New Research: Ebola Survivors Have Ongoing Risk of Eye Disease, Even When the Initial Outbreak Has Concluded

Cover of the journal Ophthalmology

Although worldwide attention was focused on the 2014-2016 Ebola outbreak in West Africa, considerably less attention – until now – has been paid to the eye and vision complications resulting from the disease. This month, a group of researchers from the United States, Liberia, and Uganda have published data describing the ocular findings, visual impairment, and associated complications of Ebola in a group of survivors in Monrovia, Liberia.

They conclude that “survivors of Ebola virus disease (EVD) are at risk for uveitis (explained below), which may lead to eye damage, visual impairment, and blindness. Eye care resources should be mobilized for EVD survivors throughout West Africa, who are at ongoing risk of uveitis and severe vision loss, although the acute EVD outbreak has concluded.

From the Journal Ophthalmology

This new Ebola/eye disease research, titled Ophthalmic Manifestations and Causes of Vision Impairment in Ebola Virus Disease Survivors in Monrovia, Liberia, has been published online ahead of print in the December 2016 edition of Ophthalmology, the official journal of the American Academy of Ophthalmology. Ophthalmology publishes original, peer-reviewed research in ophthalmology, including new diagnostic and surgical techniques, the latest drug findings, and results of clinical trials.

The authors are Jessica G. Shantha, MD; Ian Crozier, MD; Brent R. Hayek, MD; Beau B. Bruce, MD, MPH; Catherine Gargu; Jerry Brown, MD; John Fankhauser, MD; and Steven Yeh, MD, who represent the following organizations and institutions: Emory University School of Medicine and Emory University, Atlanta, Georgia; the Infectious Diseases Institute, Kampala, Uganda; the Ministry of Health and Sanitation, Monrovia, Liberia; and Eternal Love Winning Africa Hospital, Monrovia, Liberia.

About the Ebola and Uveitis Research

Edited and excerpted from Vision impairment and eye diseases continue to be concerns for Ebola survivors, via Medical Xpress:

The acute outbreak of Ebola virus disease (EVD) has subsided in West Africa, but the medical community continues to learn about long-term complications for survivors – including the potential for blinding eye disease. One particular condition of concern is uveitis.

Uveitis refers to inflammation of the eye, which can lead to problems ranging from mildly reduced vision to severe vision loss and blindness. Patients with uveitis can experience eye redness, blurred vision, eye pain, headache and/or sensitivity to light.

The [study] reports on nearly 100 EVD survivors in Monrovia, Liberia. Liberia, along with Sierra Leone and Guinea, were the three countries most affected by the 2014 EVD outbreak. More than 10,000 cases of EVD were reported in Liberia alone during the recent outbreak; over 28,000 cases were reported during the West African EVD outbreak between 2013 and 2016.

Of the 96 patients examined, 21 had developed an EVD-associated uveitis and three developed an EVD-associated optic neuropathy [i.e., damage to the optic nerve]. In addition, nearly 40 percent of the patients with uveitis were legally blind. Other findings include cataract and [floaters/flashes of light], which can both be complications of untreated uveitis.

“These findings have implications from medical and surgical perspectives, particularly given our prior finding of live Ebola virus in the ocular fluid of a recovered Ebola survivor,” said [study co-author] Steven Yeh, MD.

The public health risk in these cases lies in knowing what kinds of precautions health care workers should take when treating Ebola survivors who develop cataracts.

What is Ebola Virus Disease?

From the World Health Organization (WHO) Ebola key facts:

  • Ebola virus disease (EVD), formerly known as Ebola hemorrhagic [i.e., bleeding, both internally and externally] fever, is a severe, often fatal illness in humans.
  • The virus is transmitted to people from wild animals and spreads in the human population through human-to-human transmission.
  • The average EVD case fatality rate is around 50%. Case fatality rates have varied from 25% to 90% in past outbreaks.
  • The first EVD outbreaks occurred in remote villages in Central Africa, near tropical rainforests, but the most recent outbreak in West Africa has involved major urban as well as rural areas.
  • Community engagement is key to successfully controlling outbreaks. Good outbreak control relies on applying a package of interventions, namely case management, surveillance and contact tracing, a good laboratory service, safe burials, and social mobilization.
  • Early supportive care with rehydration, and [treatment of symptoms] improves survival.
  • There is as yet no licensed treatment proven to neutralize the virus, but a range of blood, immunological, and drug therapies are under development.
  • There are currently no licensed Ebola vaccines but two potential candidates are undergoing evaluation.

