a 17-year - old female patient , resident of south india , presented with the complaints of sudden onset of the decrease in vision with gradual worsening in the left eye for the last 3 months duration .
the patient was diagnosed with p. falciparum malaria about a week prior to the onset of the ophthalmic symptoms with sudden onset of chills and rigor with high grade fever , and peripheral blood film showing p. falciparum trophozoites and ring forms .
there was no history of convulsions , seizures or unconsciousness during or preceding the treatment .
the patient recovered from the fever within 10 days , with a gradual onset of decreased vision in the left eye . during the treatment ,
an ophthalmic referral was taken , which showed features suggesting neovascularization and vitreous hemorrhage . at presentation to us , the visual acuity in the right eye was 20/20 , n6 , and in the left eye was 20/1200 , n36 .
the dilated fundus examination of the right eye revealed a normal fundus [ fig . 1 ] .
2 ] were as follows : the media was clear , with a small amount of vitreous hemorrhage inferiorly .
the major retinal arcade veins showed a severe obliteration of various degrees at the posterior pole as well as the periphery , with visible small neovascular fronds along the superior arcade vessels .
color fundus picture of the right eye showing a normal posterior pole color fundus picture of the left eye showing a pale optic disc , with a few exudates along superior arcade vessels , and over macula .
the major retinal arcade veins showing a patchy and severe obliteration of various degrees at the posterior pole , with visible small neovascular fronds along the superior arcade vessels ( black arrows ) , and a small subhyaloid hemorrhage along the inferior arcade ( white arrow ) .
the superior arcade veins are dilated and tortuous as compared with the inferior veins the fundus fluoresceine angiogram of the right eye showed a normal study . the left eye , however [ fig .
3 ] showed large areas of capillary drop out in the superior , temporal and inferior retina , various degrees of retinal vessel obliteration as well as multiple neovascular fronds along the superior arcade vessels .
the vessel wall staining was evident , as was the capillary obliteration of the foveal avascular zone .
the optical coherence tomography ( oct ) in the right eye showed a normal foveal contour with a central subfield thickness of 171 microns .
4 ] showed a schitic retina superior to the macula , with a few cystic spaces inferiorly , and subhyaloid hemorrhage with a central subfield thickness of 67 microns .
the fundus fluoresceine angiogram of the left eye with following prominent findings : ( a ) the late arterio - venous phase of the posterior pole with obliteration of capillaries at the foveal avascular zone with capillary drop out areas ( hypofluorescent ) and neovascular fronds ( hyperfluorescent ) seen superiorly ; ( b and c ) large areas of capillary drop out in the superior , temporal and inferior retina , various degrees of retinal vessel obliteration as well as multiple neovascular fronds along the superior arcade vessels ; while ( d ) late leakage from the neovascular fronds superiorly , with generalized vascular staining optical coherence tomography of the left eye showing a schitic retina superior to the macula with a few cystic spaces , and a central subfield thickness of 67 microns the patient was advised for scatter laser photocoagulation in the left eye .
she was followed over a period of 2 years , with slow but complete resolution of the proliferative changes in the left eye [ fig . 5 ] , with resultant fibro - vascula proliferation causing intermittent vitreous hemorrhage , which cleared spontaneously .
the vision at the last follow - up in the left eye was 20/400 , n36 .
a color fundus montage picture of the left eye at the last follow - up showing a pale disc , well ablated retina , with regressed neovascular fronds and sclerosed retinal vessels superiorly
malaria is a mosquito borne infectious disease caused by parasitic protozoa of the genus plasmodium .
the retinopathy seen in association with severe malaria is well - described in african sub - continent .
p. falciparum has been found to be associated with retinopathy in malaria in almost all the cases .
actually the term malaria retinopathy has been used in association with severe malaria caused by p. falciparum .
cerebral malaria is typically diagnosed based on the clinical signs of fever and deranged cerebral dysfunction ( impaired consciousness , convulsions , focal neurological deficit , or psychosis ) with a recent history of travel to the endemic area .
diagnosis of malaria is confirmed with the blood films for asexual forms of the malarial parasite , and computed tomography scan , followed by lumbar puncture ( to exclude other causes like viral encephalitis or meningitis ) .
since our patient was diagnosed as malaria based on the peripheral blood films , with no other neurological signs , further investigations were not deemed necessary by the primary physician .
malaria retinopathy has been described to have four distinct components , namely patchy retinal whitening , focal changes in vessel wall coloration , retinal hemorrhages , and papilledema .
so characteristic are the first two findings , that they have been characterized to diagnose malaria in a comatose patient , even if the peripheral blood smear is negative for malarial parasites .
fundus changes in non - cm have also been studied by various investigators in pediatric and adult populations .
even though , some or all the retinal findings may be noted in noncm , retinal whitening and hemorrhages have been found to be particularly associated with the cm .
since the severe retinopathy has been described mainly in patients with cm so far , the hypothesized patho - physiology has also been described accordingly in both the organ systems .
obstruction of microvasculature by sequestration of erythrocytes has been thought to play a central role , both in cerebral and retinal manifestations .
the physical obstruction by these rigid cytoadherent parasitized erythrocytes is compounded by reduced red cell deformability and adhesive forces between infected erythrocytes ( autoagglutination ) and between infected and uninfected erythrocytes ( rosetting ) .
impaired retinal vessel perfusion was demonstrated in vivo by fluorescein angiography in 28 of 34 children with cm in a study in malawi .
these patients similarly showed large areas of capillary drop outs as in our case study , but with no evidence of proliferative retinopathy secondary to these changes .
authors hypothesize that the perfusion was impaired in the retinal circulation to such an extent so as to produce large areas of capillary nonperfusion , resulting in the formation of new blood vessels .
the treatment in the form of 360 scatter laser photocoagulation resulted in reduced ischemic load and regression of the neovascularization , thus stabilizing the retinopathy .
the present case report underlines the importance of having early ophthalmic examination and possible intervention in all patients of malaria , even if the central nervous system is not affected .
this case appears to be the first in the literature describing the presence of unilateral proliferative retinopathy , in a patient with severe non - cm caused by p. falciparum , being described in indian population .
 the retinopathy in association with malaria fever described so far includes retinal hemorrhages , vessel changes , retinal discoloration / whitening and papilledema . 
 malaria retinopathy has been mostly described in severe cases , associated with plasmodium falciparum , correlating the patho - physiology of retinal and cerebral manifestations . 
 we report an unusual case of proliferative retinopathy as a manifestation of malaria fever , caused by p. falciparum with no cerebral involvement . 
 the patient had features of unilateral retinal vascular occlusion with proliferative changes and vitreous hemorrhage . 
 to the best of our knowledge , such a case has never been reported so far in the literature . 
 this report highlights the possible occurrence of severe proliferative changes associated with malaria fever , which if diagnosed early can prevent possible blindness . 
Case Report
Discussion