Ebola warning for ophthalmologists

The New England Journal of Medicine (NEJM)recently announced that Ebola was discovered inside the eyes of a patient months after the virus was gone from his blood, and now the American Academy of Ophthalmology (AAO) is urging physicians to take extreme precautions when performing surgery on survivors of the deadly virus.

“The medical community has appreciated that the Ebola virus can remain viable in some body fluids for an extended period of time after the initial onset of the disease,” said Russell N. Van Gelder, MD, PhD, president of the AAO and a uveitis specialist. “This remarkable case now demonstrates that the virus can remain viable in ocular fluids long after the patient has recovered from the systemic infection.

Russell N. Van Gelder, MD, PhD

“If the Ebola epidemic continues, ophthalmologists throughout the world will be seeing patients with post-Ebola uveitis, will need to recognize and treat this condition, and will need to take appropriate increased precautions in performing surgical procedures on these patients,” Dr. Van Gelder explained.

More in this issue: Office-based surgery coming sooner than you think

According to the International Business Times (IBT), Ian Crozier, MD, was flown last September to Emory University Hospital in Atlanta to be treated for Ebola after contracting the deadly virus while working in Sierra Leone. After battling for his life, Dr. Crozier was declared cured and released by the hospital.

“(However,) a burning sensation in his left eye, a sensitivity to light, and the feeling that something was stuck in his eye continued to bother him. Later he suffered blurred vision, pain and inflammation, and the color of his eye turned from grey to green. When doctors tested the aqueous humor, the watery substance inside the eye, it tested positive for Ebola. It was a startling discovery for doctors who were unaware that the infection could hide and grow in the eyes after it has been vanquished elsewhere in the body,” IBT reported.

What ophthalmologists need to know about the virus

Emory physicians-who speculated that immune adaptions in the eye that guard inflammation could possibly make eyes more vulnerable to Ebola-were eventually able to save Dr. Crozier’s eyes, but it took months for his vision to recover, NPR reported.

Next: 'This case highlights an important complication of [Ebola]'

"This case highlights an important complication of [Ebola] with major implications for both individual and public health," wrote the authors of the NEJM report.

Following the report, the AAO stressed that the NEJM findings “do not indicate an increased risk of Ebola infection to the general public through casual contact.”

“I want to emphasize that as far as we know, the Ebola virus is not transmitted by casual contact,” Dr. Van Gelder said. “The current study does not suggest that infection can be transmitted through contact with tears or the ocular surface of patients who have recovered from their initial infection.”

Peter McDonnell, MD, on the Ebola outbreak

However, the current study does indicate uveitis may be associated with active Ebola within the eye, and highlights “the vital importance of such safety measures for ophthalmic health care professionals when performing invasive procedures such as intraocular injections or surgery for cataracts or glaucoma on patients who have been infected with the Ebola virus,” said the AAO in a prepared statement.

The Centers for Disease Control and Prevention recommend that all health professionals take special precautions when treating patients who are or have been infected with the virus. The measures include wearing appropriate protective garments, proper disinfection of equipment, and employing appropriate waste management to minimize the spread of infection.

Following the U.S. Ebola outbreak in November, the academy released a statement breaking down what ophthalmologists need to know about the virus:

Transmission to Health Care Personnel

Ebola virus disease among healthcare personnel and other persons is associated with direct contact with persons exhibiting symptoms (or the bodies of persons who have died from Ebola virus disease) and direct contact with body fluids from these patients. Ebola is spread through direct contact (through broken skin or mucous membranes in the eyes, nose, or mouth for example) via:

·      Blood or body fluids (including saliva, mucus, vomit, feces, sweat, tears, breast milk, urine, and semen) of a person who is sick with Ebola

·      Objects (like needles and syringes) that have been contaminated with the virus

Next: Course of the virus

Airborne transmission of Ebola virus among humans has never been demonstrated in investigations of human-to-human transmission, but has been hypothesized. The risk of Ebola virus disease transmission from direct skin contact with an Ebola virus disease patient is lower than the risk from exposure to blood or body fluids, and may be more likely in cases of severe illness. Indirect exposure to blood and body fluids (via fomites) has also been implicated in transmission, but is not a common means. Ebola virus is killed with hospital-grade disinfectants, such as household bleach. Ebola virus dried on surfaces, such as doorknobs and countertops, can survive for several hours. However, the virus in body fluids, such as blood, can survive up to several days at room temperature.

