Volume 84, Issue 1
  • ISSN: 0002-9637
  • E-ISSN: 1476-1645



To establish if assessment of malarial retinopathy in adult malaria using ophthalmoscopy by non-ophthalmologists has clinical and prognostic significance, 210 Bangladeshi adults were assessed by both direct and indirect ophthalmoscopy; 20 of 20 healthy subjects and 20 of 20 patients with vivax malaria showed no retinal changes, whereas in patients with falciparum malaria, indirect ophthalmoscopy revealed malarial retinopathy (predominantly retinal hemorrhages) in 18 of 21 (86%) fatal, 31 of 75 (41%) cerebral, 16 of 64 (25%) non-cerebral but severe, and 1 of 31 (3%) uncomplicated cases. Direct ophthalmoscopy missed retinopathy in one of these cases and found fewer retinal hemorrhages (mean difference = 3.09; 95% confidence interval = 1.50–4.68; < 0.0001). Severity of retinopathy increased with severity of disease ( for trend < 0.0001), and renal failure, acidosis, and moderate/severe retinopathy were independent predictors of mortality by both ophthalmoscopic techniques. Direct ophthalmoscopy by non-ophthalmologists is an important clinical tool to aid diagnosis and prognosis in adults with severe malaria, and indirect ophthalmoscopy by non-ophthalmologists, although more sensitive, provides minimal additional prognostic information.


Article metrics loading...

The graphs shown below represent data from March 2017
Loading full text...

Full text loading...



