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The prevalence of adverse birth outcomes is highest in resource-limited settings such as sub-Saharan Africa. Maternal consumption of diets with adequate nutrients during pregnancy may protect against these adverse outcomes.To determine the association between maternal dietary animal source foods (ASF) consumption and the risk of adverse birth outcomes among HIV-negative pregnant women in Tanzania.Using dietary intake data from 7564 HIV-negative pregnant, we used Poisson regression with the empirical variance (GEE) to estimate the relative risk (RR) of adverse birth outcomes (preterm birth, very preterm birth, small for gestation age (SGA), low birth weight (LBW), stillbirth and neonatal death) for higher versus lower ASF frequency of intake.Median (interquartile range) daily dietary intake of animal protein was 17 (1-48) grams. Higher ASF protein intake frequency was associated with lower risk of neonatal death (Q4 vs Q1 RR: 0.59; 95% CI: 0.38, 0.90; P for trend = 0.01). Higher fish intake was associated with lower risk of very preterm birth (high vs low tertile RR: 0.76; 95% CI: 0.58, 0.99; P for trend = 0.02). Meat intake was protective of preterm birth (RR = 0.73; 95% CI: 0.65, 0.82; P0.001), very preterm birth (P0.001), LBW (P0.001), and neonatal death (P = 0.01) but associated with increased risk of SGA (RR = 1.19; 95% CI: 1.01, 1.39; P = 0.04). Any egg intake was protective of very preterm birth (RR = 0.52; 95% CI: 0.32, 0.86; P = 0.01) compared to no egg intake. Finally, dairy intake was associated with lower risk of preterm birth (RR = 0.82; 95% CI: 0.68, 0.98; P = 0.03) and very preterm birth (RR = 0.53, 95% CI: 0.34, 0.84; P = 0.01).Higher frequency of dietary intake of ASF is associated with lower risk of adverse birth outcomes in urban Tanzania. Promoting prenatal dietary intake of ASF may improve birth outcomes in this region and similar resource-limited settings.Clinical Trial Registry Number: NCT00197548.

Background Zinc and vitamin A supplementation have both been shown to affect iron status, hemoglobin (Hb) concentration, and anemia in animal and human studies. However, evidence on their combined use in pregnancy, in the context of iron-folic acid (IFA) supplementation, remains limited. Objective This study determined the effects of prenatal zinc, vitamin A, and iron supplementation on maternal hematologic and micronutrient status at delivery in Tanzania. Methods We analyzed 2 large randomized controlled trials, using generalized estimating equations, and examined the effect of daily zinc (25 mg) and vitamin A (2500 IU) supplementation starting in the first trimester of pregnancy compared with placebo (n = 2500), and separately evaluated the safety and efficacy of daily iron (60 mg) supplementation among iron-replete pregnant women (n = 1500). Blood samples from baseline and delivery were tested for Hb, serum ferritin, soluble transferrin receptor, plasma zinc, and zinc protoporphyrin. Results Zinc and vitamin A supplementation were associated with lower Hb concentrations at delivery of -0.26 g/dL (95% CI: -0.50, -0.02 g/dL) and -0.25 g/dL (95% CI: -0.49, -0.01 g/dL), respectively. Vitamin A increased mean ferritin concentrations at delivery (14.3 μg/L, 95% CI: 1.84, 29.11 μg/L), but was associated with increased risk of severe anemia (RR: 1.41; 95% CI: 1.06, 1.88). Among women who were iron replete at baseline, iron supplementation reduced the risk of iron depletion at delivery by 47% (RR: 0.53; 95% CI: 0.43, 0.65). There was no effect of zinc or iron supplements on plasma zinc concentrations. Conclusions Our findings support existing WHO guidelines on prenatal iron, vitamin A, and zinc supplementation among pregnant women. In this setting, scaling uptake of prenatal iron supplements is warranted, but prenatal zinc and vitamin A supplementation did not benefit maternal hematologic status at delivery. In settings where vitamin A deficiency is endemic, the efficacy and safety of the WHO recommended prenatal vitamin A supplementation require further evaluation.

