Keywords

Overview

  • Definition

    • Acute, highly contagious, airborne disease caused by Paramyxoviridae ribonucleic acid (RNA) virus

    • While rare in the United States after the measles, mumps, and rubella (MMR) vaccine was introduced in 1965, it is the fifth leading cause of death worldwide in children <5 years of age

  • Symptoms

    • Redness

    • Tearing

    • Blurry vision

    • Sudden loss of vision if + retinopathy, after rash

  • Laterality

    • Bilateral

  • Course

    • Self-limited; visual acuity may be affected by retinopathy initially, but generally recovery over weeks to months

  • Age of onset

    • Children and young adolescents

  • Gender/race

    • No gender or racial predilection

  • Systemic association

    • Congenital measles

      • Infection during third trimester results in abortion in 20% of women

      • Premature birth common

      • Cardiopathy, pyloric stenosis, genu valgum, deafness, mongolism, vertebral anomalies, cleft lip/palate, rudimentary ear

    • Acquired measles

      • Generalized rash for 3+ days

      • Classic Triad: Cough, coryza, and conjunctivitis

      • Possible complications: encephalitis, myocarditis, glomerulonephritis, otitis media, laryngotracheitis, pneumonia, disseminated intravascular coagulation, appendicitis

Exam: Ocular

External

  • Dacryostenosis (congenital measles only)

Anterior Segment

  • Mild, non-purulent papillary conjunctivitis

    • The most common ocular manifestation along with keratitis

    • +/− pseudomembrane

    • Stimson’s line: sharply demarcated transverse injection of lower lid margin

  • Epithelial keratitis

    • Begins at limbus and spreads centrally

    • Normal corneal sensation

    • Corneal scarring is cause of “post-measles blindness” worldwide

  • Hirschberg spots: Koplik’s spots at caruncle

  • Cataracts (congenital measles only)

Posterior Segment

  • Retinopathy with salt and pepper pattern involving the posterior pole and periphery

    • 1–2 weeks after onset of body rash

  • Neuroretinitis (blurry disc margin with possible star-shaped macular edema)

  • Attenuated arterioles

  • Scattered retinal hemorrhages

Exam: Systemic

  • Rash starts as pink macules behind ear, on forehead, and on neck, then rapidly becomes maculopapular and spreads downwards over 3 days to face, trunk, arms, and legs

  • Fever >101°F

  • Respiratory mucosal inflammation with petechial lesions of palate and pharynx

  • Koplik’s spots of buccal mucosa (small, bluish-white spots surrounded by a red areola): 1–2 days after rash onset

Imaging

  • FA

    • Windows defect from RPE changes

  • ERG

    • Normal or mildly reduced response

  • Perimetry

    • May be constricted

Laboratory and Radiographic Testing

  • Viral culture by swabbing of nasopharynx and conjunctiva

Differential Diagnosis

Congenital Measles

  • TORCH infections

    • Toxoplasmosis

    • Other infections (syphilis, parvovirus, varicella zoster, Zika)

    • Rubella

    • Cytomegalovirus

    • Herpes simplex

Acquired Measles

  • Retinitis pigmentosa

  • Toxoplasma retinochoroiditis

  • Vogt-Koyanagi-Harada syndrome

  • Other causes of neuroretinitis, including Bartonella, Lyme, leptospirosis, toxocariasis, and mumps

Treatment

  • No known treatment for congenital form

  • For acquired form, gamma-globulin 0.25 mL/kg body weight recommended for high risk patients (pregnant, child <1 year, immunosuppressed)

  • Topical NSAIDs and artificial tears to reduce conjunctival hyperemia

  • Topical antibiotics to prevent secondary bacterial keratitis

  • Systemic corticosteroids for cases of severe retinopathy

Referral/Co-management

  • Appropriate specialists for specific systemic complications