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Ophthalmic Manifestations Of Coronavirus (COVID-19)
Chapter · April 2020
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Bhupendra C. K. Patel
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Ophthalmic Manifestations Of
Coronavirus (COVID-19)
Article Editor:
Assigned Author:
Updated:
Bhupendra CK Patel ([email protected])
Katherine Hu ([email protected])
Jay Patel ([email protected])
4/13/2020 11:28:02 AM
Introduction
Since December 2019, coronavirus disease 2019 (COVID-19) has become a global pandemic caused by
the highly transmissible severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).[1] There have
been several reports of eye redness and irritation in COVID-19 patients, both anecdotal and published,
suggesting that conjunctivitis may be an ocular manifestation of SARS-CoV-2 infection.
A study conducted during the 2003 Severe Acute Respiratory Syndrome (SARS) outbreak detected
SARS-CoV in tear samples in SARS patients in Singapore.[2] Lack of eye protection was a primary risk
factor of SARS-CoV transmission from SARS patients to healthcare workers in Toronto, prompting a
concern that respiratory illness could be transmitted through ocular secretions.[3][[4] Similar concerns
have been raised with SARS-CoV-2, especially among eye care providers and those on the front lines
triaging what could be initial symptoms of COVID-19.
As conjunctivitis is a common eye condition, ophthalmologists may be the first medical professionals
to evaluate a patient with COVID-19. Indeed, one of the first providers to voice concerns regarding the
spread of Coronavirus in Chinese patients was Li Wenliang, MD, an ophthalmologist. He later died from
COVID-19 and was believed to have contracted the virus from an asymptomatic glaucoma patient in his
clinic.
The authors of this article have attempted to collect the most up-to-date information on ophthalmic
manifestations of COVID-19 as a resource for identifying symptoms, providing diagnostic pearls, and
mitigating transmission.
Etiology
SARS-CoV-2 is a novel enveloped, positive single-stranded RNA beta coronavirus that causes COVID-19,
originally linked to an outbreak in Wuhan of China's Hubei province.[1] Direct contact with mucous
membranes, including the eye, is a suspected route of transmission.
Coronaviruses can cause severe ocular disease in animals, including anterior uveitis, retinitis, vasculitis,
and optic neuritis in feline and murine species. However, ocular manifestations in humans are mild
and rare.[5] There are no described ocular manifestations of Middle East Respiratory Syndrome (MERS)
or SARS, though, as previously stated, SARS-CoV was isolated in ocular secretions.[2] Other
coronaviruses have been found to cause viral conjunctivitis in humans.[6]
Epidemiology
At the time of writing this article on April 4, 2020, there have been 1,272,953 confirmed cases and
69,428 deaths due to COVID-19 worldwide, according to the World Health Organization (WHO), with
79,332 new cases confirmed in the last 24 hours. The Center for Disease Control and Prevention (CDC)
has reported 337,278 cases and 9,637 deaths in the United States to date.
Ocular manifestations of COVID-19 are overall rare in the published literature. Only 9 (0.8%) out of
1,099 patients from 552 hospitals across 30 provinces in China were reported to have "conjunctival
congestion."[7]
A recent case series reported ocular symptoms in 12 (31.6%) of 38 hospitalized patients with COVID-19
in Hubei province, China.[8] These 12 of 39 patients had conjunctival hyperemia (3 patients), chemosis
(7 patients), epiphora (7 patients), or increased secretions (7 patients). Of note is that one patient who
had epiphora presented with epiphora as the first symptom of COVID-19. Of those with ocular
manifestations, 2 (16.7%) patients had positive results of SARS-CoV-2 on reverse-transcriptase
polymerase chain reaction (RT-PCT) by a conjunctival swab as well as by nasopharyngeal swabs. Only
one patient in this study presented with conjunctivitis as the first symptom.[8] The authors noted that
patients with ocular symptoms had higher white blood cell and neutrophil counts, C-reactive protein,
and higher levels of procalcitonin and lactate dehydrogenase compared to patients without ocular
abnormalities.