You can read more about Ebola transmission, symptoms, diagnosis, treatment, prevention, and controlling infection in health-care settings at Ebola virus disease: Fact sheet from WHO.

What is Uveitis?

an eye with anterior uveitis
An eye with anterior uveitis

Uveitis (you-vee-EYE-tis) is an internal inflammation of the eye, involving the middle layers of the eye, also called the uveal tract. The uveal tract contains veins and arteries that transport blood to the parts of the eye that are critical for vision:

  • Ciliary body: Contains the ciliary muscles, which change the lens shape and curvature, and the ciliary processes, which produce aqueous humor, a clear, watery fluid that provides nutrients to all parts of the eye.
  • Iris: A tissue inside the eye that has a hole in the center, forming the pupil. The iris contains muscles that allow the pupil to become larger (open up or dilate) and smaller (close up or constrict). The iris regulates the amount of light that enters the eye by adjusting the size of the pupil opening. The iris also determines eye color.
  • Choroid: A dark brown membrane that is rich with blood vessels. It supplies blood and nutrients to the retina and nourishes all other structures within the eye.

Uveitis has many potential causes, including inflammatory disease affecting other parts of the body; a viral infection; bacteria; a fungal infection; a parasite, or an injury to the eye. Symptoms of uveitis include eye redness and irritation; blurred vision; eye pain; and increased sensitivity to light.

Complications of uveitis can include glaucoma; cataracts; abnormal growth of blood vessels in the eyes that interfere with vision; fluid within the retina; and vision loss. Early diagnosis and treatment is critical. See New Research: Uveitis, an Inflammatory Eye Disease, May Signal the Onset of Multiple Sclerosis for other potential complications.

More about the Ebola Study from Ophthalmology

From the study summary and abstract:

Purpose: To describe the ocular findings, visual impairment, and association of structural complications of uveitis with visual impairment in a cohort of survivors of Ebola virus disease (EVD) in Monrovia, Liberia.

Participants: Survivors of EVD who were evaluated in an ophthalmology clinic at Eternal Love Winning Africa (ELWA) Hospital in Monrovia, Liberia.

Methods: A cohort of EVD survivors who underwent baseline ophthalmic evaluation at ELWA Hospital were retrospectively [i.e., examining data and records that were collected in the past] reviewed for demographic information, length of Ebola treatment unit (ETU) stay, visual acuity (VA), and ophthalmic examination findings. For patients with uveitis, disease activity (active vs. inactive) and grade of inflammation were recorded according to Standardization of Uveitis Nomenclature criteria.

The level of VA impairment was categorized according to World Health Organization classification as follows: normal/mild, VA 20/70 or better; moderate, VA 20/70–20/200; severe, VA 20/200–20/400; blindness, VA less than 20/400. Visual acuity, length of ETU stay, and structural complications were compared between EVD survivors with and without uveitis. Structural complications associated with moderate VA impairment or poorer were analyzed.

Results: A total of 96 survivors of EVD were examined. A total of 21 patients developed an EVD-associated uveitis, and 3 patients developed an EVD-associated optic neuropathy. Visual acuity was blind in 38.5% of eyes with uveitis. Examination findings associated with at least moderate visual impairment by World Health Organization criteria (VA less than 20/70) included keratic precipitates [i.e., inflammatory deposits on the cornea]; posterior synechiae [i.e., the iris adhering to the lens]; vitritis [i.e., inflammation of the vitreous]; and chorioretinal scars [i.e., scarring or inflammation of the choroid and retina].

Conclusions: Survivors of EVD are at risk for uveitis, which may lead to secondary structural complications, visual impairment, and blindness. Eye care resources should be mobilized for EVD survivors in West Africa because of the frequency of this spectrum of disease complication and its potential for severe VA impairment and blindness.

Additional Information at VisionAware