This article is more than 5 years old. Information may no longer be current.
Post-Ebola syndrome poses threat of ocular complications
Ebola hemorrhagic fever is a deadly disease caused by several species of Ebolavirus, a RNA virus of the Filoviridae family. This virus outbreak continues to affect different parts of Africa, and an outbreak reported in the Democratic Republic of the Congo in 1995 had only 71 survivors out of 316 cases. Human-to-human transmission is known to occur through exposure to body fluids. The current outbreak, which began in 2014, affected a greater number of people than ever before. The disease usually starts with nonspecific findings such as fever, weakness, diarrhea, vomiting, abdominal pain, headaches and myalgias, and in severe cases can lead to hemorrhagic manifestations.
Ocular perspective
Ocular signs have been observed in both the acute and late phases of the disease. Conjunctival injection and subconjunctival hemorrhage are seen in most infected patients and often have a bilateral presentation. Patients who have been infected with Ebolavirus follow one of two pathways: Either they succumb to a more intense hemorrhagic state, or they enter a convalescent phase in which subacute or chronic ophthalmic manifestations gain importance in the form of anterior uveitis, posterior uveitis or panuveitis.
Chronic headache and eye problems such as pain, redness, photophobia and blurred vision are some of the “post-Ebola syndrome” symptoms seen among survivors in West Africa. Uveitis, or inflammation of the inner vascular layer of the eyeball, can be particularly severe in a few patients, leading to blindness. Retinal hemorrhages are also seen in a few patients with persistent inflammation.
How to tackle Ebola and eye complications
The Zaire ebolavirus species was responsible for the current Ebola hemorrhagic fever outbreak, which has infected more people than ever previously recorded. The threat of the disease spreading to other continents makes it increasingly important for medical professionals in every arena to become familiar with its signs and symptoms. Thus, the ophthalmic community has to be on high alert whenever coming in contact with patients suffering from fever and subconjunctival hemorrhage or congestion with a recent history of international travel to Ebola-affected countries. These patients should be transferred to a tertiary care center for serologic testing and quarantined if required. Patients entering the convalescent phase of the disease should also be followed up for evidence of uveitis.
Topical steroids and cycloplegic drugs have been proven to be effective in most cases of post-Ebola uveitis, but further investigation into the natural history and long-term effects of this disease are warranted. As the Ebola virus is transmitted by contact with body fluids, health care workers should wear personal protective equipment covering all skin, the face and eyes. According to recommendations from the U.S. Centers for Disease Control and Prevention, a trained observer should be present for all steps to ensure adherence to the strict protocol. The Ebola virus can be killed with hospital-grade disinfectants, and thus all equipment in contact with the patient needs to be sterilized or disposed of appropriately. A complete ophthalmic check-up beginning with visual acuity and examination of the anterior and posterior segments is mandatory to look for any signs of the Ebola virus in the eyes. Although a general ophthalmic examination can be safe, the active virus still persists in the aqueous humor, so any ocular surgery is a potential risk factor for exposure to the virus.
Cure with care
Retrospective studies have shown the occurrence of uveitis to be between 42 days and 72 days after onset of the disease. Although most of the patients responded well to atropine and steroid eye drops, there is a report of treating a health care provider with severe ocular inflammation with oral favipiravir, periocular triamcinolone and oral prednisolone. The precise role of various corticosteroid interventions and antiviral treatments, along with the natural history of the disease and its different severities, all still need to be studied.
In the post-Ebola analysis of tears, conjunctival samples can help in determining the viability period of the virus in ocular fluid. Screening for ocular signs can help in early detection of post-Ebola uveitis and its subsequent treatment with topical steroids and cycloplegics to avoid visual complications. Education and proper dissemination of vaccines are recommended to help prevent the spread of the disease and future outbreaks. Studies on long-term sequelae for the affected and treated individuals and new viral treatment therapies under investigation may reveal new possibilities of eliminating Ebola virus infection in the future. Survivors need long-term, ongoing care, particularly as we continue to assess the incidence and prevalence of the eye disease as well as try to determine the best evidence-based treatment for Ebola-affected eyes.
References:
Ebola. CDC website. http://www.cdc.gov/vhf/ebola/diagnosis. Updated April 25, 2015.
Formenty P. Ebola-Marburg viral diseases. In: Heymann DL, ed. Control of Communicable Diseases Manual. Washington, DC: American Public Health Association; 2008:204-207.
Kibadi K, et al. J Infect Dis. 1999;doi:10.1086/514288.
Moshifar M, et al. Clin Ophthalmol. 2014;doi:10.2147/OPTH.S73583.
For more information:
Dennis S.C. Lam, MD, FRCOphth, can be reached at State Key Laboratory in Ophthalmology, Sun Yat-Yen University, 54 South Xianlie Road, Guangzhou 510060, People’s Republic of China; email: dennislam.gm@gmail.com.
Disclosures: Das and Lam report no relevant financial disclosures.