi: 10.1590/s0004-27492008000200025. PMID: 18516431.