Background: In 2015, a China-UK-Tanzania tripartite pilot project was implemented in south-eastern Tanzania to explore a new model to reduce the malaria burden with the aim of eventually scaling-up the approach in Africa. Chinese and Tanzanian teams have developed a locally-tailored malaria control approach screening for febrile cases in endemic villages on Day 1 followed by focal treatment of holoendemic villages within 7 days to stop transmission at the same phase of the plasmodium life-cycle. This 1,7-Reactive Community-based Testing and Response (1,7-mRCT) model can utilize existing health facility data and locally trained community-based health workers to conduct community-level testing and treatment. Methods: Matched malaria incidence pairs of control and intervention wards were chosen. The latter arm was selected for the 1,7-mRCT approach, while the control wards relied on long-lasting insecticide-treated bednets only. The 1,7-mRCT activities included community testing and treatment of malaria infection. Case-to-suspect ratios of malaria cases were aggregated at the village level weekly to identify the village with the highest ratio. Community-based mobile test stations (cMTS) were used for mass testing and treatment. The pilot project was implemented from September 2015 to June 2018 with 85 rounds of 1,7-mRCT implemented in the intervention wards. Comparing the two arms of approach we look for any change in malaria prevalence from the baseline to the endline survey. Besides we also studied the malaria incidence reported at the health facilities after interventions in the treated villages. Findings: Compared to the control wards, the 1,7-mRCT model significantly reduced the malaria infections by 66% (adjusted OR 0.34, 95%CI 0.26-0.44, p

OBJECTIVES: Preterm birth, small for gestational age (SGA) and low birth weight (LBW) are risk factors for morbidity and mortality among infants. High-quality maternal diets during pregnancy may protect against these adverse birth outcomes. The objective of this research is to prospectively examine the association of maternal dietary diversity and quality during pregnancy with birth outcomes among women in Dar es Salaam, Tanzania. METHODS: We analyzed data from 7553 HIV-negative pregnant women enrolled in a multivitamin trial at 12–27 weeks gestation. Dietary intake was assessed using 24-hour dietary recalls. Log binomial regression methods were used to assess associations of Minimum Dietary Diversity for Women (MDD-W) and Prime Diet Quality Score (PDQS) with preterm, SGA, LBW, fetal loss, very preterm, severe SGA and very low birth weight (VLBW). RESULTS: In the previous 24 hours, 99.9% of women reported consuming grains, roots and tubers, 57.9% meats, 4.7% eggs and 0.5% nuts and seeds. Median MDD-W score was 3.0 ± 1.0. For the PDQS, women consumed at least 4 servings/week of green leafy vegetables (100%) and other vegetables (64.7%) and consumption of refined grains was high (99.6%). Higher MDD-W scores were associated with lower risk of SGA (RR highest vs. lowest quintile 0.74, 95% CI: 0.62, 0.89). Higher PDQS scores were associated with lower risk of preterm birth (RR: 0.55, 95% CI: 0.46, 0.67); LBW (RR: 0.53, 95% CI: 0.40, 0.71); fetal loss (RR: 0.53, 95% CI: 0.34,0.82), very preterm (RR: 0.33, 95% CI: 0.17, 0.64) and VLBW (RR: 0.49, 95% CI: 0.26, 0.92) comparing women in highest vs. lowest quintiles. CONCLUSIONS: PDQS was inversely associated with preterm, very preterm, LBW, VLBW and fetal loss, and MDD-W was inversely associated with SGA. These findings suggest that in addition to diet diversity, diet quality should be considered as important in understanding dietary risk factors for poor birth outcomes. FUNDING SOURCES: This work has been supported by the National Institutes of Child Health and Human Development. Co-authors were supported by a grant from the National Institute of Child Health and Human Development and the National Institutes of Health.

The impact of vitamin A supplementation on childhood diarrhea may be determined by the regulatory effect supplementation has on the mucosal immune response in the gut. Previous studies have not addressed the impact of vitamin A supplementation on the production of monocyte chemoattractant protein 1 (MCP-1), an essential chemokine involved in pathogen-specific mucosal immune response. Fecal MCP-1 concentrations, determined by an enzyme-linked immuno absorption assay, were compared among 127 Mexican children 5-15 mo of age randomized to receive a vitamin A supplement (12 mo of age, 20,000 IU of retinol;or =12 mo, 45,000 iu) every 2 mo or a placebo as part of a larger vitamin A supplementation trial. Stools collected during the summer months were screened for MCP-1 and gastrointestinal pathogens. Values of MCP-1 were categorized into 3 levels (nondetectable,median,or =median). Multinomial logistic regression models were used to determine whether vitamin A-supplemented children had different categorical values of MCP-1 compared with children in the placebo group. Differences in categorical values were also analyzed stratified by gastrointestinal pathogen infections and by diarrheal symptoms. Overall, children who received the vitamin A supplement had reduced fecal concentrations of MCP-1 compared with children in the placebo group (median pg/mg protein +/- interquartile range: 284.88 +/- 885.35 vs. 403.39 +/- 913.16; odds ratio 0.64, 95% CI 0.42-97, P = 0.03). Vitamin A supplemented children infected with enteropathogenic Escherichia coli (EPEC) had reduced MCP-1 levels (odds ratio = 0.38, 95% CI 0.18-0.80) compared with children in the placebo group. Among children not infected with Ascaris lumbricoides vitamin A supplemented children had reduced MCP-1 levels (OR = 0.62, 95% CI 0.41-0.94). These findings suggest that vitamin A has an anti-inflammatory effect in the gastrointestinal tract by reducing MCP-1 concentrations.