Out of 30 hospitalized patients with COVID-19 tested by Xia et al., one patient had conjunctivitis and
was also the sole patient in the study to test positive for SARS-CoV-2 in ocular secretions by a
conjunctival swab. This patient did not have a severe fever or respiratory symptoms at the time of
testing.[9]
Pathophysiology
The potential of infection through ocular secretions is currently unknown, and it remains unclear how
SARS-CoV-2 accumulates in ocular secretions. Possible theories include direct inoculation of the ocular
tissues from respiratory droplets or aerosolized viral particles, migration from the nasopharynx via the
nasolacrimal duct, or even hematogenous spread through the lacrimal gland.[5]
History and Physical
Patients infected with SARS-CoV-2 can present with symptoms of conjunctivitis, including eye redness,
ocular irritation, foreign body sensation, tearing, and chemosis. These symptoms have more
commonly affected patients with severe systemic symptoms of COVID-19, though they can rarely
present as an initial manifestation of the disease.[8]
Examination findings include those consistent with mild follicular conjunctivitis, including unilateral or
bilateral bulbar conjunctiva injection, follicular reaction of the palpebral conjunctiva, watery discharge,
and mild eyelid edema. Bilateral chemosis alone may represent third-spacing in a critically ill patient
rather than a true ocular manifestation of the virus.
There have been no reports of COVID-19 patients experiencing blurred vision, subconjunctival
hemorrhage, eyelid ecchymoses, conjunctival scarring, keratitis, or pseudomembrane formation.
Evaluation
A thorough history should be conducted regarding the onset, duration, and characteristics of
symptoms. A presumptive diagnosis can be made based on detailed history taking alone, provided that
the patient denies more concerning symptoms such as significant eye pain, decreased vision, or light
sensitivity. Anterior segment examination at the slit lamp or bedside can confirm findings of
conjunctivitis. Measurement of visual acuity, intraocular pressure, and dilated fundus examination may
be warranted to rule out more harmful ocular diseases.
SARS-CoV-2 can be detected in RT-PCR by sweeping the lower eyelid fornices to collect tears and
conjunctival secretions with a virus sampling swab.[9]
All patients should be questioned about recent fever, respiratory symptoms, exposure, and travel
history to assess the need for further evaluation of COVID-19.
Treatment / Management
As with other viral infections, ocular manifestations of COVID-19 are presumed to be self-limited and
can be managed with symptomatic care.
As of March 18, 2020, the American Academy of Ophthalmology has urged all ophthalmologists to
provide only urgent or emergent care to reduce the risk of SARS-CoV-2 transmission and to conserve
disposable medical supplies. In the absence of significant eye pain, decreased vision, or light sensitivity,
many patients can be managed remotely with a trial of frequent preservative-free artificial tears, cold
compresses, and lubricating ophthalmic ointment. A short course of topical antibiotics can be added to
prevent or treat bacterial superinfection based on the patient's symptoms and risk factors (e.g., contact
lens wear).[10] Specific criteria are presented below.
Although preliminary studies suggest that the risk of viral transmission through ocular secretions is
low, large-scale research has not yet been done, and new data is emerging daily. Healthcare providers
are, therefore, still urged to wear proper protection of the eyes, nose, and mouth when examining
patients (see below). It has been suggested that ocular transmission of the COVID-19 virus may occur.
[4]
Eye care providers and technicians may be more susceptible to infection due to the nature and
proximity of the ophthalmic examination.[11] Eye care providers are encouraged to use slit lamp
breath shields and should counsel patients to speak as little as possible when sitting at the slit lamp to
reduce the risk of virus transmission. Disinfection and sterilization practices should be employed for
shared clinic equipment such as tonometers, trial frames, pinhole occluders, B-scan probes, and
contact lenses for laser procedures.[2][11] Disposable barrier protection of clinic tools should be used
where possible.
Stratification of Ophthalmic Patients for Clinic Visits
In the presence of life-threatening infections such as this, ophthalmologists have to achieve a balance
between providing ophthalmic care and infection control. Most ophthalmic conditions are not lifethreatening. Furthermore, many can be managed with some delay in treatment as they progress
relatively slowly (cataracts, glaucoma, ptosis, etc.). However, some conditions like retinal detachments,
acute infections (cellulitis, orbital cellulitis), severe inflammation (uveitis), and trauma require more
urgent attention. To that end, the following is suggested for the management of ophthalmic patients:
1. All routine ophthalmic patients are delayed until the severity of disease spread reduces as
determined by the WHO and the local Chief Medical Officer. These include chronic conditions and
routine clinic annual and other follow-ups as well as new patients with chronic conditions like
cataracts, ptosis, etc.
