EyeRounds Online Atlas of Ophthalmology

Contributor: William Charles Caccamise, Sr, MD, Retired Clinical Professor of Ophthalmology, University of Rochester School of Medicine and Dentistry

*Dr. Caccamise has very generously shared his images of patients taken while operating during the "eye season" in rural India as well as those from his private practice during the 1960's and 1970's. Many of his images are significant for their historical perspective and for techniques and conditions seen in settings in undeveloped areas.

Category: Systemic Disorders

Smallpox: photographs of the ocular complications of the disease

Smallpox: photographs of the ocular complications of the disease

Smallpox: A brief history with photographs of the ocular complications of the disease.

By William Charles Caccamise Sr. , M.D.
Historically, four major causes of worldwide blindness have been smallpox, trachoma, leprosy, and vitamin A deficiency. However, for the past 25 years Smallpox has been absent from this group. Presumably the smallpox virus no longer exists except under two controlled laboratory situations. The last naturally occurring case of smallpox was reported in Somalia in October 1977. There were two additional cases of smallpox in 1978. However, they occurred in a laboratory setting in England. One smallpox patient died. In addition, the superintendent of the involved research laboratory committed suicide.

No cases of smallpox have been reported in America since an occurrence in Texas in 1949. During that outbreak in the Rio Grande Valley a prompt and efficient vaccination program limited the disease to 8 cases with one death. An earlier and more publicized smallpox incident occurred in New York City in 1947. That occurrence with its 12 cases with 2 deaths was well-controlled through proper public health measures and a cooperative citizenry - an example for any future outbreak of this disease. Within a period of one month more than 6.35 million people were vaccinated - 5 million of those within 2 weeks of Mayor O’Dwyer’s request for "universal" vaccination.

Now with the threat of bio-terrorism, it is essential that all ophthalmologists be thoroughly aware of the characteristics of ocular smallpox and the essentials for preventing corneal damage during a smallpox attack.

Unfortunately, recent reports in the eye literature seem to place greater emphasis on the eye dangers - although relatively infrequent - of vaccination rather than the more frequent realities of smallpox - blindness and death. Although most articles concerning vaccinia and the eye show vaccinia lesions of the lids - often with impressive albeit only temporary lid swelling - authenticated corneal pathology has rarely if ever been presented in recently vaccinated patients.

In 1980, the World Health Assembly (WHA) formally announced that - except for controlled laboratory stocks in America and in Russia - the death knell of the smallpox virus had been sounded. Worldwide there was no longer an indication for vaccination. In America, routine vaccination had already ceased in 1972.

The clinical elimination of the smallpox virus can be considered one of the most significant positive events in the history of man. This accomplishment through massive public health programs demonstrates the importance of public health not only for the general welfare but also for individual well-being. Countless individuals have been spared the horrors of smallpox infection and smallpox blindness. In his 1806 letter to Jenner who had initiated vaccination in 1796, Thomas Jefferson - in a manifestation of his great wisdom - presaged, " future generations will know by history only that this loathsome disease has existed ".

With the threat of bio-terrorism and its specter of a resurrected smallpox virus, there must be renewed interest in this disease. A bio-terrorism attack with the smallpox virus should be considered a battlefield - under the generalship of qualified public health officials. For individual patients there should be infectious disease experts assisted by other willing medical personnel. The latter must include ophthalmologists. To reduce eye damage to a minimum, each case of smallpox must be followed constantly and carefully for the status of the cornea. A break in the corneal surface is a condition that could lead to a fulminating corneal infection. Only the expertise of ophthalmologists will lead to a definitive diagnosis of incipient corneal involvement. Of course, in all smallpox patients the ophthalmologists would already have initiated preventive measures in an attempt to avoid such corneal damage - proper general hydration

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