Purpose To determine the effect of corneal drying on the outcome of optical coherence tomography (OCT). Design Cohort study. Participants Seventeen normal participants (mean age, 39±12 years). Methods Subjects underwent a series of peripapillary circular StratusOCT scans (version 3.0; Carl Zeiss Meditec, Inc., Dublin, CA) in a randomly selected eye. Baseline scan sets were acquired, and thereafter, blinking was prevented by taping the eyelid. Eyelid taping was immediately followed by 6 to 8 serial scan sets, each separated by 20 seconds. After removing the eyelid tape, 3 additional scans were acquired at 1, 2, and 4 minutes of blinking freely. Main Outcome Measures The analyzed outcome measures were scan quality as defined by signal-to-noise ratio (SNR) and signal strength (SS) provided by the built-in OCT software and mean nerve fiber layer (NFL) thickness. Results Significant reductions in SNR, SS, and NFL were noted at each scanning point in the drying phase (for each, P t test) except for NFL thickness measurements acquired at 140 and 160 seconds. The reduction in NFL thickness exceeded the 95% confidence limit of the reported reproducibility error of StratusOCT after 15 seconds of corneal drying. After 1 and 2 minutes of blinking freely, there was still a significant reduction in NFL thickness compared with the baseline value, which was no longer evident at the 4-minute scan. Conclusions Corneal dryness affects OCT scan quality and measured NFL thickness after a short exposure time. It is recommended to instruct those who are scanned to blink frequently or to instill artificial tears.

Purpose To evaluate macular volume in normal and glaucomatous eyes using optical coherence tomography (OCT). Design Case control study. Methods The authors assessed 272 eyes of 164 subjects as part of an institutional study at New England Eye Center in Boston, Massachusetts; 202 eyes were in the study group and 70 eyes in the control group. Eyes were categorized as normal (70 eyes of 43 subjects), glaucoma suspect (70 eyes of 44 subjects), early glaucoma (70 eyes of 47 subjects), or advanced glaucoma (62 eyes of 43 subjects). Subjects underwent analysis with the commercially available OCT1 unit. Optical coherence tomography macular neurosensory retinal thickness maps were used to calculate macular volume for comparison to Humphrey visual field testing, intraocular pressure measurement, and stereo biomicroscopy of the optic nerve head and nerve fiber layer. Results Using repeated measures regression, macular volume in normal (2.37 ± 0.11 mm 3 ) glaucoma suspect (2.33 ± 0.16 mm 3 ), and early glaucoma eyes (2.27 ± 0.13 mm 3 ) was significantly greater than in eyes with advanced glaucoma (2.12 ± 0.23 mm 3 , P = .0001, P = .0001, and P = .0008, respectively). Macular volume in normal eyes was significantly greater than in early glaucoma eyes ( P = .01). Conclusions Optical coherence tomography retinal macular volume correlates with known structural defects of glaucoma, providing a potential objective and quantitative parameter for evaluation. Our data show a significant difference in macular volume between normal, glaucoma suspect, and early glaucoma eyes, compared with advanced glaucomatous eyes as well as between normal and early glaucomatous eyes. This correlates with a trend of decreasing macular volume in eyes with more advanced disease.

