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Letter

Congenital rubella syndrome: Global issue

Jyoti, Matalia DNB; Shirke, Sheetal MS; Matalia, Himanshu MS

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Journal of Cataract & Refractive Surgery: May 2015 - Volume 41 - Issue 5 - p 1127
doi: 10.1016/j.jcrs.2015.04.021
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Congenital rubella syndrome is a devastating consequence of rubella infection in pregnancy characterized by the combination of cardiac, ocular, and hearing defects, although the active rubella virus in a fetus can infect virtually any organ. Shah et al.1 discussed in detail the long-term postoperative outcomes after congenital cataract surgery in children with congenital rubella syndrome, thereby addressing this important preventable cause of congenital cataract that continues to be a significant factor for ocular morbidity in children in developing countries.2 Globally, rubella is the leading cause of preventable congenital defects, with more than 110 000 infants born with congenital rubella syndrome in 2008. Although, rubella is eradicated from most of the developed countries,3 clinicians should be aware of congenital rubella syndrome globally because there have been reports of rubella outbreaks in developed countries.4,5 Also, it remains a risk in susceptible immigrant populations from developing countries5 with low immunization against rubella. A study showed 54% of rubella cases in the United States were internationally imported or epidemiologically or virologically linked to importation.3

With the advent of improved microsurgical techniques and availability of good quality intraocular lenses (IOLs), there has been a changing trend in the management of rubella cataract in terms of type and timing of surgery. Implantation of IOLs, once considered to be a contraindication in rubella eyes, is now practiced. From late surgery, we had moved to early surgery at 3 to 4 months of age and now to as early as 1 month. The surgical technique has changed from a 2-stage procedure (first iridectomy at 6 months followed by lens removal at 2 years of age) to lensectomy with anterior vitrectomy and now to IOL implantation after primary posterior capsulectomy and vitrectomy.

In our unpublished data of 17 children (31 eyes) with congenital rubella syndrome having cataract surgery between 2007 and 2012, we found comparable results except for the fewer postoperative complications in our study, a finding probably related to a relatively shorter follow-up. The mean age at surgery was 5.47 months ± 6.88 (SD) (range 2 to 29 months), and the median follow-up was 24 months (range 3 to 71 months). Of the 17 children, all had heart disease, 7 had hearing problems, and 4 had developmental delay. Microcornea was the most common ocular feature, seen in 29 eyes, followed by salt-and-pepper retinopathy in 25 eyes. Postoperative complications included transient corneal edema in 4 eyes, capsule phimosis in 2 eyes, secondary glaucoma in 2 eyes, and postoperative fibrinous uveitis in 4 eyes. Of the 18 eyes with more than 1-year follow-up, 12 eyes (66.6%) attained a corrected distance visual acuity better than 6/60.

Although early surgical intervention and rehabilitation can improve the visual outcomes of cataract surgery in children with congenital rubella syndrome, overall visual outcomes might remain poor. This can be the result of ocular abnormalities such as corneal opacity, microcornea, microphthalmos, salt-and-pepper retinopathy, glaucoma, and amblyopia and associated systemic anomalies such as intellectual disability. Timely recognition and appropriate intervention with a multidisciplinary team approach would give the best chance of development to a child with congenital rubella syndrome.

References

1. Shah SK, Praveen MR, Vasavada AR, Vasavada VA, Carelli R, Trivedi RH, Rasoebala V. Long-term longitudinal assessment of postoperative outcomes after congenital cataract surgery in children with congenital rubella syndrome. J Cataract Refract Surg. 2014;40:2091-2098.
2. Eckstein M, Vijayalakshmi P, Killedar M, Gilbert C, Foster A. Use of intraocular lenses in children with traumatic cataract in south India. Br J Ophthalmol. 82, 1998, p. 911-915, Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1722709/pdf/v082p00911.pdf. Accessed April 17, 2015.
3. Papania MJ, Wallace GS, Rota PA, Icenogle JP, Fiebelkorn AP, Armstrong GL, Reef SE, Redd SB, Abernathy ES, Barskey AE, Hao L, McLean HQ, Rota JS, Bellini WJ, Seward JF. Elimination of endemic measles, rubella, and congenital rubella syndrome from the Western hemisphere; the US experience. JAMA Pediatr. 168, 2014, p. 148-155, Available at: http://archpedi.jamanetwork.com/article.aspx?articleid=1787786. Accessed April 17, 2015.
4. Centers for Disease Control and Prevention (CDC). Nationwide rubella epidemic — Japan, 2013. MMWR. 62, 2013, p. 457-462, errata, 62:558. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6223a1.htm. Errata available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6227a6.htm. Accessed both April 17, 2015.
5. Sheridan E, Aitken C, Jeffries D, Hird M, Thayalasekaran P. Congenital rubella syndrome: a risk in immigrant populations. Lancet. 2002;359:674-675.
© 2015 by Lippincott Williams & Wilkins, Inc.