Ebola: Doctor's Eye Turns Green From Infection

Ebola infection isn't always over even when the viremia is cleared. In an account in the New England Journal of Medicine, Ian Crozier, MD, and colleagues report on a sight-threatening Ebola eye infection that mysteriously turned his left eye from blue to green before it retreated. Crozier, a World Health Organization volunteer working in West Africa, was the patient.

The book on the Ebola virus is still being written and the convalescence of one victim, Ian Crozier, MD, adds a riveting chapter. The virus, known to cause blind spots and other vision problems, temporarily changed his left eye from blue to green—then the puzzling effect retreated.More importantly, the infection nearly cost him his vision in that eye, a complication that is likely more common than has yet been documented in epidemics in West Africa.

Reporting in the New England Journal of Medicine, Crozier and colleagues who treated him at Emory University Hospital in Atlanta, GE, tell of finding the virus in his eye and eye fluid 14 weeks after he came down with an Ebola infection and 9 weeks after clearance of viremia.

Crozier was working for the World Health Organization in an Ebola treatment unit in Sierra Leone when he became ill and in September 2014 was diagnosed with Ebola virus infection. A native of Zimbabwe, Crozier moved to the US with his family when he was 10, and he eventually went to medical school at Vanderbilt University where he became an infectious disease specialist. After Ebola broke out he left a hospital job in Uganda in August, 2014, to work with WHO, an assignment he thought would last a few weeks. Then he became ill.

Evacuated back to the US he was treated at Emory University Hospital in Georgia. There he got the experimental antiviral TKM-100802, (TKM Ebola/ Tekmira Pharmaceuticals). He also got plasma from another patient who had recovered from the virus as well as getting aggressive supportive care.

Crozier had been desperately ill, with multi-organ system failure that had him on mechanical ventilation for 12 days and dialysis for 24 days.

His illness continued long after he was extubated, he and colleagues reported. Symptoms included extreme fatigue, difficulty walking, and sometimes trouble finding the words to speak.

Though there was no more virus in his blood or urine, a semen sample was positive and he was told to refrain from unprotected sex for 3 months—in keeping with the recommended timeline for recovered Ebola patients at the time. (Last week the US Centers for Disease Control changed that time period and advised recovered patients to use condoms “indefinitely.” A report on the new recommendation is here.)

It was not until 10 weeks after the original infection, and after he had been discharged that Crozier started to develop eye symptoms. Those included photophobia, ocular burning, foreign-body sensation and a vision acuity change that caused him to get a new eyeglass prescription. At the 14-week point, Crozier’s left eye was getting worse with high intraocular pressure and anterior uveitis. Both conditions continued worsen, so a doctor extracted fluid from the inflamed eye. Tests showed the ocular fluid contained Ebola virus—even though the patient’s tears were negative for the virus and thus his infection was not contagious.

In discussing the case in the NEJM article, the authors note that a similar eye infection had been seen earlier in a 25 year old Ebola patient. Again, the eye problems did not occur until weeks after the patient’s viremia had cleared. In a study of 20 Ebola survivors of a 1995 epidemic, 3 had similar problems, but researchers said they could find no reports of how well those patients fared after the study.

Though Crozier’s eye symptoms were treated with steroids and other standard eye remedies, the NEJM article reached no conclusion about the mechanism of the eye infection or why it subsided. The fact that the eye is an “immune-privileged organ” likely played a role, the authors said. The very cellular mechanisms that protect the eye from the machinations of the immune system could also cause it to harbor a virus.

Discussing the episode in The New York Times, Crozier said he believes it was an experimental anti-viral that turned the tide. According to that account, the manufacturer of that drug and the researchers testing it refused to allow publication of its name because they expect to write about it soon in a journal article.

A week after getting that drug his vision began to return. But it is not clear that the drug was responsible. Recovery took months, and eventually the peculiar eye color change was gone. Both eyes were blue again.

Elated, Crozier decided to return to West Africa, embarking April 9 on trip to Liberia. He told the newspaper he wants to help research in vision-threatening infections in former Ebola patients and hopes to help “change the natural history of the disease for survivors,”