Volume 75, Issue 5
  • ISSN: 0002-9637
  • E-ISSN: 1476-1645


Severe malaria is commonly misdiagnosed in Africa, leading to a failure to treat other life-threatening illnesses. In malaria-endemic areas, parasitemia does not ensure a diagnosis of severe malaria because parasitemia can be incidental to other concurrent disease. The detection of malarial retinopathy is a candidate diagnostic test for cerebral malaria. Malarial retinopathy consists of a set of retinal abnormalities that is unique to severe malaria and common in children with cerebral malaria. Its presence and severity are related to risk of death and length of coma in survivors. A large, prospective autopsy study of children dying with cerebral malaria in Malawi found that malarial retinopathy was better than any other clinical or laboratory feature in distinguishing malarial from non-malarial coma. However, visualization has to date relied on specialist examination techniques. Further studies are planned to evaluate the usefulness of funduscopy by general clinicians in a variety of settings across Africa. Studies of the retina and retinal blood vessels provide an unparalleled opportunity to visualize an infected microvasculature and its effect on neural tissue . This report reviews current knowledge of malarial retinopathy, including its use as a diagnostic test in the comatose child, and its value as a tool for research into the pathophysiology of cerebral malaria.


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  1. World Health Organization, 2000. Severe falciparum malaria. Trans R Soc Trop Med Hyg 94 : S1–S90.
  2. Reyburn H, Mbatia R, Drakeley C, Carneiro I, Mwakasungula E, Mwerinde O, Saganda K, Shao J, Kitua A, Olomi R, Greenwood BM, Whitty CJ, 2004. Overdiagnosis of malaria in patients with severe febrile illness in Tanzania: a prospective study. BMJ 329 : 1212–1217.
  3. Mwangi TW, Ross A, Snow RW, Marsh K, 2005. Case definitions of clinical malaria under different transmission conditions in Kilifi District, Kenya. J Infect Dis 191 : 1932–1939.
  4. Smith T, Charlwood JD, Kihonda J, Mwankusye S, Billingsley P, Meuwissen J, Lyimo E, Takken W, Teuscher T, Tanner M, 1993. Absence of seasonal variation in malaria parasitaemia in an area of intense seasonal transmission. Acta Trop 54 : 55–72.
  5. Kallander K, Nsungwa-Sabiiti J, Peterson S, 2004. Symptom overlap for malaria and pneumonia–policy implications for home management strategies. Acta Trop 90 : 211–214.
  6. English M, Punt J, Mwangi I, McHugh K, Marsh K, 1996. Clinical overlap between malaria and severe pneumonia in Africa children in hospital. Trans R Soc Trop Med Hyg 90 : 658–662.
  7. Taylor TE, Fu WJ, Carr RA, Whitten RO, Mueller JS, Fosiko NG, Lewallen S, Liomba NG, Molyneux ME, 2004. Differentiating the pathologies of cerebral malaria by postmortem parasite counts. Nat Med 10 : 143–145.
  8. Lewallen S, Taylor TE, Molyneux ME, Wills BA, Courtright P, 1993. Ocular fundus findings in Malawian children with cerebral malaria. Ophthalmology 100 : 857–861.
  9. Lewallen S, Bakker H, Taylor TE, Wills BA, Courtright P, Molyneux ME, 1996. Retinal findings predictive of outcome in cerebral malaria. Trans R Soc Trop Med Hyg 90 : 144–146.
  10. Hero M, Harding SP, Riva CE, Winstanley PA, Peshu N, Marsh K, 1997. Photographic and angiographic characterization of the retina of Kenyan children with severe malaria. Arch Ophthalmol 115 : 997–1003.
  11. Lewallen S, Harding SP, Ajewole J, Schulenburg WE, Molyneux ME, Marsh K, Usen S, White NJ, Taylor TE, 1999. A review of the spectrum of clinical ocular fundus findings in P. falciparum malaria in African children with a proposed classification and grading system. Trans R Soc Trop Med Hyg 93 : 619–622.
  12. Beare NA, Southern C, Chalira C, Taylor TE, Molyneux ME, Harding SP, 2004. Prognostic significance and course of retinopathy in children with severe malaria. Arch Ophthalmol 122 : 1141–1147.
  13. Hirneiss C, Klauss V, Wilke M, Kampik A, Taylor TE, Lewallen S, 2005. Ocular changes in tropical malaria with cerebral involvement: results from the Blantyre Malaria Project. Klin Monatsbl Augenheilkd 222 : 704–708.
  14. Browning DJ, 2004. Patchy ischemic retinal whitening. Ophthalmology 111 : 606–607.
  15. Schemann JF, Doumbo O, Malvy D, Traore L, Kone A, Sidibe T, Keita M, 2002. Ocular lesions associated with malaria in children in Mali. Am J Trop Med Hyg 67 : 61–63.
  16. Beare NA, Southern C, Kayira K, Taylor TE, Harding PS, 2004. Visual outcomes in children in Malawi following retinopathy of severe malaria. Br J Ophthalmol 88 : 321–324.
