Ebola Lingers in Survivors and Care Team Precautions Needed

Marcia Frellick

August 07, 2019

CHICAGO — New evidence of significant vitreoretinal pathology in Ebola survivors has surgical teams taking note of the considerable precautions that will be needed to treat these people, even years later.

It is important to remember that the virus remains in the eyes of survivors long after they have otherwise recovered from Ebola, and it is not yet known whether there will be progression, said Dilraj Grewal, MD, from the Duke Eye Center in Durham, North Carolina.

If these patients need treatment or surgery down the road, the surgical team would be well advised to take extensive precautions, Grewal advised.

The research comes amid an Ebola outbreak in the Democratic Republic of Congo — the second biggest in history — which was recently declared a "public health emergency of international concern" by the World Health Organization (WHO). The largest outbreak was in West Africa from 2013 to 2016.

Anterior uveitis has been the most common finding in the few large studies of eyes of Ebola survivors, Duncan Berry, MD, a retina fellow at Emory University in Atlanta, pointed out.

"We know with some of the other viruses — Zika, for instance — that there is considerable involvement of the back of the eye in terms of scarring," Grewal explained. "That is new because, traditionally, we have thought it causes inflammation or uveitis, but we didn't appreciate the full involvement with scarring the retina."

Berry presented new results from the Ebola Virus Persistence in Ocular Tissues and Fluids Study (EVICT), which was started to determine the safety of performing cataract surgery in these patients (EBioMedicine. 2018;30:217-224).

On the EVICT team were Berry's two Emory colleagues — Jessica Shantha, MD, and Steven Yeh, MD — who worked as part of an international team with the Ministry of Health in Sierra Leone and the WHO.

Participants were referred from local eye clinics to a central location — compliant with WHO biosafety standards— for screening, evaluation, and manual small-incision cataract surgery when needed.

For their analysis, Berry, Shantha, and Yeh reviewed the screened cohort of EVICT patients to look for vitreoretinal findings. All patients had been examined by an ophthalmologist using dilated fundus exams and ultrasound when indicated.

Of the 137 patients, 125 had eye exam data sufficient for analysis. Average visual acuity was 20/30, but ranged from 20/20 to light perception only, and median age was 28 years. Uveitis was present in 35.6% of patients and visually significant cataract was present in 23.2%. There was a significant association between vitreoretinal findings — documented in 26 of the 250 eyes — and worse visual acuity (median visual acuity, 20/800)

Chorioretinal scarring, present in 7.8% of the eyes, was the most common finding affecting the fundus. And choroidal thickening, detected with ultrasound, was present in 19.6% of the eyes screened. Retinal detachment, identified on fundus exam or ultrasound, was detected in 2.8% of the eyes.

The cross-sectional nature of the analysis, the lack of multimodal imaging in the field, and possible confounding from high rates of baseline uveitis are all limitations to the study, Berry acknowledged during his presentation here at the American Society of Retina Specialists 2019 Annual Meeting.

Although the safety of cataract surgery was established in the large cohort of Ebola survivors in the EVICT study, the safety of vitreoretinal surgery has yet to be confirmed, and specialists are recommending considerable precautions be taken at this time.

EVICT was supported by an unrestricted grant from Research to Prevent Blindness to the Emory Eye Center and National Eye Institute and a National Institutes of Health Core Grant to Emory University. Berry, Shantha, Yeh, and Grewal have disclosed no relevant financial relationships.

American Society of Retina Specialists (ASRS) 2019 Annual Meeting. Presented July 30, 2019.

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