2. New patient referrals are reviewed by the consultant surgeon to determine urgency. If necessary,
telephone interviews with the referring doctor and/or the patient are held.
3. All patients considered for a clinic visit are reviewed for three things:
presence of a fever, cough or shortness of breath
any foreign travel or travel to an area with a high infection rate within the prior 14 days
any contact with patients who have been diagnosed as having COVID-19
The presence of any of these would be a reason to consider the necessity of seeing and examining the
patient more closely. If a patient has two of the three are referred for medical assessment. If a patient
with COVID-19 or one with a fever, cough, or shortness of breath needs to be examined, the patient is
seen in a separate isolation room. Ideally, only one person (physician, technician, etc.) should be
present in the room (as ophthalmic rooms tend to be small) and should wear the full personal
protective equipment (PPE): gown, N95 mask, face shield, and gloves. Hands are washed before and
after examination for a minimum of 20 seconds with soap and water. Once the ophthalmic
examination is completed, the patient is referred for further assessment by the medical team.
Protection of Medical Workers:
Although the 2003 SARS-CoV crisis did not create quite so severe a spread of infection in the United
States, it was noted that health care workers (HCW) accounted for about 20% of all patients with
infections.[12] Most recent figures show that HCWs make up 9% of Italy's COVID-19 cases, and more
than 100 health care workers have died from COVID-19 infections, including, at the last count, more
than 60 doctors (in Italy). Figures in other countries will continue to increase.
It is, therefore, vital that proper protection of the front-line medical workers is absolutely vital.
Secondly, it is important to monitor these health care workers for disease and implement appropriate
containment measures.
As has become depressingly evident, there is a severe shortage of appropriate personal protective
equipment for healthcare providers. To that end, it behooves us to choose the level of protective gear
based upon the risk of infection. The following is suggested:
For all patients who have none of the three criteria mentioned above, the medical workers will
wear a surgical mask, a face shield, and gloves. Hands are washed before and after every
encounter.
If a patient is positive for any of the three criteria, the full PPE of gown, face shield, gloves, and
the N95 mask are worn.
It has been noted that droplets from sneezes can travel up to 6 m.[13] To that end, inventive
ophthalmic technicians at the Moran Eye Center have developed a slit-lamp shield made by
passing two plastic sheets through a laminator without a paper in between and cutting openings
for the eye-pieces (Fig 1). Others have used old x-ray films in a similar way since commercially
available shields are in short supply.
Conversations are kept to a minimum during the consultation. Ophthalmologists are, by nature, a
gregarious lot. Such temptations are to be resisted.
As a shortage of surgical masks has become a reality, some institutions are storing used masks at
the end of each day in a container with a view to re-sterilization if necessary.
As many as a quarter of patients being injected under sedation may develop a severe involuntary
sneeze.[14][15] This is more common with eyelid injections than with retrobulbar injections.
Ophthalmic surgeons should be acutely aware of this to take appropriate precautions during the
administration of the local anesthetic.
Surveillance of Medical Workers:
In Singapore, they have health workers report their temperatures twice a day via an online
system: this is eminently sensible as the "walk-by" temperature-testing that is currently practiced
may not be as accurate or complete with staff arriving early, leaving late, etc.[16]
All travel outside the state or country should be declared to the medical administration for
review.
All health workers should self-report any symptoms, so appropriate testing may be performed:
isolation and contact-tracing would then be undertaken as deemed necessary.
Sterilization of Equipment
The slit-lamp shields are disinfected with 70% ethyl alcohol after each patient. 70% ethyl alcohol
has been shown to reduce coronavirus infectivity.[13]
Slitlamps, b-scan probes, and any other tools are similarly cleaned with 70% ethyl alcohol.
