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Ophthalmologists should not ignore Ebola
Although the appalling epidemic of Ebola virus infection in West Africa had passed from the headlines of the world’s news media, we have recently been reminded of the disease. A British nurse who had gone to Sierra Leone to help treat those with the disease had herself caught it. She returned to the U.K., was treated at a specialist isolation unit at the Royal Free Hospital in London and appeared to recover. However, the Ebola virus can remain in body fluids for extended periods of time after symptoms have resolved, and this unfortunate woman developed meningitis caused by the virus.
Ebola virus is a very small single-stranded negative-sense RNA virus that can mutate rapidly, even while infecting a single host. This of course makes finding a vaccine much more difficult. In the recent outbreak of Ebola hemorrhagic fever caused by the virus, more than 28,000 people lost their lives. This represents a mortality of more than 80%. The virus causes a severe hemorrhagic fever with hematemesis, bloody diarrhea, abdominal cramping, dehydration and death in the vast majority of cases in 3 to 4 days.
Although the WHO recommends “Level 4 Biosafety” when exposed to an infected individual, which is the highest level of protection, tragically, many of those killed were health care workers. This was even more important in an area already severely short of trained health care providers. Many doctors and nurses became infected while caring for the sick and rapidly died.
The virus is spread by direct contact with body fluids such as feces, blood, vomit, saliva, urine and semen. Of interest to us as ophthalmologists is that the virus can also apparently persist in aqueous and vitreous. To date, no known approved effective antiviral therapy has been found. A few patients have been treated with an investigational drug developed to treat influenza called favipiravir (MediVector). A few others were treated with serum from affected individuals who had survived and thus developed antibodies to the virus. Overall, though, most patients had only supportive treatment with intravenous therapy to treat dehydration, blood pressure support and oxygenation.
The fact that the Ebola virus can continue to exist in aqueous and vitreous after blood culture is clear should be of interest to ophthalmologists because it can cause severe panuveitis. Thus, a careful history of any exposure to the Ebola virus should be sought in such cases. The treatment is that of any severe panuveitis, with potent topical steroids, cycloplegics, and possibly subconjunctival or even intravitreal steroids. Although drugs such as favipiravir may be helpful, these patients are best treated at specialist centers, where experts in infectious diseases can cooperate with ophthalmologists and isolation facilities are available.
The disease caused by Ebola virus has been devastating in its high mortality. That the virus can continue to exist for many months in many body fluids, including those of the eye, after apparent cure should be more widely known. It is to be hoped that, as with other deadly infections, a definitive cure will soon be available. Until then, ophthalmologists need to be aware that a severe panuveitis may have Ebola virus as the cause.
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- Richard B. Packard, MD, FRCS, FRCOphth, is the OSN Europe Chairperson of the Editorial Board. He can be reached at Arnott Eye Associates, 22a Harley St., London W1G 9BP, England; email: eyequack@vossnet.co.uk.
Disclosure: Packard reports no relevant financial disclosures.