Dr Harish Kumar (K19635 )
- Malaria is the most common parasitic disease in INDIA and remain today as large burden on tropical communities such as JHARKHAND AND BIHAR.
- Cerebral malaria is the leading cause of death in JHARKHAND.
- Approximately 2/3rd of such patient have retinopathy that can be seen using an opthalmoscope (Direct or Indirect).
Retinal inVolVement in CereBral malaria
- Eye being extension of brain , retina provides a unique opportunity to observe the central nervous system vasculature and to study cerebral vascular pathology directly thus providing a clue to the mysteries of cerebral malaria.
Components of malarial retinoPathy
Retinal Whitening :
- Retinal whitening affecting the macula is termed as Macular Whitening and this feature outside the macula is termed as Peripheral Whitening.
- Macular whitening is a patchy opacification of the retina centered on the fovea , but it spares the centeral fovea or foveola and frequently extends temporally between the vascular arcades.
- How to differentiate it from Cotton Wool spots
- Patches of peripheral whitening are less well demarcated , less brightly white and more widely distributed than cotton wool spots.
- VESSEL DISCOLOURATION
- vascular changes such as discolaration of retinal vessels to orange or white mainly in the peripheral fundus.
- Either discrete section of vessels , or peripheral vascular trees can be involved . White or orange Tramlining within larger vessels can occur.
Retinal Haemorrhage
- Retinal Haemorrhage are predominantely white centered , intra retinal , blot haemorrhage . In severe case , these can be extermely numerous (>120 in each eye).
Papilloedema
It is not specific to malaria and can occour in many other condition.
Aim of Study
To study the retinal changes associated with cerebral malaria
To determined the significance of study of retinal changes that can reveal insight into the pathophysiology of cerebral malaria
material and metHod
DESIGN
- Cross sectional study
PLACE
- RIO , RIMS , RANCHI
DURATION
- May 2016 to Nov 2016
Inclusion Criteria
Diagnosed case of P. falcipraum positive cerebral malaria.
Haemoglobin < 7gm/dl , fully consious with no episodes of severe bleeding and no reported or observed convulsion.
No record of recent head trauma , no other cause of coma or neurogical disease.
Age < 24 years.
No H/O blood transfusion.
Exclusion Criteria
Patient with evidence of other infectious disease.
Abnormal cerebrospinal fluid test.
Positive sickling status.
Previous history of vitroretinal disease.
Examination ProtoCol
On admission , a full history and general examination were carried out.
Pupillary reaction to light.
Direct ophthalmoscopy.
Indirect opthalamoscopy.
Fundus photography.
Fluroscein angiography.
ParticiPant
- A Total of 62 patient with Plasm. Falciparum malaria are enrolled , of that 26 pt had cerebral malaria and 36 pt had severe malaria.
- Out of 26 pt. 15 (57%) are male patients and 11 (43%) are female patients.
- Mean age of presentation is 15 ±10 years.
Demographic ProFile
| AGE GROUP | MALES | FEMALES | TOTAL |
| (in years) | |||
| 5 – 10 | 5 | 4 | 9 |
| 11 – 20 | 6 | 3 | 9 |
| 21 – 30 | 4 | 4 | 8 |
| TOTAL | 15 | 11 | 26 |
Results
- Out of 26 Pt of cerebral malaria 16 showed one or more retinal abnormalities.
| Retinal changes | no of patient |
| Any retinal changes | 16 |
| (combination of the following) | |
| Retinal whitening (macular and | 8 |
| peripheral) | |
| Vascular changes | 7 |
| Retinal hemorrhage | 6 |
| Papilloedema | 5 |
No of Patient in different Group with here Ggs Score
| No of patients | GCS Score | |
| Retinal whitening with | 10 | 4-6 |
| vascular changes with | ||
| other retinal changes | ||
| and papilloedema | ||
| Retinal hemorrhage | 5 | 7-8 |
| with Vascular changes | ||
| Retinal hemorrhages | 4 | 9-10 |
| Vascular changes | 7 | 11-12 |
Discussion
- More retinal changes in cerebral malaria signifies more severity of disease and association with coma.
- Retinal whitening was the only retinopathy that showed significant association with cerebral malaria and reflect a compromised cerebral microvasculature associated with coma.
- There was a significant trend of increasing severity of retinopathy with increasing severity of malaria.
Limitation of the Study
- Following are the limitations of present study :
- Small Sample size
- Subject were chosen for the study in a non randomised manner
- Subject are not followed – up beyond 1 month
Study So Far . . . .
Retinopathy in adults with plasmodium falciparum malaria.
Retinopathy in severe malaria in Ghanain children
Conclusion:
- High occurrence of retinal changes in patient with cerebral malaria.
- Detection of malarial retinopathy through opthalmoscopy may potentially be very useful from diagnostic and prognostic point of view.
- Retinal whitening and vascular changes ,are unique to cerebral malaria.
- The number of retinal hemorrhages seen on fundoscopic examination correlates with the number of cerebral hemorrhage in fatal cerebral malaria . Also benefit of studying retinopathy in severe malaria is that it can be done in vivo.
- Signifies relation of retinal finding and association of severity of cerebral malaria
- Retinal whitening a sign suggestive of retinal ischaemia was found in cerebral malaria suggesting that the brain suffers from ischaemia in cerebral malaria.
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