• Comprehensive Ophthalmology

    This article was updated on May 6, 2020

    This study presents information found on ocular signs and symptoms in patients infected with SARS-CoV-2.

    Study design

    This is a case series of 38 patients with clinically confirmed COVID-19 between February 9 to 15, 2020, at the Yichang Central People’s Hospital in the Hubei Province of China. Ocular signs and symptoms were documented and reverse transcriptase-polymerase chain reaction (RT-PCR) from nasopharyngeal and conjunctival swabs for COVID-19 were analyzed.

    Outcomes

    Twenty-eight patients had positive results for COVID-19 on RT-PCR from nasopharyngeal swabs, but only 2 had positive results on RT-PCR from conjunctival swabs as well. Twelve patients (32%) had eye findings which included conjunctival hyperemia, chemosis, epiphora and secretions. Approximately 92% of patients with eye findings had positive results for COVID-19 on nasopharyngeal swabs; 6 of these patients were judged to be critically ill.

    Univariate analysis showed that patients with ocular findings were more likely to have higher white blood cell and neutrophil counts, and higher levels of procalcitonin, C-reactive protein and lactate dehydrogenase.

    Limitations

    This study has many limitations. The small sample size was limited only to 38 patients. Slit-lamp biomicroscopy and detailed ocular examinations were not performed to confirm conjunctival and intraocular disease. Without discrete biomicroscopic exams, the findings of conjunctival hyperemia, chemosis, epiphora and secretions could be nonspecific and not necessarily clear-cut manifestations of conjunctivitis. Of note, 6 of the patients who had ocular findings were deemed to be critically ill; it is not uncommon to see the above-stated findings in many hospitalized patients with chronic inflammation or fluid overload as well as in patients receiving continuous positive airway pressure or ventilator support.

    Finally, conjunctival swabs for RT-PCR were obtained at only a single time-point during the patients’ hospital course. Findings from other studies have suggested that the virus may only be transiently present in the conjunctiva, necessitating conjunctival swab testing at various time points. In addition, the accuracy of RT-PCR assays used in various research and clinical settings may vary.

    Clinical significance

    Since the publication of this article,  many new reports have emerged to try to characterize the ocular signs and symptoms in patients with COVID-19.1 Some are anecdotal in the form of case reports2,3 and others are now showing that the incidence of ocular findings, including conjunctivitis, in patients with COVID-19 is overall low.4,5 A recent larger study in press in Ophthalmology found that only 8 of 121 COVID-19 positive patients displayed ocular symptoms (itching, redness, tearing, discharge, and foreign body sensation) and that only 3 patients had positive results on RT-PCR from conjunctival swabs.6 The ocular findings noted in this study are largely nonspecific and may not necessarily be intrinsic to the coronavirus infection. Additional research and detailed assessment of patients are needed to validate these results.

    Given the rapidly evolving nature of research regarding ocular signs and findings of COVID-19, refer to the Academy's page on coronavirus updates for ophthalmologists for ongoing reviews and analyses of new reports in the literature regarding this topic 

    References

    1. Kuo IC. A Rashomon moment? Ocular involvement and COVID-19. Ophthalmology, in press.
    2. Chen L et al. Ocular manifestations of a hospitalised patient with confirmed 2019 novel coronavirus disease. British Journal of Ophthalmology, April 2020
    3. Colavita F et al. SARS-CoV-2 isolation from ocular secretions of a patient with COVID-19 in Italy with prolonged viral RNA detection. Annals of Internal Medicine, April 2020
    4. Zhang X et al. The infection evidence of SARS-COV-2 in ocular surface: a single-center cross-sectional study. medRxiv, Feb 2020
    5. Zhou Y et al. Ophthalmologic evidence against the interpersonal transmission of 2019 coronavirus through conjunctiva. medRxiv, Feb 2020
    6. Zhou Y et al. Ocular findings and proportion with conjunctival SARS-COV-2 in COVID-19 patients. Ophthalmology, in press