Purpose To evaluate the relationship between optic nerve head (ONH) measurements generated by optical coherence tomography (OCT; versions 2 and 3) and confocal scanning laser ophthalmoscopy (CSLO) and to compare the association between OCT and CSLO ONH measurements with glaucoma disease status, as determined by clinical evaluation and perimetry. Design Cross-sectional study. Methods In a prospective study in the glaucoma service of an academic department of ophthalmology, 159 eyes (97 subjects) and 77 eyes (44 subjects) were recruited in two separate periods. All subjects were scanned with a CSLO device. Subjects tested within the first period of recruitment were scanned with OCT version 2 and in the second period with OCT version 3. The main outcome measure was the correlation between automatic and manually defined OCT ONH measurements and the correlation of CSLO and OCT ONH measurements between devices and with glaucoma disease status. Results A high correlation was found between ONH measurements obtained by the automatic determination of ONH margin and those obtained by manual tracing of the disk margin (r = .93 to .98). Optical coherence tomography and CSLO ONH measurements were highly correlated. Optical coherence tomography-measured mean disk area was significantly larger than that measured by CSLO, as were all other disk size-related parameters. The areas under the receiver operator characteristic (AROC) curves for the associations between CSLO and OCT ONH measurements and clinical diagnosis were found to be similar and in the range of 0.47 to 0.79 for both devices. Conclusions Automated OCT ONH measurements correlate highly with those obtained by manual tracing of disk margin. Optical coherence tomography and CSLO ONH analyses are highly correlated and have similar associations with glaucoma disease status.

To evaluate the hypothesis that macular thickness correlates with the diagnosis of glaucoma.Cross-sectional study.We studied 367 subjects (534 eyes), including 166 eyes of 109 normal subjects, 83 eyes of 58 glaucoma suspects, 196 eyes of 132 early glaucoma patients, and 89 eyes of 68 advanced glaucoma patients.We used optical coherence tomography (OCT) to measure macular and nerve fiber layer (NFL) thickness and to analyze their correlation with each other and with glaucoma status. We used both the commercial and prototype OCT units and evaluated correspondence between measurements performed on the same eyes on the same days.Macular and NFL thickness as measured by OCT.All NFL parameters both in prototype and commercial OCT units were statistically significantly different comparing normal subjects and either early or advanced glaucoma (P0.001). Inner ring, outer ring, and mean macular thickness both in prototype and commercial OCT devices were found to be significantly different between normal subjects and advanced glaucomatous eyes (P0.001). The outer ring was the only macular parameter that could significantly differentiate between normal and early glaucoma with either the prototype or commercial OCT unit (P = 0.003, P = 0.008, respectively). The area under the receiver operator characteristic (AROC) curves comparing mean NFL thickness between normal and advanced glaucomatous eyes was 1.00 for both the prototype and commercial OCT devices for eyes scanned on both machines on the same day. The AROC comparing mean macular thickness in normal and advanced glaucomatous eyes scanned on both machines on the same day was 0.88 for the prototype OCT device and 0.80 for the commercial OCT.Both macular and NFL thickness as measured by OCT showed statistically significant correlations with glaucoma, although NFL thickness showed a stronger association than macular thickness. There was good correspondence between findings using both the prototype and commercial OCT units. Macular and NFL thickness measurements made with OCT may have usefulness in the clinical assessment of glaucoma.

PURPOSE: To determine if optical coherence tomography (OCT) measurements of nerve fiber layer (NFL) thickness can be used to predict the presence of visual field defects (VFD) associated with glaucoma. DESIGN: Quota-sampled, cross-sectional study. METHODS: Retrospective study of OCT NFL thickness measurements in 276 eyes of 276 subjects. All persons received OCT NFL thickness analysis; 136 eyes underwent frequency-doubling technology (FDT) perimetry; and 140 eyes underwent Swedish interactive threshold algorithm (SITA) perimetry. We defined a parameter called NFL 50 , which is the NFL thickness value at which there was a 50% likelihood of a VFD with either SITA or FDT perimetry. We evaluated the use of NFL 50 . RESULTS: The mean NFL thickness with (n = 68) and without (n = 68) a VFD in the FDT group was 93.2 μm ± 22.6 and 108.4 μm ± 14.1, respectively. The mean NFL thickness with (n = 70) and without (n = 70) a VFD in the SITA group was 78.9 μm ± 24.8 and 103.0 μm ± 18.0, respectively. The FDT mean NFL 50 value was 98.5 μm. The SITA mean NFL 50 value was 87.0 μm. The area under the receiver operator characteristic (AROC) curve for mean NFL was 0.73, and the positive predictive value (PPV) for FDT mean NFL 50 was 72.2%. For SITA mean NFL, the AROC was 0.79 and the PPV for NFL 50 was 77.2%. CONCLUSION: Nerve fiber layer thickness analysis using OCT may be clinically useful in identifying subjects who have visual field loss. However, the PPV suggests that OCT may need higher resolution and better reproducibility to enhance its sensitivity and specificity for population screening.

