Microencephaly

1. Ophthalmological
findings in infants with
microcephaly and
presumable intra-uterus
Zika virus infection.
By: Mireya Marilú Balderas Ruíz.

2. vocabulary
• Flavivirus; Enveloped viruses
• Malaise; general discomfort
• Rash; skin inflammation
• Arthralgia; joint pain
• Exophoria; outward deviation of the eye
• Esophoria; inward deviation of the eye
• Cycloplegic; paralysis of the intraocular muscles

3. Abstract
• Zika virus (ZIKV) is a neurotropic flavivirus related to West Nile virus,
yellow fever and dengue. Since then, it is estimated that more than 1 million
Brazilians had ZIKV infection, reflecting the ability of the virus to cause
large-scale outbreaks where the biological vector Aedes aegypti is an
endemic species. In 2015, 1,248 new and suspected cases were recorded,
representing an increase of contrast compared to recent years.
Maternal-fetal transmission of ZIKV has been previously demonstrated. In
Brazil, ZIKV has been detected in the amniotic fluid of pregnant two babies
with microcephaly and tissue of a newborn with microcephaly who died after
birth.

4. Methods
• We report the results of the 10 children with microcephaly, defined by a
occipitofrontal circumference of more than two standard deviations below
the mean for age and sex, with a clinical diagnosis vertical infection ZIKV
and previously diagnosed with eye abnormalities that refers to the Altino
Ventura Foundation in Recife, Brazil, for ophthalmological examination on
December 14, 2015.

5. Results
• Six (60.0%) were women. Their average age at test day
was 1.9 ± 0.9 months (range 0.7 to 2.9 months).
Exploratory computerized tomography shows cerebral
calcifications in patients. They born during the
outbreak of infection ZIKV, and seven (70.0%) of
mothers had dengue-like symptoms (malaise, rash and
arthralgia) during pregnancy, of which six (85.7%) were
in the first quarter. The average age of mothers at work
was 29.1 ± 7.3 years (range: 19-42 years). Since
children had negative serology for toxoplasmosis,
rubella, cytomegalovirus and human immunodeficiency
virus (HIV) they were clinically diagnosed with
presumed intrauterine infection ZIKV.
At birth, the mean gestational age was 38.3 ± 0.5 weeks
(range: 37.6 to 39 weeks), average head circumference
was 1.5 cm ± 28.8 (range: 26 to 31.5 cm), and average
weight it was 461.6 ± 2,901 g (range: 2105-3800 g). An
axial length measured by ultrasound immersion of 18.4
± 0.6 mm (range: 17.6 to 19.3 mm) average in the right
eye (OD) and 18.3 ± 0.4 mm (range: 17.6 to 19.1 mm) in
the left eye (OS). The pupils were usually reactive,
without afferent pupillary defect, and Hirschberg test
revealed exophoria in four patients (40.0%) and
esophoria in two (20.0%). Cycloplegic refraction showed
an average of -0.40 ± 2.40 diopters (D) (range: -3.50 to
2.00) spherical equivalent in OD and 0 ± 2.50 D (range -
3.00 to 3.50 D) in OS.
The evaluation revealed retinal macular changes and
optic nerve were 17 eyes (85%) (Table 1).

6. Tabla 1

7. Discussion
• The outbreak of infection Brazilian ZIKV 2015 was the first to have an association between this virus and severe
complication of newborns with microcephaly. In this document, the ophthalmologic evaluation of 10 children
presented with abnormal ophthalmologic examination, born with microcephaly related ZIKV.
Seven mothers had symptoms of dengue fever in the first or second trimester of pregnancy, and toxoplasmosis,
rubella, cytomegalovirus and HIV were removed by serology. Since approximately 80% of patients are
asymptomatic infection ZIKV, the absence of symptoms does not rule out infection. In addition, the only available
method for diagnosing infection ZIKV is real-time polymerase chain reaction (PCR), which is useful for detecting
the virus in the acute phase of the disease (first 5 days of acute infection). Similarly, in this report, fifteen eyes
(75.0%) had these macular abnormalities, which had not been reported in other outbreaks ZIKV in the world.
In addition, alterations of the optic nerve were observed for the first time. ZIKV hypothesize that abnormalities
can cause severe eye when infection occurs in the first or second trimester of pregnancy, following the reasoning of
other vertical infections such as toxoplasmosis, rubella and cytomegalovirus. In addition, other unknown factors
as the amount of viral circulation and the immune response of the mother and fetus, can play an important role in
the abnormalities observed in newborns.

8. Conclusion
• In conclusion, we report the ophthalmologic findings of 10 children with
microcephaly related to ZIKV born during the outbreak of infection ZIKV in
Brazil with abnormal eye exams. Other studies assess the visual significance
of these changes, it will be important to understand the natural history of
this manifestation of the new and devastating disease ZIKV.