We thank Dr Lewallen for her letter and her valuable comments. The retinal opacification seen in severe childhood malaria seems to be the most specific ocular lesion in the disease. In our independent observational study in Kenya we believe that this opacification was in the inner rather than outer retina. We do not believe that the visibility or otherwise of retinal vessels can help to determine the layer involved. The whitening in our patients did not involve retina adjacent to larger vessels but left a "tram line" of normal retina as illustrated in Figure 5 of our article. Furthermore retinal vessels do not remain visible in other lesions causing opacification or whitening such as retinal artery occlusion and acute retinal necrosis. We agree that the "sheathing" seen in these children is often orange. Unlike Dr Lewallan and her colleagues we did not have the opportunity to examine many children in the recovery phase as they became uncooperative at this stage. New light should be shed on the exact nature of many of the lesions that both groups have now described by further studies being conducted in Malawi in 1998 including electrophysiological and capillary flow investigations and especially an important histopathological study. We look forward to our planned collaboration with the Malawi team on some of these studies this year.
Harding SP, Hero M, Winstanley PA. The Fundus in Severe Malaria—Reply. Arch Ophthalmol. 1998;116(4):542-543. doi: