Zika Virus: Brazil and Beyond

Observations and suggestions for managing babies with ocular manifestations of this disease.

By Luis Acaba, BA; Camila V. Ventura, MD; Marcelo C. Ventura Filho, MS; Liana O. Ventura, MD, PhD; Maria H. Berrocal, MD; and Audina Berrocal, MD

The Zika virus (ZIKV) is a flavivirus that is mainly transmitted by Aedes aegypti, one of the most common mosquitoes worldwide, also responsible for spreading dengue, chikungunya, yellow fever, and West Nile virus.1 The emergence of ZIKV has caused great alarm in many countries because of its capacity to cause microcephaly in newborns, along with other malformations, including hearing loss, limb anomalies, and ocular findings (Figure 1), which characterize a new clinical condition called congenital Zika syndrome (CZS).2


• The Zika virus (ZIKV), transmitted by a mosquito common worldwide, can cause microcephaly in newborns, along with other malformations, including hearing loss, limb anomalies, and ocular findings, which characterize congenital Zika syndrome (CZS).

• One of the biggest challenges to the health care profession is getting laboratory confirmation of CZS.

• Every baby exposed to ZIKV should receive an eye screening and undergo fundus photography.

In June 2016, we visited the Altino Ventura Foundation (FAV) in Recife, Brazil, the epicenter of the ZIKV epidemic (Figures 2-6). A nonprofit eye hospital, FAV provides eye care to approximately 35,000 patients each month in one of the poorest regions of the country. Since the beginning of the Zika outbreak, the institution’s team has examined more than 300 babies that were suspected to have acquired ZIKV infection in utero. This philanthropic institution has not only addressed the ocular findings associated with ZIKV but has also developed early intervention and multidisciplinary rehabilitation (visual, auditory, motor, and intellectual) strategies for patients with these findings.


During our visit, we examined and photographed approximately 25 babies affected with CZS. It was shocking to see firsthand the extent of the systemic involvement of this virus in these children and the immense burden it places on their mothers and on Brazilian society.

Figure 1. Fundus image showing optic nerve hypoplasia and pallor, chorioretinal scar, and retinal pigmentary changes in the macular region, with vascular attenuation.

Figure 2. María Berrocal, MD, examining a baby with CZS.

Figure 3. María Berrocal, MD (left), and Audina Berrocal, MD (right), documenting fundus lesions using the PanoCam Pro (Visunex Medical Systems) portable imaging system.

Figure 4. Mothers and babies in therapy at FAV rehabilitation center in Recife, Brazil.

The lifelong medical and socioeconomic ramifications of babies born in Brazil with CZS are dramatic, particularly given the population’s limited resources. It was evident to us that most of the mothers we met were in their late teens, lived in significant poverty, were uneducated, and came from the poor areas of Pernambuco, the Brazilian state that includes Recife.

Because abortion is illegal in Brazil, it is expected that the incidence of CZS in newborns will continue to increase.3 To meet this challenge, FAV, through its rehabilitation center, has created an early intervention program for motor, intellectual, visual, and auditory assessment. Visual rehabilitation with glasses and stimulation begins early, and mothers are taught how best to care for their babies.

Figure 5. Babies in therapy at FAV rehabilitation center in Recife, Brazil.

FAV has also founded a support group for mothers and families that provides psychological support, encourages the exchange of experiences between families, and helps raise funding for transportation and for daily life products such as diapers, milk, and clothes.

Of the babies we examined and photographed, those with the most severe cases of CZS had contracted the virus in the first trimester. Interestingly, a substantial number of these mothers had no recollection of experiencing any symptoms of the disease during their pregnancies.4,5 No doubt this has crucial implications worldwide, for ZIKV can go unnoticed and thus underdiagnosed.


Figure 6. Baby with microcephaly caused by CZS.

Currently, one of the biggest challenges to the health care profession is getting laboratory confirmation of CZS. Real-time polymerase chain reaction serology and IgM antibody-capture enzyme-linked immunosorbent assay testing are considered the most accurate tests for intrauterine infection, but these tests only became available after February 2016, and they are costly and of limited availability.2 Consequently, most testing of these babies is pending.

The second most frustrating challenge is that the current serology test is not reliable because of its high cross-reactivity with other flaviviruses such as dengue fever, which is endemic in Brazil.1 Thus, until we have better ways to confirm exposure, we advise that, in countries affected by ZIKV, routine laboratory screening should be performed on all pregnant women. In addition, regardless of the mother’s symptoms, we believe that all babies born in epidemic areas should be submitted to an ophthalmic examination with fundus documentation after birth.


Our experience has taught us some important lessons. First, regardless of the presence or absence of microcephaly, every baby exposed to ZIKV should receive an eye screening examination. Second, a fundus photograph should also be taken of every baby that undergoes screening because subtle changes can be missed by clinical examination alone. Third, education and prevention must be a priority in countries affected by this devastating intrauterine disease. Fourth, as far as early intervention is concerned, psychological support and early multidisciplinary rehabilitation are of utmost importance.

This ongoing epidemic reminds us that, due to globalization, diseases tend to spread faster and reach a greater extent. The ZIKV epidemic is expected to reach most countries in tropical and subtropical regions in the near future. Just recently, Florida’s Department of Health reported the first cases of local transmission of ZIKV in the United States.6 In addition, more than 7,800 cases have been reported in the US territory of Puerto Rico, which is located 1,000 miles from Florida.7 Therefore, the sooner we have an effective plan in place to prevent, screen, identify, and treat this disease, the better. n


1. Pinto Junior VL, Luz K, Parreira R, Ferrinho P. Zika Virus: a review to clinicians [article in Portuguese]. Acta Med Port. 2015;28(6):760-765.

2. Miranda-Filho DdeB, Martelli CM, Ximenes RA, et al. Initial description of the presumed congenital zika syndrome. Am J Public Health. 2016;106(4):598-600.

3. Teixeira MG, Costa MCN, de Oliveira WK, et al. The epidemic of Zika virus-related microcephaly in Brazil: detection, control, etiology, and future scenarios. Am J Public Health. 2016;106:601-606.

4. Ventura CV, Maia M, Travassos SB, et al. Risk factors associated with the ophthalmoscopic findings identified in infants with presumed Zika virus congenital infection. JAMA Ophthalmol. 2016;134(8):912-918.

5. de Paula Freitas B, de Oliveira Dias JR, Prazeres J, et al. Ocular findings in infants with microcephaly associated with presumed Zika virus congenital infection in Salvador, Brazil [published online Feb. 9, 2016]. JAMA Ophthalmol.

6. Florida State Government. Gov. Scott: with likely mosquito-borne Zika cases, state will use full resources to protect Floridians. www.flgov.com/2016/07/29/gov-scott-with-likely-mosquito-borne-zika-cases-state-will-use-full-resources-to-protect-floridians. July 29, 2016. Accessed August 22, 2016.

7. Centers for Disease Control and Prevention. Zika virus: case counts in the US. www.cdc.gov/zika/geo/united-states.html. August 17, 2016. Accessed August 22, 2016.


Luis Acaba, BA
• medical student at the Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia, Pa.
• financial interest: none acknowledged
• luis.acaba@jefferson.edu

Audina M. Berrocal, MD
• professor of clinical ophthalmology, co-director of the vitreoretinal fellowship, and medical director of pediatric retina and retinopathy of prematurity at the Bascom Palmer Eye Institute in Miami, Fla.
• member of the Retina Today editorial advisory board
• financial disclosure: Visunex and Clarity
• aberrocal@med.miami.edu

María H. Berrocal, MD
• director, Berrocal & Associates, San Juan, Puerto Rico
• member of the Retina Today editorial advisory board
• financial interest: none acknowledged
• mariahberrocal@hotmail.com

Camila V. Ventura, MD
• retina specialist at the Altino Ventura Foundation and HOPE Eye Hospital in Recife, Brazil; pediatric retina research fellow at Bascom Palmer Eye Institute in Miami, Fla.; and PhD student at Federal University of São Paulo, Brazil
• financial interest: none acknowledged
• camilaventuramd@gmail.com

Liana O. Ventura, MD, PhD
• pediatric ophthalmologist and president of the board of trustees of the Altino Ventura Foundation in Recife, Brazil; coordinator of the pediatric ophthalmology and strabismus department at the HOPE Eye Hospital in Recife, Brazil; and president of the Pan-American Association of Ophthalmology
• financial interest: none acknowledged

Marcelo C. Ventura Filho, MS
• medical student at the Nova Esperança Medical School in Paraíba, Brazil
• financial interest: none acknowledged
• marcelov218@gmail.com


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