Goldman tonometers are sterilized with a 10% diluted sodium hypochlorite solution, which
inactivates coronaviruses.[17]
Differential Diagnosis
Ocular manifestations of COVID-19 have so far been uncommon, with most patients experiencing mild
conjunctivitis otherwise indistinguishable from other viral etiologies. Differential diagnosis includes a
broad range of common ocular manifestations of eye redness and increased tearing:
Other viral conjunctivitis (e.g., Adenovirus)
Bacterial conjunctivitis
Allergic conjunctivitis
Herpes simplex virus keratitis
Anterior uveitis
Corneal abrasion
Foreign body
Dry eye syndrome
Exposure keratopathy in an intubated patient
Chemosis in a critically ill patient
Prognosis
Ocular manifestations of COVID-19 are currently thought to be self-limited. There are currently no
reports of sight-threatening manifestations of COVID-19.
Complications
There have been no complications of ocular manifestations of COVID-19 reported, though larger
studies and long-term follow up of these patients have not yet been conducted.
Deterrence and Patient Education
Prevention strategies are vital to limiting the spread of disease. In addition to physical distancing and
practicing good hand-washing hygiene, patients should employ behavioral changes that reduce the
direct touching of the eyes and face.
Refraining from wearing contact lenses during the outbreak
Refraining from applying cosmetics
Wearing glasses and sunglasses
Pearls and Other Issues
Ocular shedding of the COVID-19 virus via tears is a distinct possibility of which ophthalmologists
should be aware.
Conjunctivitis or tearing can be the first presentation in a patient with the COVID-19 infection.
Patients may present with chemosis in advanced cases (fig 2), or follicular conjunctivitis (fig 3).
The ocular examination should be performed while wearing gloves and the use of extension
instruments (cotton swabs, etc.) to avoid direct contact with secretions.
As many patients who visit the ophthalmic clinic are elderly, many with comorbidities, it is
important to screen the need for the visit ahead of time and only see patients who need urgent
care.
Social distancing, as advocated in many countries, means being 6 ft away from others: this is
clearly impossible in the clinical world and certainly in the small confines of ophthalmic
examination lanes. One way to practice it is to have only one person in the room with the patient.
Anecdotally, it has been observed that physicians most at risk of becoming infected include
ophthalmologists, otolaryngologists, and anesthesiologists because of the proximity of the
examiners to mucosal surfaces.
When performing surgery under general anesthesia, it has been recommended that surgeons
and other staff do not enter the room for 15 minutes after intubation or extubation. In our
institution, this is applied to all general anesthesia cases, whether the patient is COVID-19
positive or negative.
Enhancing Healthcare Team Outcomes
Within the outpatient, inpatient, and surgical settings, an interprofessional approach is necessary to
manage COVID-19 patients and mitigate the spread of disease successfully.
There should be clear communication between hospital administration, provider teams, and clinic
support staff regarding expectations for screening patients, wearing personal protective equipment,
and utilizing new technologies for telemedicine consultations. [Level 5 evidence]
References
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[PubMed PMID: 23793905]
Description: A slit-lamp shield to protect the examiner as designed by Moran Technicians Stein Erickson, Emily Petersen and
Anna Reed together with help from others: made by passing two lamination sheets together through a laminator without
anything inbetween. Results in a rigid shield which can be cleaned with alcohol and reused. Other materials that may be used
include used X-Ray films but these do not have the clarity needed.
Attributed To: Contributed on behalf of the Moran Eye Center by Dr. Katherine Hu MD and Prof. BCK Patel MD, FRCS
Description: Chemosis: conjunctival edema and inflammation. Can be seen with viral and bacterial infections, after eyelid
surgery, trauma, thyroid disease and orbital tumors
Attributed To: Contributed by Prof. BCK Patel MD, FRCS
Description: Follicular conjunctivitis may be seen with viral infections like herpes zoster, Epstein-Barr virus infection, infectious
mononucleosis), chlamydial infections, and in reaction of topical medications and molluscum contagiosum. Follicular
conjunctivitis has been described in patients with the Clovid-19 infection (coronavirus infection). The inferior and superior tarsal
conjunctiva and the fornices show gray-white elevated swellings which are about 105 - 1 mm in diameter and have a velvety
appearance
Attributed To: Contributed by Prof. BCK Patel MD, FRCS
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