Contact Lens Correction in Congenital Rubella Syndrome

Rubella, also called German measles, is a communicable viral illness that typically begins with mild fever and lymphadenopathy followed by a characteristic brief appearance of a generalized erythematous, maculopapular rash. Postnatal rubella is generally a mild, self-limited, and relatively benign infection. However, maternal rubella infection during the first trimester of pregnancy can be devastating and can result in miscarriage or the birth of an infant with a constellation of congenital anomalies referred to as congenital rubella syndrome. Prior to the introduction of the rubella vaccine, rubella was endemic worldwide. Since the introduction of the vaccine in 1969, rubella has become rare in North America and many developed countries[1].

Cataracts, congenital heart defects, and sensorineural deafness are the classic triad of congenital rubella syndrome [2]. Ophthalmic abnormalities including cataracts pigmentary retinopathy, infantile glaucoma, corneal clouding, chorioretinitis, iris hypoplasia, lacrimal drainage anomalies, and microphthalmia occur in approximately 40% of cases. Cataracts occur in approximately 25% of children with congenital rubella and are bilateral in approximately 50% of cases[3]. Congenital rubella syndrome is the most common cause of congenital cataracts[4]. Dense cataracts obscuring the visual axis produce deprivation amblyopia and require prompt surgical intervention and proper subsequent visual correction[5]. Contact lenses are a good option for managing refractive error induced from congenital cataracts[6]. 

Take for example a Hispanic female with congenital rubella syndrome who was  adopted by a US military family from Latin America at the age of 5 years. This young patient had a medical history of the classic findings of congenital rubella including cataracts, cardiac problems, and deafness. She also had bilateral cataract surgery before 1 month of age and was left aphakic. Additionally she had a history mental and psychomotor retardation, pigmentary retinopathy, and microphthalmia. At age 8 years, she formed a habit of repetitious facial and eye rubbing which caused bilateral central corneal abrasions and her soft contact lenses to continually dislodge from her eyes. Scleral contact lenses have good on-eye stability and been shown to protect the cornea from mechanical shearing action [7]. Thus, corneal scleral lenses were fitted on this patient in order to correct for aphakia and protect her cornea from further mechanical injury (FIGURE).

Figure 1. Corneo-scleral lenses corrected aphakia and prevented further mechanical injury to the cornea in this patient.

Managing patients with congenital rubella syndrome present challenges due to the  wide range of ophthalmic and systemic disorders. Aphakia from congenital cataracts is common in those affected from fetal viral disease and can be well corrected through contact lenses. Corneal scleral contact lenses should be considered in such cases where the child rubs their eyes creating mechanical injury to the cornea, and continual dislodgment of the corrective lens. Large diameter corneal scleral lenses have the benefit of good on-eye stability and are able to protect the eye from mechanical harm.

REFERENCE

1. Leung, A.K.C., K.L. Hon, and K.F. Leong, Rubella (German measles) revisited. Hong Kong Med J, 2019. 25(2): p. 134-141.

2. Cordier, A.G., et al., Pitfalls in the diagnosis of congenital rubella syndrome in the first trimester of pregnancy. Prenat Diagn, 2012. 32(5): p. 496-7.

3. Best, J.M., Rubella. Semin Fetal Neonatal Med, 2007. 12(3): p. 182-92.

4. Fang, J., et al., Case report: congenital rubella syndrome: a rare but persistent concern in the United States. J Perinatol, 2013. 33(11): p. 899-902.

5. Zetterstrom, C., A. Lundvall, and M. Kugelberg, Cataracts in children. J Cataract Refract Surg, 2005. 31(4): p. 824-40.

6. Lindsay, R.G. and J.T. Chi, Contact lens management of infantile aphakia. Clin Exp Optom, 2010. 93(1): p. 3-14.

7. Rathi, V.M., et al., Fluid-filled scleral contact lenses in vernal keratoconjunctivitis. Eye Contact Lens, 2012. 38(3): p. 203-6.

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