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PHOTO ESSAY
Year : 2020  |  Volume : 68  |  Issue : 4  |  Page : 642-644

Severe acute onset dry eye following presumed Epstein.Barr viral infection


1 Cornea and Anterior Segment, Sunayan Advanced Eye Institute, Tamluk, West Bengal, India
2 CJ Shah Cornea Services/Dr G Sitalakshmi Memorial Clinic for Ocular Surface Disorders, Medical Research Foundation, Sankara Nethralaya, Chennai, Tamil Nadu, India

Date of Submission29-Jun-2019
Date of Acceptance22-Sep-2019
Date of Web Publication16-Mar-2020

Correspondence Address:
Dr. Sumana Chatterjee
Jeet Topaz, B-6, 459, Kalikapur Road, Kolkata - 700 099, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_1212_19

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Keywords: Conjunctivitis, dacryoadenitis, dry eye, EBV, Epstein-Barr virus


How to cite this article:
Chatterjee S, Iyer G, Srinivasan B, Agarwal S, Kuila J. Severe acute onset dry eye following presumed Epstein.Barr viral infection. Indian J Ophthalmol 2020;68:642-4

How to cite this URL:
Chatterjee S, Iyer G, Srinivasan B, Agarwal S, Kuila J. Severe acute onset dry eye following presumed Epstein.Barr viral infection. Indian J Ophthalmol [serial online] 2020 [cited 2020 Apr 4];68:642-4. Available from: http://www.ijo.in/text.asp?2020/68/4/642/280699



A 16-year-old girl presented with a right knee joint pain and severe redness with photophobia in both eyes for 3 weeks. Her uncorrected visual acuity was 20/60 in the right eye and 20/40 in the left eye. A slit lamp examination revealed an early shallowing of inferior fornices with fine bands of symblepharon inferolaterally, a significantly reduced tear meniscus height, and thick membranes that easily peeled off the tarsal surface [Figure 1] in both eyes. There was diffuse grade 3 punctate epitheliopathy with filaments, but the rest of the ocular examination was normal. An extensive rheumatological evaluation for joint pain was negative except for a raised erythrocyte sedimentation rate (ESR). A working diagnosis of postinfective (? viral) reactive arthritis was made. Viruses can act as adjuvants in the development of autoimmunity.[1] Infection by the Epstein-Barr virus (EBV) may be related to lacrimal gland lymphocytic proliferation of Sjögren syndrome, causing severe dry eyes.[2]
Figure 1: Slit lamp image of the right (a) and left (b) eye at the onset of the condition showing the presence of pseudomembranes, mucoid discharge, and severe dry eye with congestion. Evidence of superotemporal scarring in the left eye (c) at 1 month with the persistence of dry eye. At 3 months following punctal cautery, the right (d and f) and the left eye (e and g) showing an improvement in the dryness, as well as corneal staining

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As the ocular symptoms did not improve with lubricants and topical steroids and severe dry eye with no Schirmer's wetting persisted, she underwent punctual cautery at 8 weeks. Keratography revealed increased tear meniscus height with significant improvement in symptoms on the second day with improving epitheliopathy [Figure 1], [Figure 2], [Figure 3]. We investigated the patient further for infection by EBV, a possible etiology for the entire spectrum of manifestations.
Figure 2: Prepunctal cautery keratograph image of the right (a) and left (b) eye shows reduced tear meniscus height (0.07 and 0.14 mm, respectively) and distortion of mires because of severe dryness. Postpunctal cautery keratograph image of the right (c) and left (d) eye shows improved tear meniscus height (0.62 and 0.56 mm, respectively) with significantly improved mires

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Figure 3: The external appearance of the eye at onset (a) and at 2 months (b) after punctal cautery

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Serum IgG for EBV antibody to viral capsid antigen (VSA) level was > 150 U/mL with EBV Epstein-Barr nuclear antigen (EBNA) IgG level of 263 U/mL (considered positive if > 21.99).

EBV typically infects adolescents.[3] Arthralgias are the most common joint manifestation of EBV infection.[4] In an observational case report, severe keratoconjunctivitis sicca (KCS) was described postconjunctivitis because of EBV dacryoadenitis.[5]

At 4 months from the onset, the patient had visual acuity of 20/20 and was comfortable with Schirmer's wetting of 4 mm in both eyes. She resumed her daily activities with a maintenance dose of lubricants.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Costenbader KH, Karlson EW. Epstein-Barr virus and rheumatoid arthritis: Is there a link? Arthritis Res Ther 2006;8:204.  Back to cited text no. 1
    
2.
Pflugfelder SC, Wilhelmus KR, Osato MS, Matoba AY, Font RL. The autoimmune nature of aqueous tear deficiency. Ophthalmology 1986;93:1513-7.  Back to cited text no. 2
    
3.
Crawford DH. Biology and disease associations of Epstein Barr virus. Philos Trans R Soc Lond B Biol Sci 2001;356:461-73.  Back to cited text no. 3
    
4.
Feced Olmos CM, Fernández Matilla M, Robustillo Villarino M, de la Morena Barrio I, Alegre Sancho JJ. Afectación articular secundariaainfección por virus de Epstein-Barr. Reumatol Clin 2016;12:100-2.  Back to cited text no. 4
    
5.
Merayo-Lloves J, Baltatzis S, Foster CS. Epstein–Barr virus dacryoadenitis resulting in keratoconjunctivitis sicca in a child Am J Ophthalmol 2001;132:922-3.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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