More than a year after the epidemic in West Africa was recognized, doctors are still learning about the course of the disease and its lingering effects on survivors.
ATLANTA — When he was released from Emory University Hospital in October after a long, brutal fight with Ebola that nearly ended his life, Dr. Ian Crozier’s medical team thought he was cured. But less than two months later, he was back at the hospital with fading sight, intense pain and soaring pressure in his left eye.
Test results were chilling: The inside of Crozier’s eye was teeming with Ebola.
His doctors were amazed. They had considered that the virus had invaded his eye, but they had not expected to find it. Months had passed since Crozier became ill while working in an Ebola treatment ward in Sierra Leone as a volunteer for the World Health Organization (WHO). By the time he left Emory, his blood was Ebola-free.
Although the virus may persist in semen for months, other body fluids were thought to be clear of it once a patient recovered. Almost nothing was known about the ability of Ebola to lurk inside the eye.
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Despite the infection within his eye, Crozier’s tears and the surface of his eye were virus-free, so he posed no risk to anyone who had casual contact with him.
More than a year after the epidemic in West Africa was recognized, doctors are still learning about the course of the disease and its lingering effects on survivors. Information about the aftermath of Ebola has been limited because past outbreaks were small: no more than a few hundred cases, often with death rates of 50 to 80 percent. But now, with at least 10,000 survivors in Guinea, Liberia and Sierra Leone, patterns are emerging.
Crozier, 44, ruefully calls himself a poster child for “post-Ebola syndrome”: Besides eye trouble, he has had debilitating joint and muscle pain, deep fatigue and hearing loss. Similar problems are being reported in West Africa, but it is not clear how common, severe or persistent they are. There have been reports of survivors left completely blind or deaf, but these accounts are unconfirmed.
Doctors say the eye problems, because they threaten sight, are the most worrisome part of the syndrome and most urgently need attention. Crozier’s condition, uveitis — a dangerous inflammation inside the eye — has also been diagnosed in West Africans who survived Ebola.
At the height of the epidemic, health workers were too overwhelmed with the sick to worry much about survivors. But as the outbreak wanes, WHO has begun to gather information to help those who have not fully recovered, said Dr. Daniel Bausch, a senior consultant to WHO and an infectious-disease specialist at Tulane University. He added that the reports of eye trouble were of particular concern.
“It’s a major thing we need to study and provide support for,” Bausch said.
But there are few ophthalmologists in West Africa, and only they have the skills and equipment to diagnose conditions such as uveitis that affect the inner chambers of the eye.
When Crozier’s eye trouble began, he and the Emory team suspected Ebola had weakened his immune system and left him vulnerable to some other virus that had invaded his eye, maybe one that would be treatable with an antiviral drug.
So Dr. Steven Yeh, an ophthalmologist, pierced Crozier’s eye with a hair-thin needle, drew a few drops of fluid from its inner chamber and sent them to the lab. The results came as a shock.
Uveitis had been reported in some Ebola survivors from previous outbreaks, and a related virus, Marburg, had been recovered from one patient’s eye. But those cases had seemed uncommon.
A report about Crozier’s eye condition was published on Thursday in The New England Journal of Medicine.
The inside of the eye is mostly shielded from the immune system to prevent inflammation that could damage vision. The barriers are not fully understood, but they include tightly packed cells in minute blood vessels that keep out certain cells and molecules, along with unique biological properties that inhibit the immune system.
But this protection, called immune privilege, can sometimes turn the inner eye into a sanctuary for viruses, where they can replicate unchecked. The testes are also immune-privileged, which is why Ebola can persist in semen for months.
The big question was whether the doctors could save Crozier’s sight. They worried about both eyes, because ailments in one eye can sometimes spread to the other. But there was no antiviral drug proven to work against Ebola, and even if there were, there was no precedent for treating an eye full of the virus.
The usual treatment for inflammation is steroids. But they can make an infection worse.
The biggest shock came one morning about 10 days after his symptoms started, when he glanced in the mirror and saw that his left eye had changed color. His iris, normally bright blue, had turned a vivid green. Rarely, severe viral infections can cause such a color change, and it is usually permanent.
As the days passed with no sign of improvement, Crozier and the Emory team began to think he had little to lose. Dr. Jay Varkey, an infectious-disease specialist who had handled much of Crozier’s care, got special permission from the Food and Drug Administration to use an experimental antiviral drug taken in pill form. (The doctors declined to name it.)
To add to the treatment for inflammation, Yeh also gave Crozier a steroid injection above his eyeball that would slowly release the drug into his eye.
At first, there seemed to be no effect. But one morning a week or so later, Crozier realized that if he turned his head, he could find “portals” and “wormholes” through the obstructions in his eye and could see his brother Mark.
Gradually, over the next few months, his sight returned. Surprisingly, his eye turned blue again.
Was it the antiviral drug? He cannot be sure, but he thinks so.
“I think the cure was Ian’s own immune system,” Varkey said, explaining that he suspected the treatments had reduced Crozier’s symptoms and helped preserve his sight long enough for his immune system to kick in and clear out the virus — just as supportive care during the worst phase of his initial illness had kept him alive until his natural defenses could take over.
On April 9, Crozier headed to Liberia with Yeh and several other Emory physicians to see patients who had recovered from Ebola and examine their eyes.
“Maybe we can change the natural history of the disease for survivors,” Crozier said. “I want to start that conversation.”