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Clinical Updates — Clinical Updates

Persistence of Ebola Virus in Ocular Fluid During Convalescence

The largest outbreak of Ebola virus disease (EVD) in history is currently ongoing in West Africa with over 27,000 cases leading to 11,169 reported deaths as of June 17, 2015.^[1]  The majority of cases have been reported in Sierra Leone, Liberia, and Guinea with the fatality rate ranging from 57% to 60% in these 3 intense-transmission countries.

In the current issue of the New England Journal of Medicine, physicians from Emory University Hospital report the detection of live Ebola virus from the intraocular fluid of a patient during EVD convalescence.^[2]  In collaboration with the Serious Communicable Diseases Unit at Emory University Hospital, ophthalmologists from the Emory Eye Center have been treating a patient with anterior uveitis that progressed to a severe panuveitis.  The clinical findings and the detection of viable Ebola virus in the aqueous humor have significant individual and public health implications relevant to the ongoing West African outbreak.

Clinical and Laboratory Findings

A 43-year-old physician working in an Ebola treatment unit in Kenema, Sierra Leone was transferred to Emory University Hospital four days after the onset of symptoms.  His hospital course was complicated by multi-organ failure requiring mechanical ventilation for 12 days and hemodialysis for 24 days.^[3] The patient was discharged after 40 days of inpatient care.  Blood and urine were negative for Zaire ebolavirus (EBOV) by quantitative reverse transciptase-polymerase chain reaction (qRT-PCR) testing at the time of discharge.

One hundred days following the initial diagnosis of EVD, the patient presented with an acute anterior uveitis and severe ocular hypertension.  Topical corticosteroids and ocular hypotensive medications were initiated.  Because of clinical worsening, an anterior chamber paracentesis was performed using strict sterile technique and infectious precautions.  The sample tested positive for EBOV RNA.  A viral culture of the aqueous humor performed at the Centers for Disease Control and Prevention confirmed viable EBOV.  A conjunctival swab and tear film specimen taken prior to and 24-hours post procedure were both negative for EBOV RNA.  

Ophthalmic treatment consisting of topical and systemic corticosteroids, oral antiviral therapy, and a periocular corticosteroid injection led to an improvement in the patient’s visual acuity and clinical findings at a three-month follow-up examination.  Monitoring for disease recurrence is ongoing.

Implications for Patients and Health Care Providers

The detection of viable EBOV in the aqueous humor demonstrates that EBOV may persist in patients during EVD convalescence following clearance of EBOV from the blood.  Therefore, it is imperative that health care providers and institutions caring for EVD survivors or suspected EVD survivors take appropriate infection control precautions for the safety of all individuals involved in the treatment of ocular complications secondary to EVD. 

Specific measures include the development of standard operating protocols for donning and doffing personal protective equipment, laboratory specimen handling, and waste management. The samples of conjunctivae and tears were negative for EBOV.  In the absence of exposure to intraocular fluid, EVD survivors pose no risk of spreading the infection through casual contact (e.g. ophthalmic examination including intraocular pressure, gonioscopy, indirect ophthalmoscopy).

However, invasive procedures such as intraocular injections and surgical procedures (e.g. cataract surgery, vitreoretinal procedures, glaucoma procedures) should be avoided during EVD convalescence.  Only after careful infection control precautions and protocols have been established, should any invasive procedures be considered.

 Take Home Points

1. Uveitis may occur in EVD survivors during disease convalescence. 
2. Live Ebola virus was detected in intraocular fluid by viral culture and molecular testing.
3. Infection control precautions in EVD survivors undergoing invasive ocular procedures are imperative to ensure the safety of all individuals involved.
4. Patients who recover from EVD do not pose any known risk of infection transmission by casual contact.

References

1. Ebola Situation Reports. Geneva: World Health Organization, 2015 http://apps.who.int/ebola/en/current-situation/ebola-situation-report
2. Varkey JB, Shantha JG, Crozier I, Kraft CS, Lyon GM, Mehta AK, Kumar G, Smith JR, Kainulainen MH, Whitmer S, Stroher U, Uyeki TM, Ribner BS, Yeh S.  Persistence of Ebola Virus in Ocular Fluid during Convalescence. N Eng J Med. 2015: 372: 2423-7.
3. Connor MJ Jr, Kraft C, Mehta AK, Varkey JB, Lyon GM, Crozier I, Stroher U, Ribner BS, Franch HA. Successful delivery of RRT in Ebola virus disease. J Am Soc Nephrol. 2015;26:31-7.

Published June 2015