Low birth weight (LBW) increases the risk of infant death, but little is known about its causes among HIV-infected populations in sub-Saharan Africa.We assessed sociodemographic, nutritional, immunologic, parasitic, and infant risk factors for birth weight, LBW, and small-for-gestational-age (SGA) status in a cohort of 822 HIV-positive women enrolled in a clinical trial of vitamin supplementation and pregnancy outcomes in Dar es Salaam, Tanzania.Women were enrolled at prenatal care clinics during their second trimester, at which time blood, stool, urine, and genital specimens were collected, and anthropometric measurements and sociodemographic data were recorded. Birth weight was measured at hospital delivery.The mean (+/-SD) birth weight was 3015 +/- 508 g, 11.1% of newborns weighed2500 g (LBW), and 11.5% were SGA. In multivariate analyses, maternal weight at enrollment and a low CD8 cell count were inversely associated with LBW. Advanced-stage HIV disease, previous history of preterm birth, Plasmodium falciparum malaria, and any helmintic infection were associated with higher risk of LBW. The intestinal parasites Entamoeba histolytica and Strongyloides stercoralis were predictors of LBW despite their low prevalence in the cohort. In a multivariate-adjusted linear regression model, BMI, midupper arm circumference, a CD4 cell count200 x 10(6) cells/L (200 cells/mm(3)), primiparity, maternal literacy, and infant HIV infection at birth were significantly associated with birth weight in addition to risk factors included in the LBW model. Determinants of SGA included maternal weight, low serum vitamin E concentration, candidiasis, malaria, and infant HIV infection at birth.Prevention of HIV disease progression and vertical transmission, improved nutritional status, and better management of malaria and intestinal parasitic infections are likely to reduce the incidence of LBW in Tanzania.

Multiple subtypes of HIV-1 have been identified; however, there is little data on the relative transmissibility of viruses belonging to different subtypes. A matched case-control study addressed whether viruses with different long terminal repeat (LTR) subtypes were transmitted equally from mother to infant. The LTR subtype was determined for 45 matched cases and controls who participated in a clinical trial in Tanzania. HIV-1 subtypes A, C, and D and intersubtype recombinant sequences were identified. Exact matched logistic regression analysis showed that viruses containing subtype A or intersubtype recombinant LTRs were 3.2 and 4.8 times more likely to be transmitted from mother to infant than viruses with subtype D LTRs. Viruses containing subtype C LTRs were 6.1 times more likely to be transmitted than those with subtype D LTRs. These differences in transmission were independent of maternal CD4 at enrollment. Thus, it appears that HIV-1 subtype may be associated with differing rates of perinatal transmission in Tanzania.

Objective: To determine the effect of vitamin A supplementation on the risk of diarrhea and of acute respiratory infection. Design: Double-blind, randomized, placebo-controlled trial. Setting: Dar-es-Salaam, Tanzania. Subjects: Six hundred eighty-seven children, 6 to 60 months old, hospitalized with pneumonia, who received vitamin A or placebo at baseline and at 4 and 8 months after discharge from hospital. Main outcome variables: Incidence and duration of episodes of diarrhea and respiratory tract infections during the year after discharge from the hospital. Results: Relative to those receiving placebo, children receiving vitamin A had a significantly smaller risk of severe watery diarrhea (multivariate odds ratio = 0.56, 95% CI = 0.32-0.99, P =.04) but a higher risk of cough and rapid respiratory rate (multivariate odds ratio = 1.67, 95% CI = 1.17-2.36, P =.004). Vitamin A supplementation was also associated with increased risk of acute diarrhea among normally nourished children or children with stunted growth but was relatively protective among children with wasting disease (P value for interaction =.01). The apparently increased risk of respiratory tract infection was limited to children who were seronegative for human immunodeficiency virus (HIV) (P value for interaction =.07). Conclusions: Vitamin A supplements provide a low-cost intervention against morbidity in HIV-infected and undernourished children. Supplements may also have serious non-lethal adverse outcomes in well-nourished individuals. Whether these apparent detrimental effects of vitamin A are transient or long-term needs to be examined. (J Pediatr 2000;137:660-7)

