Keeping an eye on COVID-19: An ophthalmologist's perspective

Coronavirus disease 2019 (COVID-19) is a highly infectious disease caused by the severe acute respiratory syndrome (SARS) coronavirus 2 (CoV-2), also known as the novel coronavirus.[1] The current COVID-19 pandemic has plunged the globe into a state of turbulence. Unfortunately, much regarding the disease and its pathogenicity, clinical characteristics and management remain unknown, with health-care workers of all specialties forced to learn as they go and in a remarkably short space of time in order to mitigate rapidly rising rates of infection and mortality.[12] With this in mind, it is critical that we examine the implications of our current understanding of this disease from an ophthalmological perspective. As with SARS, human-to-human transmission of SARS-CoV-2 primarily occurs either directly from close contact with an infected individual or following exposure to infective respiratory droplets as a result of coughing, sneezing or exhaling, or indirectly following contact with contaminated surfaces and objects.[2] The incubation period of the virus is between 2 and 14 days.[1] Common symptoms include fever (≥90%), coughing (≈75%), and dyspnea (≤50%); however, according to the World Health Organization, up to 80% of those infected may be asymptomatic.[34] Some cases may also present with gastrointestinal symptoms, such as diarrhea and nausea.[35] There is evidence that COVID-19 may be linked to ophthalmic symptoms, particularly conjunctivitis.[6] In January 2020, a member of the national expert panel on pneumonia developed conjunctivitis several days after having traveled to Wuhan, China, the epicenter of the pandemic.[7] Similarly, Cheema et al. reported a 29-year-old female in whom keratoconjunctivitis was the first presenting symptom of COVID-19, although mild respiratory symptoms were also noted during the initial examination.[8] In another report, Chen et al. described a 30-year-old male patient with confirmed COVID-19 who developed acute bilateral conjunctivitis 13 days after disease onset.[9] In both of the latter cases, reverse transcription–polymerase chain reaction (RT-PCR) analysis of conjunctival swabs revealed positive results for SARS-CoV-2.[89] In addition, a retrospective study of 552 hospitals across China documented conjunctival congestion in 0.8% out of 1099 cases of confirmed COVID-19.[10] Wu et al. also observed ocular symptoms in 31.6% out of 28 patients with COVID-19 managed at a hospital in Hubei Province, China, including conjunctival hyperemia, chemosis, epiphora, and increased secretions; of these patients, RT-PCR indicated that 16.7% tested positive for SARS-CoV-2 in conjunctival as well as nasopharyngeal samples.[11] The researchers noted that ocular manifestations might be linked to disease severity, with such symptoms being more prevalent among more severe cases.[11] In a prospective interventional analysis, Xia et al. assessed the presence of SARS-CoV-2 nucleic acid in the tears and conjunctival secretions of 30 patients with COVID-19-related pneumonia.[12] Only one of the patients had conjunctivitis; interestingly, it was solely in this patient that both tear and conjunctival swabs yielded positive RT-PCR results.[12] However, in another study, Seah et al. found no evidence of viral shedding in the tears of COVID-19 patients without ocular symptoms, even when tested at multiple points throughout the course of the disease; in contrast, the researchers detected elevated viral loads in nasal and throat swabs for a 2-week period following the onset of COVID-19-related symptoms.[13] Regardless, the existence of the virus in the tears of patients without ocular symptoms cannot be ruled out at this stage.[513] Ophthalmological practice needs to change in response to the current pandemic. Ophthalmologists may be the first point of call for COVID-19 cases who present initially with conjunctivitis or are asymptomatic. Moreover, the nature of most ophthalmic diagnostic and treatment procedures necessitates that ophthalmologists be in close proximity with their patients, placing these health-care professionals at an increased risk of direct infection.[5] In addition, patients often require multiple investigations, thereby increasing the likelihood of nosocomial transmission.[5] Various international organizations including the Canadian Ophthalmological Society have recommended deferring nonurgent procedures which involve aerosols, general anesthesia, or irrigating or manipulating the lacrimal system, including noncontact tonometry, endoscopic dacryocystorhinostomy, and lacrimal surgeries.[2514] In urgent cases where deferral is not feasible, such as stent removal, lacrimal sac tumor excision, and surgical correction of canalicular lacerations or trauma, it is advised that all patients undergo preoperative COVID-19 testing.[14] Due to their risk of occupational exposure, ophthalmologists should take precautionary measures to mitigate the risk of infection, such as wearing appropriate personal protective equipment (PPE) at all times, including gloves and protective gear for the eyes as well as the mouth and nose.[141516] Other important precautions include utilizing plastic breath shields during slit-lamp examinations, spacing out appointment slots, and avoiding unnecessary small talk to minimize the duration of patient visits as well as ensuring mandatory use of masks for patients with respiratory symptoms.[1718] Furthermore, alcohol- or bleach-based disinfectants should be applied to all instruments, surfaces, and office furniture after each appointment, especially in examination rooms. In addition, ophthalmologists should closely monitor their own health, routinely check their temperature before work, and report any potential symptoms to the relevant hospital authorities.[5] Medical staff who suspect they may have contracted the disease should take measures to self-isolate to avoid spreading the infection to other health-care workers and patients. In conclusion, ophthalmologists should maintain a high degree of clinical suspicion for COVID-19 when treating and evaluating patients – regardless of whether such individuals present with common symptoms – as it is likely that they represent the first point-of-care for asymptomatic patients or those with ocular manifestations. With that in mind, ophthalmologists should take precautions to lower their personal risk of infection as well as the cross-infection of other health-care workers and patients, including wearing appropriate PPE, minimizing direct contact with patients, ensuring thorough sterilization of all equipment and surfaces, and deferring all nonurgent procedures to a later date.

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