Corticosteroid Dosing for Dengue Maculopathy
For a 30-year-old male with dengue fever and suspected dengue maculopathy presenting with blurred vision, initiate oral prednisolone at 0.5 to 1 mg/kg/day, tapered over 4 to 6 weeks. 1
Initial Assessment and Diagnosis
Before initiating corticosteroids, confirm dengue maculopathy through:
- Fundoscopic examination looking for dilated veins, hyperemic optic discs, flame and blot hemorrhages, soft exudates, and macular ischemia 2
- Optical coherence tomography (OCT) to identify vitreous cells, disruption of outer retinal layers (foveolitis), conical foveal elevation, or cystoid macular edema 1, 3
- Positive dengue serology (NS1 antigen or dengue antibodies) 2, 1
Corticosteroid Treatment Protocol
Oral Corticosteroid Therapy (First-Line)
- Dosing: Oral prednisolone 0.5 to 1 mg/kg/day 1
- Duration: Taper over 4 to 6 weeks 1
- Rationale: This dosing range has demonstrated resolution of vitreous cells, improvement in retinal layer integrity, and significant visual acuity improvement from mean 0.80 logMAR to 0.23 logMAR 1
The pathophysiology involves both inflammatory and ischemic components, with early corticosteroid therapy addressing the inflammation-driven vitreoretinal alterations 1. High-dose steroids have shown marked improvement in visual acuity and color vision in dengue maculopathy cases 2.
Alternative: Intravitreal Corticosteroid Therapy
For patients where systemic steroids are contraindicated or in elderly patients with bilateral severe disease:
- Intravitreal triamcinolone acetonide injection in affected eyes 4
- Timing: Can be performed at 3-day intervals between eyes if bilateral 4
- Outcome: Rapid resolution of foveal lesions and macular edema with restoration of normal foveal architecture within 6 weeks 4
Monitoring Requirements
During corticosteroid therapy, monitor for:
- Visual acuity improvement at regular intervals 1
- OCT imaging to assess resolution of vitreous cells and restoration of outer retinal layer integrity 1
- OCT angiography to evaluate persistent retinal plexus flow deficits, which correlate with initial visual acuity and may indicate permanent structural changes 1
- Standard corticosteroid complications including hyperglycemia, hypertension, and gastrointestinal effects 1
Critical Considerations
Indications for systemic corticosteroids in dengue maculopathy include: 5
- Poor presenting visual acuity
- Progressive ocular symptoms
- Lesions involving the optic nerve and/or threatening the macula
Expected outcomes:
- Most cases show spontaneous improvement over 8 weeks to 4 months 2, 3
- However, deep retinal plexus ischemia may persist despite corticosteroid therapy and cause permanent structural and functional changes 1
- Complete recovery is possible, particularly in younger patients with early treatment 2, 3
Common pitfall: Delaying treatment in patients with bilateral involvement or optic nerve involvement, as these cases benefit most from early corticosteroid intervention 5. While many cases are self-limiting 3, patients with significant visual impairment (worse than 20/40) or bilateral disease warrant aggressive treatment 2, 1.