Post-Ebola Survival Eye Clinic In Liberia Part 2

    Medecins Sans Frontieres / Doctors Without Borders is usually an emergency / crisis health organization  rather than a developmental health NGO. As they frequently state, they go where others don’t. They are happy enough eventually to hand over their operations / programs to other NGO’s ( non-government developmental organization ) or to the national Ministry of Health.  As part of my briefings in NYC,  I was given a handout titled “Psychosocial Survival Guide to Kidnapping’’. I thought that could potentially make for interesting reading.  I mean that’s a different perspective for this ophthalmologist.

     While in Liberia I have held  eye clinics twice weekly for the post-Ebola survival patients that are having eye signs / symptoms. Many of these patients acknowledged redness, decreased vision, ocular pain, tearing, etc. during their acute Ebola phase when many of these patients were hospitalized in the Ebola Treatment Units ( ETU ) which were scattered about Monrovia and elsewhere. Once the ETU’s  were full ( overflowing ) no additional patients were admitted and people literally died in the streets. Monrovia City was the hardest hit area of Liberia for Ebola hemorrhagic fever.

   There has been described a post-Ebola uveitis syndrome which is not uncommon. I saw seven survivors with old inactive anterior unilateral uveitis --- old fine KP’s, pigment clumping, posterior synechiae ( uncommon ),  no cells in A.C., etc.  Three of these patients had a secondary significant  cataract. Most of these patients had unilateral eye findings only. I did not find any patient that had any iris retroillumination defects which, as we know, can be seen with / after anterior uveitis secondary to herpes. I saw one patient only with  ( sector ) optic atrophy ( + RAPD ), two patients with active intermediate uveitis and marked vitritis  ( hazy ) one requiring peribulbar trimcinolone twice. I placed this patient on doxycycline 100 mg bid  and sent him off eventually for a limited work up.

   Apparently no one knows how long the active ( live ) virus remains in the eye ( aqueous/ vitreous ), in the testicles ( semen ), or in the mammary gland ( breast milk ) --- “ immunologically privileged sites “ .  The active Ebola phase in Liberia was around May 2013 – January 2015 ( depending on who you ask ). The conventional assumptions and field observations is that most EBOV transmission comes from direct contact with blood or bodily fluids of an infected patient during the acute phase of the disease. So cataract surgery later this year may not be a concern.  However no one knows for sure and extra surgical precautions may be in order. With cataract surgery,  collecting the nucleus ( hold the phaco unit ) and aqueous / vitreous samples have been suggested.

Some of these patients claim an episode of blurred vision after their acute phase. Sometimes this blurred vision has been ongoing. Some of these survival patients claimed blurred vision although the eye exam was “normal. “

I saw one patient with advanced bilateral glaucoma  with increased C/D ratios which was not related to his Ebola episode. I’m surprised I did not see more glaucoma in this African population. I initially did a confrontation test on this glaucoma patient and his left  nasal field was defective. I went back to check again his right eye which again was OK in my hands. So anyway my point is I initially spotted a red flag in this glaucoma patient with confrontational visual fields before checking the IOP which were in the 30’s OU. This glaucoma patient had somewhat sluggish pupils but no RAPD. As we all know to have a RAPD you probably need a difference in damage to the two optic nerves and perhaps this patient had about equal damage OU.

The illiteracy  rate in Liberia appears quite high. As we know,  Snellen charts using numbers  ( or tumbling E’s)  often are more useful as many patients know their numbers but not their letters. However what the PA’s in the MSF pediatric hospital  do for take home instructions  for the mother is write out “1—1--1 “ which would mean three times per day. So instead of writing “ 3 “ on the eyedrop bottle, the PA’s would write “ 1---1---1 ”. Anyway, useful way to inform illiterate about dosage.

 

Ophthalmic Observations / Tips from Liberia: ( teaching points )

#1. Put dust cover over slit lamp. This is frequently not done in the developing world  and shortens the life of the biomicroscope.

#2. Do not give steroid  drops for old inactive uveitis or corneal scar.

#3. If pupil doesn’t dilate any but is still reactive to bright light, then the patient probably is not using the dilating  drops ( atropine ) you had prescribed.

#4. For itchy, burning, tearing symptoms safer to prescribe ketorolac ( NSAID ), or anti-histamine agent ( olopatadine ), cromolyn rather than topical steroids.

#5. If the visual acuity is definitely NLP then the next visit that eye should not be 20/200 or better. One of those V.A. readings is not correct.

 

Hope some of this has been interesting. Certainly for me  seeing the post Ebola eye survivors has been a learning experience.

 

Peace, Baxter

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