Blindness is an uncommon but devastating complication of tuberculosis meningitis. The main causes are chronically raised intracranial pressure (hydrocephalus and/or tuberculomas) or direct involvement of the optic chiasm or optic nerves by the basal arachnoiditis (inflammation and/or compression). Antituberculosis therapy combined with corticosteroids and control of intracranial pressure constitutes the mainstay of therapy for tuberculous meningitis. Despite these treatment measures, some patients develop blindness, mainly as a result of progressive optochiasmatic arachnoiditis. This led us to explore the role of adjuvant thalidomide therapy, and we describe the dramatic recovery of vision in 4 consecutive cases. Clinical recovery was accompanied by marked radiological improvement on magnetic resonance imaging (MRI) of the brain.

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Background. Screening guidelines for retinopathy of prematurity (ROP) used in high-income countries are not appropriate for middleincome countries, and screening requirements may vary even between units within one city. Objective. To determine optimal ROP screening criteria, and its workload implications, for Tygerberg Children's Hospital (TCH), Cape Town, South Africa. Methods. This cross-sectional study included premature infants screened for ROP at TCH from 1 January 2009 to 31 December 2014. Logistic regression analysis for prediction and classification was performed. Predictors were birth weight (BW) and gestational age (GA). Endpoints were clinically significant ROP (CSROP) and type 1 ROP (T1ROP). Results. Of 1 104 eligible infants, 33.4% had ROP (CSROP 9.1%, T1ROP 2.5%). All T1ROP infants received laser therapy. The number of screening examinations was inversely correlated with GA and BW. The number needed to screen to identify one infant requiring treatment was 41 (entailing 83 examinations, 4 screening hours, one technician and three doctors). Screening infants with a GA of ≤28 weeks or a BW of <1 000 g would have detected all infants with T1ROP but missed two outliers with CSROP. These outliers would only have been detected with a GA of ≤32 weeks or a BW <1 500 g. Conclusions. Detection of infants with T1ROP is resource intensive. Larger infants require screening to include a few outliers, but they require fewer examinations than smaller infants. Making local screening criteria narrower on the basis of a limited evidence base may be dangerous. Risk factors for CSROP in larger infants need to be researched.

A 7-year-old child, on maintenance chemotherapy for acute lymphoblastic leukemia, developed tuberculous meningitis complicated by progressive basal meningeal inflammation and abscess formation, in spite of adequate tuberculosis treatment and adjunctive corticosteriod therapy. The child became blind as a result of involvement of the optic chiasm. After 2 months of adjunctive thalidomide therapy, the child regained vision and cranial magnetic resonance imaging showed marked reduction of the inflammatory changes previously demonstrated. Progression of intracranial tuberculous infection, in spite of a treatment that is generally considered to be adequate, is well recognized. Previous reports of a possible beneficiary role of thalidomide in these cases support an immunological basis. The present case suggests a role for thalidomide in the treatment of blindness due to involvement of the optic chiasm in progressive basal tuberculous meningitis.

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In human immunodeficiency virus-infected children, cytomegalovirus causes retinitis alone, with dissemination, or with immune reconstitution inflammatory syndrome. We describe 6 severely immunosuppressed African children (median age, 6.7 months) with cytomegalovirus disease. Of the 6 children, 5 had clinical features suggesting ocular disease at presentation. The child in whom retinitis was detected through preemptive screening due to systemic disease achieved normal visual outcome.

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