Published (Peer reviewed scientific literature):
(Dr. Barbara Shang 2011 EKC Outbreak Irvine, California )
Abstract
Epidemic keratoconjunctivitis (EKC) is a common, highly contagious, and severe infection of the eye caused by adenovirus. EKC is often described as a healthcare acquired infection (HAI) and well known to cause “runs” in eye care clinics. Typically, acute symptoms of this viral infection manifest as ophthalmalgia, marked erythema, profuse clear ocular secretions, impaired vision, photophobia, edema of the eyelid, and pseudo membrane formation. Although previously thought to be self-limited disease, EKC complications may result in waxing and waning ocular debility, severe dry eye, glare, irregular and variable astigmatism, and less commonly permanent ocular damage and scarring. To date, there is no universally effective cure, vaccine, or treatment available. Thus, EKC prevention through education and enhancement of best practices in sanitation in ophthalmology is paramount in disease eradication. We report an otherwise healthy 52-year-old male who developed newly diagnosed unilateral retinoschisis approximately 5 years after nosocomial contagion of EKC in the same affected eye. In this manuscript, we illustrate the morbidity, chronicity, seriousness, and high prevalence of adenoviral eye disease, and the significance of prevention through enhancing sterilization and regular application of universal precautions in eye care delivery.
The significance of (1) the newly described possible association of retinal disease (retinoschisis), and (2) newly identified chronic waxing and waning nature of EKC spanning more than 7 years, in an otherwise previously thought to be “self-limited” corneal process, as described herein, remain to be studied further and those relationships, if any, determined.
Abbreviations: EKC, epidemic keratoconjunctivitis; CDC, centers for disease control; SEIs, subepithelial infiltrates; HAI, healthcare associated infection; HCI, healthcare caused infection
Epidemic keratoconjunctivitis (EKC) is a common and highly contagious acute infection of the eye caused by various strains of adenovirus. Typically, symptoms of this severe viral infection will manifest after an incubation period of 7-14 days and include severe ophthalmalgia, marked erythema, profuse clear ocular secretions, impaired vision, photophobia, edema of the eyelid, and pseudo membrane formation. EKC complications may result in permanent ocular damage. EKC infections are known to result in positive serology for adenovirus. To our knowledge, there have been no prior reports of retinoschisis in EKC, and none as to chronic EKC disease lasting more than 7 years. The significance of (1) the newly described potential association of retinal disease (retinoschisis), and (2) identified chronic waxing and waning nature of EKC spanning 7 years, in an otherwise previously misclassified as a “self-limited” corneal disease, remains to be studied further and relationships, if any, determined.
There is no universally effective cure, vaccine, or treatment available for EKC; topical corticosteroids, while highly controversial and potentially adverse reaction prone, may provide symptomatic relief in a small subset of patients who have severe and vision limiting subepithelial infiltrates (SEIs). Ocular corticosteroid use in EKC is more often than not discouraged as it may enhance the adenovirus infectious period and result in lengthening of viral shedding.1 EKC is extremely contagious and frequently described as a healthcare associated infection (HAI)or healthcare caused infection (HCI).2 Thus, EKC frequently results in epidemics or “runs” in eye care offices, clinics, and hospital wards worldwide.2-5 In particular, the U.S. Centers for Disease Control (CDC) has repeatedly described and reported EKC runs in Southern California ophthalmology clinics and offices, outbreaks not unlike the California HAI which resulted in the subject of this case report.2,4,5 Laboratory testing such as viral cultures and PCR testing, and rapid in office testing such as Adenoplus, are available to aid in diagnosis of EKC. Accurate and early diagnosis is mandatory to correctly identify the type of virus and to initiate prevention protocols. For the majority of nosocomial EKC cases, individuals often contract the virus directly through routine eye care examinations.1,6 With an average incubation period lasting from 7-14 days, affected individuals often do not make the requisite association of contracting the virus with their recent eye examination.1,7 In other indirect HAI cases, EKC can arise in family, friends, or close contacts of those who have recently visited an eye care office. The virus is known to last on surfaces, such a slit lamps and multi-use eye drop containers, for an average of 4-6 weeks.1,6,8,9 We report of an otherwise healthy male patient who became infected with EKC during a routine eye examination in 2011 in a Southern California ophthalmology office, which was experiencing a known EKC outbreak of more than 70 patients. 2,3
Conclusion
As this case study demonstrated, EKC is often a chronic, relapsing disease with an unpredictable course.While EKC’s acute phase lasts a few weeks, the chronic phase may last years, if not a lifetime. The significance of (1) the newly described possible association of retinal disease (retinoschisis), and (2) newly identified chronic waxing and waning nature of EKC over 7 years,in an otherwise previously thought to be “self-limited” corneal process remains to be studied further and relationships, if any, determined.
EKC is not a fully “self-limited” corneal process as previously likely misunderstood and classified. EKC is a highly contagious ocular adenovirus infection that is characteristically propagated through routine eye examinations, particularly through the use of applanation tonometry and multi-use eye drops. EKC can be prevented if ophthalmologist and optometrists and staff regularly maintain a level of reasonable hygiene that is required in medical practices.2-6 If an EKC outbreak occurs, eye care providers have the responsibility to contact affected individuals, and contain and minimize the outbreak by contacting state and local health authorities for help, which some practitioner including the original ophthalmologist in the case study did notdo.1,6,3. Ultimately the responsibility falls onto eye care professionals to educate their patients on the severity of EKC infection and to prevent the spread of EKC through proper disinfection protocols.2,6,9,17 While there are currently no uniformly effective treatments, vaccines, or antiviral drugs available for EKC, larger studies are needed in order to further determine effective EKC and SEI treatment, as well as the relationship of EKC to non-corneal eye disease including retinoschisis, and other possible systemic manifestations.
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EKC AND RETINOSCHISIS PEER REVIEWED PUBLICATION- IRVINE 2011 EKC OUTBREAK COMPLICATIONS 
EKC-infection-control-508 CDC 2019 new PREVENT EKC handout
AAO 2012 AAA Infection Control Recommendations – 2016 24 pages
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