  1. Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJ, , 2006. Global and regional burden of disease and risk factors, 2001: systematic analysis of population health data. Lancet 367: 17471757.[Crossref] [Google Scholar]
  2. Maude RJ, Dondorp AM, Abu Sayeed A, Day NPJ, White NJ, Beare NAV, , 2009. The eye in cerebral malaria: what can it teach us? Trans R Soc Trop Med Hyg 103: 661664.[Crossref] [Google Scholar]
  3. Poncet F, , 1878. De la retino-choroidite palustre. Ann Ocul (Paris) 79: 201218. [Google Scholar]
  4. Lewallen S, Taylor TE, Molyneux ME, Wills BA, Courtright P, , 1993. Ocular fundus findings in Malawian children with cerebral malaria. Ophthalmology 100: 857861.[Crossref] [Google Scholar]
  5. Beare NA, Taylor TE, Harding SP, Lewallen S, Molyneux ME, , 2006. Malarial retinopathy: a newly established diagnostic sign in severe malaria. Am J Trop Med Hyg 75: 790797. [Google Scholar]
  6. 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: 11411147.[Crossref] [Google Scholar]
  7. Maude RJ, Beare NA, Abu Sayeed A, Chang CC, Charunwatthana P, Faiz MA, Hossain A, Yunus EB, Hoque MG, Hasan MU, White NJ, Day NP, Dondorp AM, , 2009. The spectrum of retinopathy in adults with Plasmodium falciparum malaria. Trans R Soc Trop Med Hyg 103: 665671.[Crossref] [Google Scholar]
  8. Tran TH, Day NP, Nguyen HP, Nguyen TH, Tran TH, Pham PL, Dinh XS, Ly VC, Ha V, Waller D, Peto T, White NJ, , 1996. A controlled trial of artemether or quinine in Vietnamese adults with severe falciparum malaria. N Engl J Med 335: 7683.[Crossref] [Google Scholar]
  9. 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: 105108.[Crossref] [Google Scholar]
  10. Harding SP, Lewallen S, Beare NA, Smith A, Taylor TE, Molyneux ME, , 2006. Classifying and grading retinal signs in severe malaria. Trop Doct 36 (Suppl 1): 113.[Crossref] [Google Scholar]
  11. World Health Organization, 2006. Guidelines for the Treatment of Malaria. Available at: http://www.who.int/malaria/docs/TreatmentGuidelines2006.pdf. Accessed January 23, 2008. [Google Scholar]
  12. 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: 143145.[Crossref] [Google Scholar]
  13. Kochar DK, Shubhakaran Kumawat BL, Thanvi I, Joshi A, Vyas SP, , 1998. Ophthalmoscopic abnormalities in adults with falciparum malaria. QJM 91: 845852.[Crossref] [Google Scholar]
  14. Looareesuwan S, Warrell DA, White NJ, Chanthavanich P, Warrell MJ, Chantaratherakitti S, Changswek S, Chongmankongcheep L, Kanchanaranya C, , 1983. Retinal hemorrhage, a common sign of prognostic significance in cerebral malaria. Am J Trop Med Hyg 32: 911915. [Google Scholar]
  15. Davis MW, Vaterlaws AL, Simes J, Torzillo P, , 1982. Retinopathy in malaria. P N G Med J 25: 1922. [Google Scholar]
  16. Haslett P, , 1991. Retinal haemorrhages in Zambian children with cerebral malaria. J Trop Pediatr 37: 8687.[Crossref] [Google Scholar]
  17. Newton CR, Winstanley PA, Marsh K, , 1991. Retinal haemorrhages in falciparum malaria. Arch Dis Child 66: 753.[Crossref] [Google Scholar]
  18. Maude RJ, Hassan MU, Beare NA, , 2009. Severe retinal whitening in an adult with cerebral malaria. Am J Trop Med Hyg 80: 881. [Google Scholar]
  19. Pongponratn E, Turner GD, Day NP, Phu NH, Simpson JA, Stepniewska K, Mai NT, Viriyavejakul P, Looareesuwan S, Hien TT, Ferguson DJ, White NJ, , 2003. An ultrastructural study of the brain in fatal Plasmodium falciparum malaria. Am J Trop Med Hyg 69: 345359. [Google Scholar]
  20. 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: 9971003.[Crossref] [Google Scholar]
  21. 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: 618621.[Crossref] [Google Scholar]
  22. Silamut K, Phu NH, Whitty C, Turner GDH, Louwrier K, Mai NHT, Simpson JA, Hien TT, White NJ, , 1999. A quantitative analysis of the microvascular sequestration of malaria parasites in the human brain. Am J Pathol 155: 395410.[Crossref] [Google Scholar]
  23. Newton CR, Kirkham FJ, Winstanley PA, Pasvol G, Peshu N, Warrell DA, Marsh K, , 1991. Intracranial pressure in African children with cerebral malaria. Lancet 337: 573576.[Crossref] [Google Scholar]
  24. Warrell DA, Looareesuwan S, Phillips RE, White NJ, Warrell MJ, Chapel HM, Areekul S, Tharavanij S, , 1986. Function of the blood-cerebrospinal fluid barrier in human cerebral malaria: rejection of the permeability hypothesis. Am J Trop Med Hyg 35: 882889. [Google Scholar]
  25. Adams S, Brown H, Turner G, , 2002. Breaking down the blood-brain barrier: signaling a path to cerebral malaria? Trends Parasitol 18: 360366.[Crossref] [Google Scholar]
  26. Looareesuwan S, Warrell DA, White NJ, Sutharasamai P, Chanthavanich P, Sundaravej K, Juel-Jensen BE, Bunnag D, Harinasuta T, , 1983. Do patients with cerebral malaria have cerebral oedema? A computed tomography study. Lancet 1: 434437.[Crossref] [Google Scholar]
  27. Newton CR, Kirkham FJ, Winstanley PA, Pasvol G, Peshu N, Warrell DA, Marsh K, , 1991. Intracranial pressure in African children with cerebral malaria. Lancet 337: 573576.[Crossref] [Google Scholar]
  28. Namutangula B, Ndeezi G, Byarugaba JS, Tumwine JK, , 2007. Mannitol as adjunctive therapy for childhood cerebral malaria in Uganda: a randomized clinical trial. Malar J 6: 138.[Crossref] [Google Scholar]
  29. Beare NA, Harding SP, Taylor TE, Lewallen S, Molyneux ME, , 2009. Perfusion abnormalities in children with cerebral malaria and malarial retinopathy. J Infect Dis 199: 263271.[Crossref] [Google Scholar]
  30. 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: 924928. [Google Scholar]
  31. White VA, Lewallen S, Beare NA, Molyneux ME, Taylor TE, , 2009. Retinal pathology of pediatric cerebral malaria in Malawi. PLoS ONE 4: e4317.[Crossref] [Google Scholar]
  32. Newton CR, Hien TT, White N, , 2000. Cerebral malaria. J Neurol Neurosurg Psychiatry 69: 433441.[Crossref] [Google Scholar]

Data & Media loading...

  • Received : 09 Apr 2010
  • Accepted : 17 Sep 2010
  • Published online : 05 Jan 2011

Most Cited This Month

This is a required field
Please enter a valid email address
Approval was a Success
Invalid data
An Error Occurred
Approval was partially successful, following selected items could not be processed due to error