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