I would like to congratulate Hero et al1 on their excellent photographic documentation of some of the fundus findings in cerebral malaria in their recent publication titled "Photographic and Angiographic Characterization of the Retina of Kenyan Children With Severe Malaria."1 Hemorrhages and white-centered hemorrhages have been described and photographed before, but this publication is the first photographic documentation of the retinal whitening and the unusual appearance of retinal vessels in children with cerebral malaria. I would like to make several points about these phenomena. I must disagree with the authors' suggestion that the whitening is in the inner retina; as their photographs show, the vessels can be seen overlying the whitening and are not obscured by it, making it difficult to imagine how the whitening could be in the inner layers of the retina. When the phenomenon occurs in the macula, and especially when it is severe in the macula, it does appear to be more superficial, but even then, careful scrutiny will reveal that small vessels are visible. Second, the authors refer to vascular sheathing, described in the vessels in Figure 2. In fact, although some photographs may resemble sheathed vessels, I do not think this is sheathing. I've followed up several hundred children with cerebral malaria and have observed that these vessels always regain a normal appearance within hours to days if the child's condition improves. Furthermore, often the vessels (which may be either venous or arterial and of any caliber) are not white at all, but rather are varying shades of orange. I wonder if their appearance is due to the phenomenon of cytoadherence of parasitized red blood cells to vascular endothelium2 combined with severe anemia. In our studies we found the white or orange vessels to be statistically significant associated with a low hematocrit. Our histological examination of several cases has not revealed any evidence of sheathing along vessels. This is more than just of academic interest because sheathing implies an inflammatory component that would be relevant to the question of the patholphysiology of cerebral malaria.
Susan Lewallen. The Fundus in Severe Malaria. Arch Ophthalmol. 1998;116(4):542–543. doi: