Eye disease, with the specter of blindness, has become a dreaded complication of Ebola. Doctors have been shocked to find cataracts in Ebola survivors as young as 5.
FREETOWN, Sierra Leone — Cataracts usually afflict the old, not the young, but doctors have been shocked to find them in Ebola survivors as young as 5. And for reasons that no one understands, some of those children have the toughest, thickest cataracts that eye surgeons have encountered, along with scarring deep inside the eye.
Before the Ebola epidemic in West Africa from 2013 to 2016, doctors did not realize how much damage the disease could leave in its wake, because previous outbreaks were small and survivors few. Eye disease, with the specter of blindness, has become a dreaded complication.
There are about 17,000 Ebola survivors in West Africa, and researchers estimate that 20 percent of them have had a severe inflammation inside the eye, uveitis. It can cause blindness, but even if it resolves and sight returns, cataracts can quickly follow. Usually, just one eye is affected.
Until recently, surgeons have hesitated to remove cataracts from Ebola survivors, for fear that the insides of their eyes might still harbor the virus.
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But physicians from Emory University have made a series of visits to West Africa to study eye problems in survivors, treat them and find ways to prevent blindness if more Ebola outbreaks occur. One goal has been to look for the virus in the eyes of survivors with cataracts, to let local surgeons know whether it is safe to operate.
“Hopefully, more patients will get access to cataract surgery, and practitioners will feel safe,” said Dr. Jessica Shantha, an ophthalmologist from Emory.
The West African epidemic was the world’s largest, infecting more than 28,600 people and killing more than 11,300 in Guinea, Liberia and Sierra Leone. There are about 4,000 survivors in Sierra Leone. The disease has left deep scars: thousands of orphaned children, worsening poverty for survivors who could not work, families shattered by multiple deaths.
Many survivors suffer from “post-Ebola syndrome” — debilitating muscle and joint pain, headaches, fatigue, hearing loss and other lingering ills, sometimes even seizures.
Like the patients he is now trying to help, Dr. Ian Crozier, an infectious-disease specialist who contracted Ebola while treating patients in Sierra Leone in 2014 and who recently joined the National Institutes of Health, was blinded in one eye by uveitis and recovered — but then lost his sight a second time, to a cataract. He had surgery in March.
His eye disease, described on May 7, 2015, in The New England Journal of Medicine, put the world on alert. Nearly two months after he had seemingly recovered from Ebola, and after his blood was free of it, severe uveitis suddenly developed — and ophthalmologist Steven Yeh was stunned to find that the fluid inside Crozier’s eye was teeming with active virus. At that time, uveitis was also emerging in West Africa.
Eventually, the immune system seems to eliminate the virus, but no one knows how long that takes. Eighteen months after the virus was first found inside Crozier’s eye, a repeat test was negative. But when the virus level actually dropped is not known.
Sierra Leone’s Ministry of Health and Sanitation was eager for Emory’s help, according to Dr. Kwame Oneill, who manages its Comprehensive Program for Ebola Survivors. “Ian’s story was the turning point for survivors.”
How many survivors have eye trouble is not known. Many live in far-flung provinces and have lost touch with health authorities. But a volunteer group, the Sierra Leone Association of Ebola Survivors, has tried to find patients who need help, and has helped pay for travel and lodging so they could consult the doctors from Emory. By this past summer, the Emory team had seen about 50 Ebola survivors with cataracts, from 5-year-olds to people in their 60s.
Cataract surgery requires cutting into the eye to remove the cloudy lens, and inserting an artificial lens. It generally takes 10 or 15 minutes.
In the case of 8-year-old Aminata Conteh, the operation took three times that. Scars had fused her lens and iris, and the surgeon had to tease them apart. The capsule of tissue around the lens was so calcified that it was like cutting through cement, he said, adding that the scarring likely would have worsened with time.
The cataract was much denser than those that occur in old people, and only after it was removed could the doctors glimpse Aminata’s retina — the layer of light-sensitive cells at the back of the eye, essential for sight. The doctors looked for a “red reflex,” the glow of a normal retina when a light is shined on it. The reflex was absent, which suggested that there might be damage to the retina, or abnormalities in the fluid in front of it.
After surgery, her vision had not improved and she could still only see hand motion. A month later, a laser procedure markedly improved Aminata’s vision. It’s still not 20/20, but she can see well enough to catch a ball, read with glasses, tell a spoon from a fork. Time will tell whether she improves further.