Course of Disease

Patients with Ebola generally have an abrupt onset of fever and symptoms that typically occurs 8 to 12 days after exposure, but can range from 2 to 21 days after exposure. Early signs and symptoms are nonspecific and can include fever, chills, myalgias, and malaise. Patients can then proceed from these initial symptoms, after about 5 days, to develop gastrointestinal symptoms, e.g., severe watery diarrhea, nausea, vomiting, and abdominal pain. Other symptoms, such as chest pain, shortness of breath, headache or confusion, can develop. Seizures can occur and there have been reports of cerebral edema. Bleeding is not always present, but can be present later as petechiae, ecchymosis/bruising, and mucosal hemorrhage. Patients may develop a diffuse erythematous maculopapular rash by days 5 to 7, usually involving the neck, trunk, and arms. The most common signs and symptoms during the current outbreak in West Africa from onset of symptoms to the time of diagnosis include: fever (87%), fatigue (76%), vomiting (68%), diarrhea (66%), and loss of appetite (65%).

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Patients with fatal disease usually develop more severe clinical signs early during infection and die between days 6 and 16, and experience multi-organ failure and septic shock. In non-fatal cases, patients may have a fever for several days and improve, typically around day 6. Patients who survive can have a prolonged convalescence. The case fatality proportion among patients in West Africa is 71%; ranging from 46% in Nigeria to 69% to 72% in Guinea, Sierra Leone, and Liberia. Risk factors associated with a fatal outcome in the recent outbreak in West Africa include: age >45 years old, unexplained bleeding, and other signs and symptoms (diarrhea, chest pain, coughing, difficulty breathing, difficulty swallowing, conjunctivitis, sore throat, confusion, hiccups, and coma or unconsciousness).

One study of clinical observations of 103 patients in the 1995 Ebola outbreak found an early sign to be conjunctival injection.² The CDC notes that patients often have conjunctival injection.¹ Another study of the same outbreak found that four survivors experienced uveitis, with ocular pain, photophobia, reduced visual acuity, and hyperlacrimation.³ These surviving patients responded to a topical treatment of 1% atropine and corticosteroids.

Infection Control Precautions

The CDC recommends the following infection control precautions:

Healthcare workers who may be at risk of exposure to persons infected with Ebola should follow these steps:

·      Wear personal protective equipment (PPE), including masks, gloves, gowns, and eye protection, based on the CDC PPE guidance and procedures. The PPE Guidance recommends that:

o   All healthcare workers undergo rigorous training and are practiced and competent with PPE, including putting it on and taking it off in a systemic manner,

o   No skin is exposed when PPE is worn, and

o   All workers are supervised by a trained monitor who watches each worker put on and take off their PPE.

o   Practice proper infection control and sterilization measures. Dedicated medical equipment should be used by healthcare personnel, preferably disposable equipment whenever possible. Appropriate cleaning and disposal of instruments, such as needles and syringes, is important. If instruments are not disposable, instruments must be sterilized before reuse. (See the CDC’s Interim Guidance for Environmental Infection Control in Hospitals for Ebola Virus.)

o   Isolate infected Ebola patients from other patients.

o   Avoid direct contact with the bodies of people who have died from Ebola.

o   Notify health officials if you have had direct contact with the blood or body fluids of an infected patient.

Next: Working to prevent further spread

Conclusion

The 2014 Ebola virus disease outbreak in Africa has affected primarily Liberia, Sierra Leone, and Guinea. The CDC and other organizations are working to prevent the further spread of Ebola virus within the United States. There are no approved treatments and vaccines, although investigational vaccines are in development. Health care personnel need to use appropriate PPE, including masks, gowns, gloves, and eye protection, to avoid exposure to any body fluids of patients with Ebola virus disease.

References

• Centers for Disease Control and Prevention (CDC). Ebola Update. Available at:www.cdc.gov/vhf/ebola/index.html. Accessed November 5, 2014.

• Bwaka MA, Bonnet M-J, Calain P, et al. Ebola Hemorrhagic Fever in Kikwit, Democratic Republic of the Congo: Clinical Observations in 103 Patients. The Journal of Infectious Diseases 1999; 179:(Suppl 1): S1-7.

• Kibadi K, Mupapa, K, Kuvula K, et al. Late Ophthalmologic Manifestations in Survivors of the 1995 Ebola Virus Epidemic in Kikwit, Democratic Republic of the Congo. The Journal of Infectious Diseases 1999; 179: (Supp 1): S13-14.