[Skip to Content]
Access to paid content on this site is currently suspended due to excessive activity being detected from your IP address Please contact the publisher to request reinstatement.
[Skip to Content Landing]
Brief Report
June 2018

Multimodal Imaging and Spatial Analysis of Ebola Retinal Lesions in 14 Survivors of Ebola Virus Disease

Author Affiliations
  • 1Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
  • 2St. Paul’s Eye Unit, Royal Liverpool University Hospital, Liverpool, United Kingdom
  • 3National Institute of Health Research Health Protection Research Unit in Emerging and Zoonotic Infections, University of Liverpool, Liverpool, United Kingdom
  • 434 Military Hospital, Freetown, Sierra Leone
  • 5Department of Eye and Vision Science, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, United Kingdom
  • 6Connaught Hospital, Freetown, Sierra Leone
JAMA Ophthalmol. 2018;136(6):689-693. doi:10.1001/jamaophthalmol.2018.1248
Key Points

Question  Can multimodal imaging of Ebola retinal lesions inform our understanding of their pathogenesis?

Findings  In this case-series study of 14 survivors, optical coherence tomography demonstrated a V-shaped increased reflectivity of the outer nuclear layer overlying discontinuities of the ellipsoid zone and interdigitation zone in the smallest lesions. A collapse of the overlying retinal structures was detected in larger lesions, corresponding visual field defects respected the horizontal raphe, and perilesional areas of dark without pressure (ellipsoid zone hyporeflectivity) accompanied 89% of lesions.

Meanings  These findings are consistent with a neuronal rather than vascular pathogenesis; the relevance of dark without pressure is undetermined.


Importance  Differentiation between Ebola retinal lesions and other retinal pathologies in West Africa is important, and the pathogenesis of Ebola retinal disease remains poorly understood.

Objective  To describe the appearance of Ebola virus disease (EVD) retinal lesions using multimodal imaging to enable inferences on potential pathogenesis.

Design, Setting, and Participants  This prospective case series study was carried out at 34 Military Hospital in Freetown, Sierra Leone. Ophthalmological images were analyzed from 14 consecutively identified survivors of EVD of Sierra Leonean origin who had identified Ebola retinal lesions.

Main Outcomes and Measures  Multimodal imaging findings including ultra-widefield scanning laser ophthalmoscopy, fundus autofluorescence, swept-source optical coherence tomography (OCT), Humphrey visual field analysis, and spatial analysis.

Results  The 14 study participants had a mean (SD) age of 37.1 (8.8) years; 6 (43%) were women. A total of 141 Ebola retinal lesions were observed in 22 of 27 eyes (81%) of these 14 survivors on ultra-widefield imaging. Of these, 41 lesions (29.1%) were accessible to OCT imaging. Retinal lesions were predominantly nonpigmented with a pale-gray appearance. Peripapillary lesions exhibited variable curvatures in keeping with the retinal nerve fiber layer projections. All lesions respected the horizontal raphe and spared the fovea. The OCT imaging demonstrated a V-shaped hyperreflectivity of the outer nuclear layer overlying discontinuities of the ellipsoid zone and interdigitation zone in the smaller lesions. Larger lesions caused a collapse of the retinal layers and loss of retinal thickness. Lesion shapes were variable, but sharp angulations were characteristic. Perilesional areas of dark without pressure (thinned ellipsoid zone hyporeflectivity) accompanied 125 of the 141 lesions (88.7%) to varying extents.

Conclusions and Relevance  We demonstrate OCT evidence of localized pathological changes at the level of the photoreceptors in small lesions among survivors of EVD with retinal lesions. The relevance of associated areas of dark without pressure remains undetermined.