When measles rush in

Measles outbreaks—67 confirmed cases in New York City as of Feb. 6 and 51 confirmed cases as of Feb. 5 in the state of Washington—underscore the role doctors of optometry can deliver as primary eye care providers.

The Centers for Disease Control and Prevention (CDC) is reporting outbreaks in 10 states. Many of the confirmed cases have been concentrated in Clark County in the state of Washington, where the governor has declared a state of emergency in all counties there. Most of the affected are children under age 10; most had not received the MMR (measles, mumps and rubella) vaccine. The CDC recommends that children receive two rounds of MMR between 12 and 15 months of age and between ages four and six years old.

Amber Gatti Dunn, O.D., practices about 45 minutes from Clark County but has patients who come from the area.

"I am not sure if it has directly affected my practice, but it is a possibility because we have been slower than normal," Dr. Dunn says of the outbreak. "As an office, we have been asking patients if they have been to Clark County recently and if so, have they been at any of the locations where there have been known cases of measles?

"We do not have a policy that says we won't see patients who aren't vaccinated, so we are seeing everyone, but it is a concern knowing that my staff or I could be exposed at any time, though we are all vaccinated," says Dr. Dunn, a mother of three. "My two older kids are vaccinated but my daughter is only eight weeks old, so she could catch it from anyone. It has prevented our family from doing some of the things we would like to do."

Ocular manifestations of measles

Measles outbreaks are not unheard of in the U.S., but the number has dropped significantly since vaccines came along in the 1960s. There were 17 outbreaks in 2018. Yet, worldwide, measles remains a highly contagious viral disease with 110,000 deaths in 2017, according to the World Health Organization. Measles symptoms include:

• Cough, runny nose and red, watery eyes.
• Ear infection
• Fever
• Diarrhea
• A rash of tiny, red sports, which starts at the head and spreads to the rest of the body.

The disease is spread virally—by coughing and sneezing—and can "live" for two hours in an airspace, the CDC reports.

"Beyond specific generalized symptoms, measles may have ocular symptoms," says Michael Dueñas, O.D., AOA's chief public health officer. "The most commonly occurring ocular symptom, conjunctivitis, the so-called 'red eye symptom,' is not characteristic only for measles infection. However, the generalized symptoms can suggest the diagnosis at the beginning of the disease.

"Viral conjunctivitis can progress to keratitis and bacterial superinfection can occur," Dr. Dueñas says. "If the infection presents in childhood, it can affect the posterior segment of the eye. Posterior segment complications can include retinal edema, vascular attenuation and macula star. Complete recovery of these posterior complications occurs in most cases without sequelae."

Precautions for practices

Doctors of optometry can help prevent the spread of measles and other contagious diseases among patients and staff. Among precautions they can take:

• Ask and encourage parents of young children to keep their vaccinations up to date, Dr. Dueñas highly recommends. "We've always encouraged parents to vaccinate their children," says Sue Lowe, O.D., who practices in Laramie, Wyoming, and chairs the AOA's Health Promotions Committee. "It is important to confirm with parents that vaccines have been done as recommended by the CDC." The CDC also recommends making sure patients are current with their immunizations if they plan to travel.
• Practice proper infection control. "There are evidence-based practices published by the CDC designed to both protect health care personnel and prevent the spread of infections among patients," Dr. Dueñas says. "Standard precautions include hand hygiene, use of personal protective equipment (such as gloves, gowns and face masks), respiratory hygiene and cough etiquette, safe injection practices and safe handling of potentially contaminated equipment or surfaces in the patient environment. For diseases that have multiple routes of transmission, a combination of Standard Precautions and Transmission-Based Precautions may be used."
• Call staff together to get on the same precautions page. Doug Totten, O.D., chair of the AOA's Ethics and Values Committee, cites the AOA Standards of Professional Conduct, which state, "the optometrist has the duty to avoid acts of omission or commission that would harm the patient." Says Dr. Totten, "It would be wise for optometrists to have a briefing on the outbreak with staff members and what steps can be taken to minimize risks for the individual and the patients being served."

Access additional resources from the CDC, including:

• Guide to Infection Prevention in Outpatient Settings.
• Guideline for Transmission-Based Precautions.
• Provider Resources for Vaccine Conversations with Parents.
• Measles Outbreak Toolkit.
• "Measles: It Isn't Just a Little Rash" infographic.