Rabies in Ophthalmology

Imagine getting bitten by a dog that was acting unusually: frothing at the mouth and behaving far more aggressively than normal. The bite might be small and relatively unnoticeable, so you treat the wound and put the strange incident of the frothy dog behind you.

By the time the first symptoms begin to manifest (i.e., fever, anxiety and headache), it’s already too late … you are going to die from rabies. This is because the virus has traveled from the site of the wound into your nervous system, and finally, into your brain. Then comes the confusion, hydrophobia, frothing at the mouth, difficulty breathing and swallowing, muscle spasms, then paralysis. Finally, death comes while you’re restrained hand-and-foot in a hospital bed.

Such is the usual course of rabies in patients who do not access treatment immediately after being bitten or scratched by a rabid animal. Ever wonder where legends about creatures like werewolves and vampires come from? Rabies is most likely the answer.

By now, you might be wondering why an ophthalmology magazine would be covering this terrifying disease…

The Bite is Worse Than the Bark

Well, wonder no more: There are two ways rabies can come across an ophthalmologist’s “desk.” The first is an injury to the eye that passes on the rabies virus, usually caused by a scratch wound (rather than a bite). The second, and far less likely way, occurs when preoperative screening doesn’t pick up the rabies virus in infected corneal tissue, which is then transplanted into a patient.

Of the first variety, a good example is Rabies Prophylaxis After an Animal Attack That Caused a Ruptured Eye and a Traumatic Cataract: A Case Report.¹ A 33-year-old man in Turkey was attacked by a rabid bobcat. His injuries included a ruptured globe with corneal laceration, two iris sphincter tears, and a ruptured anterior capsule with a traumatic cataract, as well as scratches to his arm. 

Rabies post-exposure treatment was applied immediately, and the patient’s wounds were washed with soap and water and a virucidal agent. This was followed by primary closure of the corneal laceration and an anterior chamber washout, the application of a topical fluoroquinolone antibiotic, a steroid (prednisolone acetate 1%), and cyclopentolate hydrochloride. Happily, the patient made a full recovery: He did not go on to develop symptoms of rabies, and postoperatively, he achieved an uncorrected visual acuity of 20/50, and best-corrected visual acuity of 20/20.

Receive an Organ, Get a Virus

Rabies infection via organ transplantation is extremely rare — but it does happen. A good case study is Survival After Transplantation of Corneas From a Rabies Infected Donors,² authored by a group of researchers from Johannes Gutenberg University in Mainz, Germany. They examined corneal recipients from a rabies-infected donor (as the patients actually survived).

Two patients received corneas from the same multiorgan donor. Six weeks after the procedure, three of the donor’s organ recipients became symptomatic and the rabies virus was confirmed in tissue from the donor’s central nervous system. As a result, both of the corneal recipients underwent active and passive postexposure treatment, and the corneal buttons were replaced. After this aggressive intervention, the corneas, skin biopsies, and serum and saliva samples were all examined — and happily, no rabies was detected.

If there’s a conclusion to be drawn here then it is this: Post-exposure treatment works. If there’s even the slightest chance that a patient with an ocular injury (or a cornea transplant recipient) could have come into contact with rabies, act fast and treat. This is particularly true in countries like India, China and the Philippines, where rabies is more prevalent.

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