To analyze glaucomatous eyes with known focal defects of the nerve fiber layer (NFL), relating optical coherence tomography (OCT) findings to clinical examination, NFL and stereoscopic optic nerve head (ONH) photography, and Humphrey 24-2 visual fields.Cross-sectional prevalence study.The authors followed 19 patients in the study group and 14 patients in the control group.Imaging with OCT was performed circumferentially around the ONH with a circle diameter of 3.4 mm using an internal fixation technique. One hundred OCT scan points taken within 2.5 seconds were analyzed.Measurements of NFL thickness using OCT were performed.In most eyes with focal NFL defects, OCTs showed significant thinning of the NFL in areas closely corresponding to focal defects visible on clinical examination, to red-free photographs, and to defects on the Humphrey visual fields. Optical coherence tomography enabled the detection of focal defects in the NFL with a sensitivity of 65% and a specificity of 81%.Analysis of NFL thickness in eyes with focal defects showed good structural and functional correlation with clinical parameters. Optical coherence tomography contributes to the identification of focal defects in the NFL that occur in early stages of glaucoma.

Purpose: Optical coherence tomography (OCT) is a new technology that uses near-infrared light in an interferometer to produce approximately 10-µm resolution crosssectional images of the tissue of interest. The authors performed repeated quantitative assessment of nerve fiber layer thickness in individuals with normal and glaucomatous eyes, and they evaluated the reproducibility of these measurements. Methods: The authors studied 21 eyes of 21 subjects by OCT. Each subject underwent five repetitions of a series of scans on five separate occasions within a 1-month period. Each series consisted of three circular scans around the optic nerve head (diameters, 2.9, 3.4, and 4.5 mm). Each series was performed separately using internal (fixation with same eye being studied) and external (fixation with contralateral eye) fixation techniques. The eye studied and the sequence of testing were assigned randomly. Results: Internal fixation (IF), in general, provides a slightly higher degree of reproducibility than external fixation (EF). Reproducibility was better in a given eye on a given visit than from visit to visit. Reproducibility as measured by intraclass correlation coefficients were as follows: circle diameter (CD), 2.9 mm, 0.51/0.57 (normal/glaucoma) (IF), 0.43/0.54 (EF); CD, 3.4 mm, 0.56/0.52 (IF), 0.43/0.61 (EF); CD, 4.5 mm, 0.53/0.43 (IF), 0.42/0.49 (EF). Conclusions: Nerve fiber layer thickness can be reproducibly measured using OCT. Internal is superior to external fixation; each circle diameter tested provides adequate reproducibility.

We conducted a six-month prospective, double-masked randomized trial comparing betaxolol with timolol at 0.25% and 0.5% concentrations in the treatment of primary open-angle glaucoma in 38 patients. To qualify, patients had to demonstrate an average intraocular pressure in at least one eye of greater than or equal to 26 mm Hg without treatment. The median intraocular pressure was consistently lower in the timolol group than in the betaxolol group (after four weeks of therapy, it was 20.2 mm Hg for timolol vs 22.5 mm Hg for betaxolol; P less than .04). Adjunctive therapy was required in eight patients in the betaxolol group compared to one in the timolol group (P less than .05). Betaxolol appears to be a clinically effective and safe agent in the treatment of open-angle glaucoma. However, the magnitude of the decrease in intraocular pressure with it may not be as great as that with timolol and there may be a greater need for adjunctive therapy with it than with timolol.

Two hundred twenty-seven cases of microbial keratitis reported in nonreferral county practice were studied. The staphylococci, Pseudomonas aeruginosa and Streptococcus pneumoniae, were the major isolates. A multivariate statistical model was developed to evaluate possible predisposing and outcome determinants. Several racial and age-related relationships were shown. The interaction of numerous local ocular and systemic factors played a fundamental role in causing disease. The authors found significant association between S. pneumoniae and topical steroid use, and direct and indirect linkage of S. aureus with diabetes and trauma, respectively. S. pneumoniae and Moraxella were risk factors for major complications (24% of cases); S. pneumoniae was related to enucleation and late perforation. Corneal exposure and prior topical steroids were associated with prolonged hospital stays. Hypopyon was associated with pneumococcal infection, 60 years of age or older, and trauma. The identification of groups at high-risk for microbial keratitis and problems of preventive management are discussed.