Eyeworld

EW NEWS & OPINION 28 April 2016 by Liz Hillman EyeWorld Staff Writer and Steven Yeh, MD, Emory Univer- sity Hospital—said that previously little was known and there is still much to learn. "Very little is known about the ocular complications in EVD prior to this outbreak from acute disease to convalescence," the group said. "Given the magnitude of this out- break, we are learning a great deal from our patients that will hopeful- ly prepare practitioners for future outbreaks. "The ocular complications are studied even less, but as care is shift- ed from the acute disease to survivor care, we are obtaining a better un- derstanding of ocular disease that is developing in survivors," they said. The cross-sectional study in- volved what is considered the "larg- est representative sample of West African survivors of EVD from the 2014–15 outbreak" and evaluated not only the patients' ocular status but auditory function and joint pain as well. Of the 277 survivors from Port Loko, Sierra Leone, in the study, 167 developed some form of ocular symptom either while in Ebola treatment units or up to 17 weeks after being discharged. Uveitis was observed in 18% of these patients (46% anterior, 26% posterior, 3% intermediate, and 25% panuveitis). "Each ocular symptom, com- pared with its absence, was associat- ed with uveitis," the study authors wrote. "The presence of blurry vision, light sensitivity, or itchy eye was 88% sensitive and 50.7% specif- ic for underlying uveitis." The researchers found that viral load at the time patients were diag- nosed with EVD was an "indepen- dent predictor of ocular symptoms and specifically uveitis." "Uveitis is a complex disease and can cause varying degrees of severity from anterior uveitis to panuveitis," the study authors interviewed for this article said. "In patients with mild disease the visual impact can be small, but in patients who develop panuveitis that goes untreated, the visual outcomes can lead to blindness, and structural complications may develop that can only be addressed by surgery." Treatment of uveitis, they added, depends on where it is in the eye and what caused it. With Ebola- related uveitis, physicians have successfully treated inflammatory eye disease with corticosteroids, al- though treatment strategies require further study. "Disease severity dictates if the patient will need ophthalmic drops (i.e., topical corticosteroids) or if their disease severity will necessitate oral corticosteroids," the group of ophthalmologists said. "Patients need to be monitored closely because ophthalmic and systemic complications can develop with corticosteroid treatment." The study also reported con- junctivitis in 11% of the survivors. The group said treatment for this condition involves supportive care, such as artificial tears and cold com- presses. In many cases patients with viral conjunctivitis will be complete- ly healed without any long-term effects, but in rare cases the physi- cians said conjunctival scarring can lead to chronic surface dryness. This scarring may require treatment with topical steroids, artificial tears, or in more extreme cases, surgery. So where does medicine go from here? Although the World Health Organization declared an end to this disease outbreak in January 2016, it cautioned there could be flare-ups. Couple that with the continued care survivors still need in a health sys- tem that is itself recovering after the outbreak and there is much work to be done. Sharmistha Mishra, MD, infectious diseases physician, St. Michael's Hospital, Toronto, and senior author of the paper, said if adequate medical care was difficult to come by during the outbreak, the same remains true afterward as well. "Follow-up care is important, but it has to be taken with the con- text of the overall health systems' needs of the affected areas and inte- grated into health systems strength- ening plans," she said. But access to care for Ebola sur- vivors—and everyone else for that matter—has been hampered by weak health systems that were further set back by the outbreak itself, Dr. Mishra said. This study, she continued, is a "call for continued support for health systems strengthening in West Africa and underlines the need for follow-up care for these compli- cations." "Patients are still being screened so there is still much to learn in terms of the ocular complications re- lated to Ebola survivors," the group of ophthalmologists said. "Survivors also have ocular disease unrelat- ed to Ebola including age-related cataracts, retinal detachment, and glaucoma that need to be addressed. Although uveitis is observed in Eb- ola survivors, other causes of uveitis including toxoplasmosis are seen in West African patients and need to be considered." At this point, the ophthalmol- ogists said protocols are being de- veloped on how to handle patients with uveitis who need cataract surgery, due to the ability of an infectious Ebola virus to persist in fluids. EW Reference Mattia JG, et al. Early clinical sequelae of Ebola virus disease in Sierra Leone: a cross-sectional study. Lancet Infect Dis. 2015 Dec 22. [Epub ahead of print] Editors' note: The sources have no financial interests related to their comments. Contact information Crozier: icrozier@me.com Mattia: johnjgmattia@gmail.com Mishra: sharmistha.mishra@utoronto.ca Shantha: jgshantha@gmail.com Vandy: matthewjusuvandy@yahoo.co.uk Yeh: steven.yeh@emory.edu Despite surviving a deadly disease, former Ebola patients can face ongoing health issues T he historic 2014 Ebola outbreak that hit several West African countries and trickled into others resulted in more than 28,600 docu- mented cases and more than 11,300 deaths. The focus at the time was on stopping the disease from spreading and caring for those with the ex- tremely virulent hemorrhagic fever. Now, 2 years after the outbreak start- ed, more than an estimated 17,000 survivors remain. Although they may be lucky just to be alive, some survivors now have persistent ailments resulting from the disease. In fact, a recent study published in the journal Lancet Infectious Diseases found that sur- vivors of Ebola virus disease (EVD) presented with ocular conditions such as uveitis and conjunctivitis. When asked what was known of the longer-term effects of Ebola infection on the eye, some of the authors on this study—Matthew Vandy, MD, Sierra Leone National Eye Health Program, John Mattia, MD, Christian Blind Mission Sierra Leone, Jessica Shantha, MD, Emory University Hospital, Ian Crozier, MD, World Health Organization, Largest study of Ebola survivors finds ocular complications Study co-author and ophthalmic nurse Amadu Kamara (left) conducts an eye exam at the Port Loko Ebola Survivor Clinic in Sierra Leone. Source: Sharmistha Mishra, MD

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