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Ocular Manifestations Following Snakebite

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Ocular Manifestations Following Snakebite ISSN 0972-0200 Case Report Ocular Manifestations following Snakebite Tushya Omparkash, Seema Channabasappa, Aluri Balasubramanyam, Vittal Nayak Department of Ophthalmology, Vydehi Institute of Medical Sciences and Research Centre, Bangalore,Karnataka,India Abstract could not be recorded as the patient was unconscious. A 42 year old male presented with bilateral hemorrhagic retinopathy Fundus fluorescein angiography was not done due to acute following snakebite. Bilateral retinal hemorrhages are rare ocular renal failure. The medical records revealed limb swelling complications of snake envenomation. The clinical features are and petechial hemorrhages near the bite mark. The right leg described with fundus photographs. Patients with retinal hemorrhages and both arms showed severe swelling and subcutaneous are more likely to have central nervous system manifestations and an hemorrhages. There was no history of ocular complaints. The unfavorable outcome. Fundus photographs of such patients are rare patient had received the appropriate antivenom. His blood in literature. counts a day following the snakebite were: hemoglobin 11.1gram%, total white blood cells count 15,100/microliter, Keywords: snake bite, hemotoxin, neurotoxin, hemorrhagic retinopathy platelet count 28,000/ microliter, blood urea 35.2 milligram/ deciliter and serum creatinine 1.24 milligram/ deciliter. Introduction The subsequent blood counts were: hemoglobin 9.1gram%, All snakebite cases should undergo an ophthalmic white blood cells count 25,000/microliter, platelet count examination including dilated fundoscopy. Fundoscopy 10,000/microliter, blood urea 65.9 milligram/deciliter, serum may help in giving an idea about the type of toxin in an creatinine 1.65 milligram/deciliter. He was diagnosed as unknown snakebite and therefore aid in deciding treatment strategies. Fundus manifestations may have a bearing on the prognosis of the patient. Venomous snakebites may result in hemostatic or neurological dysfunction. Ocular complications are uncommon, however, if involved are often associated with neurological and vascular manifestations. Visual loss may result from neurological abnormalities, hemostatic abnormalities or from direct ocular inoculations.1 We report a patient with bilateral hemorrhagic retinopathy following snakebite. Hemorrhagic retinopathy is a rare ocular manifestation caused by snakebite. It has not been reported commonly with fundus photographs in the literature. Case History A 42-year-old male patient, gardener by occupation, Figure 1: Subconjunctival haemorrhage admitted in the intensive care unit of our hospital, was referred to the ophthalmology unit. The unconscious patient had a history of unknown snake bite at the lateral aspect of right foot two days back. Anterior segment examination of both eyes showed sub-conjunctival hemorrhage (Figure 1). Pupillary reaction to light was normal. The intraocular pressure recordings measured 19 mm Hg in right eye and 18 mm Hg in left eye. Fundus examination with pupillary dilatation showed bilateral blurred disc margins indicating disc oedema. Venous engorgement was also noted in both eyes. Pre-retinal and intra-retinal hemorrhages with Roth’s spots were observed bilaterally (Figure 2, 3). Visual acuity Access this article online Quick Response Code Website www.djo.org.in Figure 2: Right eye haemorrhagic retinopathy with disc edema DOI having disseminated intravascular coagulation with acute http://dx.doi.org/10.7869/djo.167 renal failure. MRI brain was advised but could not be done as the patient expired due to multiorgan failure. Del J Ophthalmol - Vol 26 No: 3 January-March 2016 188 E-ISSN 2454-2784 Case Report Conclusion Hemorrhages in the fundus are indicative of viperidae bites and hence urgent treatment in association with the hematologists may save the vision and life of the patient. Due to the proximity of the eye to the central nervous system (CNS), it would be logical to presume that hemorrhages in the fundus could indicate a bad prognosis for vision and life. However, a long-term clinical study of fundus evaluation in persons with snakebite would help to assess their CNS morbidity. The platelet count also often correlates with retinal findings. Cite This Article as: Omparkash T, Channabasappa S, Balasubrahmanyam A, Nayak V. Ocular Manifestations following Snakebite. Delhi J Ophthalmol 2016;26:188-9. Acknowledgements: None Date of Submission: 31.07.2015 Date of Acceptance: 09.11.2015 Conflict of interest: None declared Source of Funding: Nil Figure 3: Left eye haemorrhagic retinopathy with disc edema Discussion References Snake venoms are classified into neurotoxins (fasciculins, dendrotoxins, alpha neurotoxins) and cytotoxins 1. Bhalla A, Jain AP, Banait S, Jajoo UN, Kalantri SP. Central (phospholipases, cardiotoxins, hemotoxins). Snake venom, retinal artery occlusion: an unusual complication of snakebite. J Venom Anim Toxins incl Trop Dis 2004; 10:311-4. a complex mixture of proteins, affects hemostatic and 2. Marsh NA. Snake venoms affecting the haemostatic neurologic systems.2 Antihemostatic factors of viper mechanism: a consideration of their mechanisms, practical venoms can lead to acute fibrinolysis, severe reduction applications and biological significance. Blood Coagul of platelet levels and damage to vascular endothelium. Fibrinolysis 19945:399-410. 3. Takeshita T, Yamada K, Hanada M, Oda-Ueda N. Extraocular The breakdown of permeability barriers causes edema. muscle paresis caused by snakebite. Kobe J Med Sci 2003; 49:11- Peripheral neutrophil count can increase up to 20,000 5. cells/microliter or more in severely envenomed patients. 4. Menon V, Tandon R, Sharma T, Gupta A. Optic neuritis The proteolytic enzymes present in viper venom following snake bite. Indian J Ophthalmol 1997; 45:236-7. 5. Singh J, Singh P, Singh R, Vig VK. Macular infarction following (hyaluronidase and collagenase) may induce disruption viperine snake bite. Arch Ophthalmol 2007; 125:1430-1. of retinal veins and retinal hemorrhages. Although the 6. Hayreh SS. Transient central retinal artery occlusion following snake was not identified in our patient, one can presume viperine snake bite. Arch Ophthalmol 2008; 126:870-1 from the hemotoxic symptoms that the snake species could 7. Rao BM. A case of bilateral vitreous haemorrhage following snakebite. Indian J Ophthalmol 1977; 25:1-2. have been a member of Viperidae family. Swelling and bruising of the bitten limb resulted from increased vascular permeability produced by proteases, phospholipases, Corresponding author: membrane-damaging polypeptide toxins and endogenous Tushya Omparkash MBBS autacoids (histamine, 5-hydroxytryptamine and kinin). Junior Resident, Department of Ophthalmology, Vydehi Ophthalmic manifestations of snakebite have rarely been Institute of Medical Sciences and Research Centre, Bangalore, Karnataka, India reported in the literature. However, the common ocular Email: [email protected] neurological disturbance is ophthalmoplegia.3 Other ocular disturbances include keratomalacia, uveitis, glaucoma, central retinal artery occlusion, macular infarction, vitreous hemorrhage, optic neuritis, penetrating eye injury, globe necrosis and visual loss due to cortical infarction.1,3-7 The signs, symptoms and magnitude of pit viper envenomation depend on multiple factors, such as patient age, presence of underlying diseases, volume of venom injected with the bite and time interval between the bite and treatment. In this case, the hemotoxic effect of the snake venom resulted in disseminated intravascular coagulation. The patient developed subconjunctival hemorrhage with bilateral hemorrhagic retinopathy. There was no further evaluation as the patient expired due to multi organ failure. www.djo.org.in 189.
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