  17. Looareesuwan S, Warrell DA, White NJ, Chanthavanich P, Warrell MJ, Chantaratherakitti S, Changswek S, Chongman-kongcheep L, Kanchanaranya C, 1983. Retinal hemorrhage, a common sign of prognostic significance in cerebral malaria. Am J Trop Med Hyg 32 : 911–915.
  18. Newton CR, Winstanley PA, Marsh K, 1991. Retinal haemorrhages in falciparum malaria. Arch Dis Child 66 : 753.
  19. Haslett P, 1991. Retinal haemorrhages in Zambian children with cerebral malaria. J Trop Pediatr 37 : 86–87.
  20. Burton M, Nyong’o O, Burton K, John W, Inkoom E, Pinder M, Corrah T, Johnson G, Bailey R, 2004. Retinopathy in Gambian children admitted to hospital with malaria. Trop Doct 34 : 214–218.
  21. Beare NA, Southern C, Lochhead J, Molyneux ME, Lewallen S, Harding SP, 2002. Inter-observer concordance in grading retinopathy in cerebral malaria. Ann Trop Med Parasitol 96 : 105–108.
  22. Ritter AM, Muizelaar JP, Barnes T, Choi S, Fatouros P, Ward J, Bullock MR, 1999. Brain stem blood flow, pupillary response, and outcome in patients with severe head injuries. Neurosurgery 44 : 941–948.
  23. Carter BG, Butt W, 2005. Are somatosensory evoked potentials the best predictor of outcome after severe brain injury? A systematic review. Intensive Care Med 31 : 765–775.
  24. Krieger DH, Adams P, Schwarz S, Rieke K, Aschoff A, Hacke W, 1993. Prognostic and clinical relevance of pupillary responses, intracranial pressure monitoring, and brainstem auditory evoked potentials in comatose patients with acute supratentorial mass lesions. Crit Care Med 21 : 1944–1950.
  25. Jiang JY, Gao GY, Li WP, Yu MK, Zhu C, 2002. Early indicators of prognosis in 846 cases of severe traumatic brain injury. J Neurotrauma 19 : 869–874.
  26. Woodward H, Winterhalther K, Donders J, Hackbarth R, Kuldanek A, Sanfilippo D, 1999. Prediction of neurobehavioral outcome 1–5 years post pediatric traumatic head injury. J Head Trauma Rehabil 14 : 351–359.
  27. Plum F, Posner JB, 1984. Supratentorial causes of coma. The Diagnosis of Stupor and Coma. Third edition. Philadelphia: F.A. Davis Company, 87–133.
  28. Marshman LA, 2002. Brain stem blood flow, pupillary response, and outcome in patients with severe head injuries. Neurosurgery 51 : 848–849.
  29. Bullock MR, 2002. Brain stem blood flow, pupillary response, and outcome in patients with severe head injuries. Neurosurgery 51 : 849.
  30. Olumese PE, Adeyemo AA, Gbadegesin RA, Walker O, 1997. Retinal haemorrhage in cerebral malaria. East Afr Med J 74 : 285–287.
  31. Hanscheid T, 2003. Current strategies to avoid misdiagnosis of malaria. Clin Microbiol Infect 9 : 497–504.
  32. Marsh K, Forster D, Waruiru C, Mwangi I, Winstanley M, Marsh V, Newton C, Winstanley P, Warn P, Peshu N, 1995. Indicators of life-threatening malaria in African children. N Engl J Med 332 : 1399–1404.
  33. Makani J, Matuja W, Liyombo E, Snow RW, Marsh K, Warrell DA, 2003. Admission diagnosis of cerebral malaria in adults in an endemic area of Tanzania: implications and clinical description. QJM 96 : 355–362.
  34. Okubadejo NU, Danesi MA, 2004. Diagnostic issues in cerebral malaria: a study of 112 adolescents and adults in Lagos, Nigeria. Niger Postgrad Med J 11 : 10–14.
  35. Kochar DK, Shubhakaran, Kumawat BL, Thanvi I, Joshi A, Vyas SP, 1998. Ophthalmoscopic abnormalities in adults with falciparum malaria. QJM 91 : 845–852.
  36. Kochar DK, Shubhakaran, Kumawat BL, Vyas SP, 2000. Prognostic significance of eye changes in cerebral malaria. J Assoc Physicians India 48 : 473–477.
  37. Beare NA, Lewis DK, Kublin JG, Harding SP, Zijlstra EE, Molyneux ME, 2003. Retinal changes in adults with cerebral malaria. Ann Trop Med Parasitol 97 : 313–315.
  38. Lewallen S, White VA, Whitten RO, Gardiner J, Hoar B, Lindley J, Lochhead J, McCormick A, Wade K, Tembo M, Mwenechanyana J, Molyneux ME, Taylor TE, 2000. Clinical-histopathological correlation of the abnormal retinal vessels in cerebral malaria. Arch Ophthalmol 118 : 924–928.
  39. White VA, Lewallen S, Beare N, Kayira K, Carr RA, Taylor TE, 2001. Correlation of retinal haemorrhages with brain haemorrhages in children dying of cerebral malaria in Malawi. Trans R Soc Trop Med Hyg 95 : 618–621.
  40. Harding SP, Lochhead J, Movaffaghy A, Falsini B, Riva CE, Molyneux ME, 1999. Electroretinography of severe malaria in Malawian children. Invest Ophthalmol Vis Sci 40 : S148.
  41. www.ophthalmos.co.uk. Accessed April 12, 2006.

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  • Received : 17 Feb 2006
  • Accepted : 07 May 2006

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