Swept-Source OCT Characterization of Dengue Retinopathy: Novel Grading System and Laminar Linear Retinal Hyperreflectivity

• Dengue fever causes posterior segment problems in 98.4% of eye complications. • Younger patients have higher risk of severe eye complications from dengue fever. • New retinal imaging marker identifies patients with severe dengue eye disease. • Novel grading system classifies three levels of dengue retinal disease severity. • Acute macular neuroretinopathy (AMN) is bilateral while AMN-like lesions are unilateral. To characterize dengue ocular disease in southern Chinese patients, identify foveolitis predictors, and investigate true acute macular neuroretinopathy (AMN) versus AMN-like presentations. We retrospectively analyzed 97 patients (190 eyes) with dengue ocular disease. Medical records, fundus photography, and swept-source optical coherence tomography (SS-OCT) were reviewed. Among 145 eyes with high-quality SS-OCT, we applied a novel grading system: Grade 1 (isolated vitritis), Grade 2 (vitritis with macular involvement without foveolitis), and Grade 3 (vitritis with macular involvement and foveolitis). Main outcomes included prevalence of ocular manifestations, OCT characteristics including angular sign of Henle fiber layer hyperreflectivity (ASHH) and laminar linear retinal hyperreflectivity (LLRH), independent foveolitis predictors, and differential characteristics between true AMN and AMN-like lesions. Patients aged 18-87 years (mean 54.8) with 41.2% male. Posterior segment involvement occurred in 98.4% (187/190) of eyes. Among 145 eyes, 55 (37.9%) had Grade 1, 53 (36.6%) had Grade 2, and 37 (25.5%) had Grade 3. Grade 3 associated with younger age (OR 0.955 per year, P = 0.030). ASHH and newly identified LLRH showed similar patterns: 18.9% in Grade 2 and 73.0% in Grade 3 eyes ( P < 0.001). True AMN (5.5%) presented bilaterally in female emmetropes, while AMN-like lesions (20.0%) were mostly unilateral, affecting both genders with myopia ( P < 0.001). Younger age independently predicts foveolitis, with LLRH as novel OCT feature for severe disease. We distinguished true AMN from AMN-like lesions based on laterality, gender distribution, and refractive status. These findings enhance our understanding of dengue retinopathy pathophysiology.