Postfever uveo-retinal sequelae as a part of a multi-organ systemic involvement – Ophthalmologists should have the eyes

Dear Editor, We profusely thank the Maharashtra Ophthalmological Society for having awarded us the “Maharashtra Ophthalmological Society International Hero” award; for our work on “Post Fever Uveoretinal Sequelae” (PFURS), which was previously awarded the “Dr. Carl Herbort Travel Grant Award for Best Free Paper” at Emirates Uveitis and Retina Update and Annual Meeting of Uveitis Society (India) at Abu Dhabi in September 2023. We would like to humbly request you to allow us an opportunity to once again highlight PFURS, also known as Postfever Retinitis. PFURS represents various uveo-retinal manifestations seen after an episode of fever in an immunocompetent individual.[1] These may be the result of direct invasion by the pathogen or by indirect mechanism mediated through immune mechanisms.[1-3] To us, ophthalmologists, the most challenging reason to be aware of PFURS arises when a patient admitted to the intensive care unit (ICU) of a multi-specialty general hospital, with pyrexia of unknown origin, develops a painless loss of vision, and be able to differentiate it from other causes of retinitis or retinopathy, like a 28-year-old fisherman from Maharashtra we encountered. He had systemic features of multi-organ affection – liver (transaminitis – 69 IU/L); cardiac myositis – ejection fraction (25%); arthropathy; and rhabdomyolysis causing acute kidney injury, with raised creatinine (2.5 m/dl), creatine phosphokinase (1847 U/L), and lactate dehydrogenase (471 U/L) levels; all thought to be postviral illness, with all routine reports for fever, including those for dengue, malaria, and leptospirosis, antinuclear antibody and antineutrophil cytoplasmic antibody being inconclusive. Notably, his erythrocyte sedimentation rate (42 mm/h) and CRP (301 mg/L) were raised. He had a loss of vision, 4 days after the onset of fever, and bedside examination in the ICU showed Grade II vitritis and bilateral disc edema with retinal vasculitis with areas of intense “retinitis” with ischemic retinal whitening (OU) akin to “cotton wool spots” and a hypopyon in a white eye (OS) [Figure 1a]. His vision was reduced to counting fingers 2–3 feet, with accurate projection of rays in both eyes. He was diagnosed by us to have PFURS and, after a multi-specialty clearance, was started on intravenous dexamethasone and oral doxycycline with oral valacyclovir, which was guided by our previous experience and available literature.[1-3] This strategy, along with a multi-specialty supportive treatment in the ICU, led to improvement in his entire general and ocular condition. He achieved a best-corrected vision of finger counting at 3 m and 20/40 in OD and OS, respectively, with reversal of disc edema and beginning of the resolution of all the fundus lesions by the 6th day of treatment [Figure 1b and c]. While the retinal features of PFURS are those of intense retinal ischemia as substantiated by reports of optical coherence tomography angiography,[4,5] these may be at times a part of a massive systemic inflammatory ischemic process; as in our patient and in such scenarios only the ophthalmologist may be “blessed” to actually witness and help interpret such a process; by a simple fundus examination; as we could in this patient; mandating widespread awareness of PFURS to all ophthalmologists.Figure 1: (a) The left eye of a 28-year-old male with postfever uveo-retinal sequelae (PFURS) showing a hypopyon in a white eye, (b) Montage fundus picture of the right eye of a 28-year-old male showing residual lesions of PFURS; one of which is involving the fovea, (c) Montage fundus picture of the left eye of a 28-year-old male showing residual lesions of PFURSDeclaration 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.