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Use of Multiple Tests Improves Screening for Glaucoma-Reply.

even the scientific proof that ZIKV is in fact the cause of microcephaly is still a matter of debate for some. In January 2016, our research group published an article from Recife, Brazil, with similar findings.1 Recife and Salvador are both populous capital cities located on the coast of the Northeast Region of Brazil. They share similar tropical weather and are where the largest ZIKV outbreaks in Brazil took place. Our article published in JAMA Ophthalmology showed large excavated chorioretinal lesions in infants evaluated in Salvador, Bahia, Brazil, that had not been previously described.2 Unpublished studies from other parts of northeastern Brazil confirm the findings in Bahia were unrelated to local conditions. We also agree that it seems plausible that there could be a dual mechanism at work in these patients, ie, microcephaly (secondary to ZIKV)–associated ocular abnormalities and directly induced ZIKV ocular abnormalities. The possibility that ZIKV and similar viruses cause microcephaly also exists. This possibility would not be the first time an unknown congenital birth defect became recognized as secondary to an infection. Research and joint efforts across institutions should uncover answers to the questions suggested by Moshfeghi and colleagues as well as aid in the development of advances we need for dealing with this global health issue. Vasconcelos-Santos and colleagues raise important issues on the challenges in ruling out other congenital infections as the cause of the ophthalmological lesions we observed in our patients. We also agree that this may be especially difficult in the case of toxoplasmosis. We excluded the diagnoses of toxoplasmosis, cytomegalovirus, and human immunodeficiency virus based on the lack of detection of IgM in neonates, and we excluded the diagnosis of syphilis based on a negative rapid plasma reagin result in mothers and neonates.2 We agree that IgM enzymelinked immunosorbent assay may not identify all cases of CT, but it seems unlikely that the lesions observed in our patients could be explained by IgM-negative CT. Furthermore, careful follow-up of the infants is being performed. None of them have developed laboratorial or clinical signs suggestive of toxoplasmosis. At the time the patients were examined (December 2015), serologic testing for ZIKV infection was unavailable for our site. Since the article was published, we have tested 7 of the 10 study patients with the anti-ZIKV IgM capture enzyme-linked immunosorbent assay and all 7 were found to have anti-ZIKV– specific IgM antibodies. Therefore, we believe the points raised by Vasconcelos-Santos and colleagues do not compromise the findings of our study. We look forward to other pieces of research that will allow better understanding of this new and serious medical problem.