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Ophthalmologists need to be aware of possibility of Ebola in eyes of survivors
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Ebola virus, or EBOV, is one of five known viruses in the genus Ebolavirus. It is a very small single-stranded negative-sense RNA virus. It mutates rapidly, even while infecting a single host, making production of an effective vaccine a challenge. The vector is the bat, usually a fruit bat. The susceptible species are large mammals including pigs, apes and us humans. It is spread by direct contact with body fluids including feces, blood, vomit, saliva, urine and semen, and apparently aqueous and vitreous fluid can also harbor the virus. The virus causes a severe hemorrhagic fever with hematemesis, bloody diarrhea, abdominal cramping, dehydration and death in 83% of cases in 3 to 4 days.
In the 2013-2015 epidemic in Western Africa, primarily centered in Guinea, Liberia and Sierra Leone, approximately 28,256 individuals were infected, with an 80%-plus mortality rate. Tragically, many of them were health care workers in an area already severely short on trained health care providers. Many doctors and nurses became infected while caring for the sick and rapidly died. The WHO recommends “Level 4 Biosafety” when exposed to an infected individual, which is the highest level of protection. Even in the United States, only a few designated centers are prepared to deal with this deadly disease, and the few patients diagnosed after traveling to the U.S. were sent to these special centers for treatment.
The treatment is primarily supportive, with intravenous therapy to treat dehydration, blood pressure support and oxygenation. There is no known approved effective antiviral therapy. A few patients have been treated with an investigational drug developed to treat influenza called favipiravir (Medi-Vector). Survivors have been shown to have virus remaining in the semen and eye (aqueous and vitreous) for up to 9 months after the systemic disease is resolved and blood cultures are negative. Some patients have been treated systemically with serum from infected surviving individuals, which apparently contains antibodies effective against the Ebola RNA virus.
The finding that the virus can access the aqueous and vitreous and result in severe panuveitis in survivors is important to the ophthalmologist. All patients who survive this terrible disease will know they had it, but once their blood is culture and serology negative, they will be released from the hospital. Many survivors may still harbor virus in the eye and, for men, in their semen. The semen can infect another human. Contact with aqueous and vitreous is unlikely to infect another, but severe panuveitis can develop and cause significant vision loss.
Treatment is with potent topical steroids, cycloplegics and, in more severe cases, subconjunctival or even intravitreal steroids. Favipiravir may be available on a compassionate-use basis, but its efficacy is not confirmed. Most of us will want to refer these patients to a tertiary care center where ophthalmologists and infectious disease specialists can collaborate in the patient’s care.
The potentially devastating ocular side effects remind me of the opportunistic infections that once commonly occurred in HIV patients. For years, those were treated with anti-inflammatory drops and intravitreal injections. Today, highly active antiretroviral therapy usually prevents these side effects and reduces the morbidity and mortality of HIV. We can only hope that a similar therapy evolves for the treatment of EBOV-induced disease.