Ophthalmology in times of epidemic and pandemic: Past and present

Nishanth S. Iyengar, BS1
1 New York University Grossman School of Medicine, New York, NY 10016, USA

Correspondence concerning this article and requests for reprints should be addressed to Nishanth S. Iyengar (nishanth.iyengar@nyulangone.org)

Epidemics and pandemics in the era of modern medicine have consistently—and rightly—catapulted infectious disease experts into the forefront of public awareness. The ongoing coronavirus disease 2019 (COVID-19) pandemic is no exception: Dr. Anthony S. Fauci, longtime head of the National Institute of Allergy and Infectious Diseases in the United States, has become a fixture of American television and a celebrity in his own right.

Less well-known are the critical roles that ophthalmologists have played in identifying, understanding, and battling catastrophic infectious disease outbreaks. The late Dr. Li Wenliang of Wuhan, China, who sounded the alarm near the beginning of the current COVID-19 pandemic, is perhaps the most salient contemporary example. Dr. Li had worked since 2014 as an ophthalmologist at Wuhan Central Hospital; in late December 2019, Dr. Li grew concerned by what he was seeing in his hospital and alerted colleagues to the potential emergence of a severe acute respiratory syndrome–like disease [1]. Despite being a qualified physician wholly invested in patient care, Dr. Li was promptly “summoned to the Public Security Bureau in Wuhan and made to sign a statement in which he was accused of making false statements that disturbed the public order” [1]. Dr. Li tragically died of COVID-19 about a month later, and hundreds of thousands of others worldwide have also lost their lives during the ongoing pandemic.

Long before COVID-19, numerous epidemics of yellow fever afflicted societies across the centuries and around the world. Yet again, an ophthalmologist played a critical role in the history of the disease and our understanding of its pathophysiology. In 1881, Dr. Carlos Finlay, a Cuban-born ophthalmologist of Scottish and French extraction, publicly posited that Aedes aegypti mosquitoes may have been responsible for outbreaks of yellow fever among human populations [2]. This was the first time that anyone had suggested that yellow fever was not transmitted directly from human to human [3]. In striking similarity to Dr. Li’s original COVID-19 tip-off, Dr. Finlay’s conjecture fell upon deaf ears [3]. Only in 1900 did the United States Army’s Yellow Fever Commission, led by the famed Dr. Walter Reed, corroborate Dr. Finlay’s groundbreaking hypothesis on the transmission of the disease [3]. General Leonard Wood, himself a physician, proclaimed that “the confirmation of Dr. Finlay’s doctrine is the greatest step forward made in medical science since [Edward] Jenner’s discovery of vaccination” [3].

The role of ophthalmologists in addressing outbreaks of infectious disease is not limited to the whistleblowing and epidemiological conjecture heretofore described. Ophthalmologists have provided—and continue to provide—vital care to individuals suffering from debilitating ocular consequences of epidemic and pandemic diseases. Perhaps the most fascinating instance of a purely ophthalmic disease that rose to epidemic proportions is trachoma. Dr. Robert M. Feibel of Washington University School of Medicine wrote in 2011 that “no ocular disease was considered more stubborn and difficult to eradicate than trachoma” [4]. Trachoma had ravaged humanity for millennia because the only therapeutic interventions were ineffective, nonspecific, and had hardly evolved since ancient times until the early 1900s, when an alarming trachoma epidemic was identified within Native American reservations [4]. This eventually spurred Dr. Fred Loe, a self-trained ophthalmologist and longtime employee of the Indian Medical Service, to make the revolutionary discovery that sulfanilamide could definitively cure trachoma [4]. Thanks to Dr. Loe’s pioneering work, by the 1970s trachoma was eliminated from Native American reservations [4].

Infectious diseases seemingly unrelated to the eye have been found to have ophthalmic complications and sequelae. The Ebola virus disease (EVD) epidemic of the mid-2010s, which wrought havoc on several countries in West Africa, is a more recent example of an infectious disease outbreak in which ophthalmologists continue to play a crucial therapeutic role. In 2017, Dr. Jessica G. Shantha of the Emory Eye Center and her colleagues described how “thousands of survivors are at-risk of systemic and ophthalmic sequelae termed the ‘post-Ebola virus disease syndrome’ [PEVDS].” Uveitis, a key component of PEVDS, affects up to one third of survivors of EVD and can lead to devastating loss of vision in the absence of necessary ophthalmic care [5,6]. Yet another example, HIV/AIDS remains an infectious disease with pandemic status, and ophthalmologists are crucial in the diagnosis and management of a critical ophthalmic sequela: cytomegalovirus retinitis [7].

In the same vein as EVD and HIV/AIDS, the present COVID-19 pandemic has spurred ophthalmologists to investigate the possible ocular implications of the disease. In March 2020, a retrospective analysis of 38 clinically-confirmed COVID-19 patients from China’s Hubei province showed that approximately one-third had ophthalmic findings consistent with conjunctivitis [8]. However, another recent study of 121 COVID-19 patients in Wuhan found that only eight patients—fewer than 10%—demonstrated ocular symptoms, including itching, redness, tearing, discharge, and foreign body sensation [9]. Indeed, this is a highly active, ongoing area of research that highlights the important contributions of ophthalmologists during outbreaks of infectious disease.

Finally, I would be remiss if I did not call attention to the extraordinary work done by ophthalmology residents and attending ophthalmologists at my own institution during the current pandemic. Residents were redeployed to medicine wards and joined forces with clinicians from a spectrum of specialties to care for COVID-19 patients. Attending ophthalmologists—including the department chairman—resurrected their knowledge of internal medicine and selflessly volunteered their time and energy to support their colleagues on the inpatient wards during this hugely challenging time. They, along with ophthalmologists around the world who have delivered exceptional care to patients battling COVID-19 and its complications, are true heroes.

REFERENCE

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  2. Haas LF. Carlos Juan Finlay y Barres (1833-1915). Journal of neurology, neurosurgery, and psychiatry. 1998;65(2):268.

  3. Finlay, Carlos. Truhlsen-Marmor Museum of the Eye, American Academy of Ophthalmology. https://www.aao.org/biographies-detail/carlos-finlay-md. Accessed May 5, 2020.

  4. Feibel RM. Fred Loe, MD, and the History of Trachoma. Archives of Ophthalmology. 2011;129(4):503-508.

  5. Shantha JG, Crozier I, Yeh S. An update on ocular complications of Ebola virus disease. Curr Opin Ophthalmol. 2017;28(6):600-606.

  6. Eye care for Ebola survivors. World Health Organization. https://www.who.int/news-room/feature-stories/detail/eye-care-for-ebola-survivors. Published 2019. Accessed.

  7. Holland GN. AIDS and ophthalmology: the first quarter century. Am J Ophthalmol. 2008;145(3):397-408.

  8. Wu P, Duan F, Luo C, et al. Characteristics of Ocular Findings of Patients With Coronavirus Disease 2019 (COVID-19) in Hubei Province, China. JAMA Ophthalmology. 2020;138(5):575-578.

  9. Zhou Y, Duan C, Zeng Y, et al. Ocular Findings and Proportion with Conjunctival SARS-COV-2 in COVID-19 Patients. Ophthalmology. 2020, in press.