LETTER TO THE EDITOR
Eyes Have It: From COVID-19 Perspective
Corresponding Author: Puneet Khanna, Department of Anesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, Delhi, India, Phone: +91-11-2659 3212, e-mail: email@example.com
How to cite this article Sarkar S, Khanna P. Eyes Have It: From COVID-19 Perspective. Indian J Crit Care Med 2020;24(11):1139–1140.
Source of support: Nil
Conflict of interest: None
Keywords: Adverse drug reactions, COVID-19, Emergency department, Eyecare, Pharmacovigilance, Trigger tool..
The “2019 novel coronavirus disease (COVID-19)”, due to the infection of “severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2)” has emerged as the most discussed topic worldwide. As of now globally it has caused 4,338,658 cases with a fatality rate of 6.8% (WHO, May 15, 2020). Medical professionals accounted for about 20% of the United States and 9% of Italy’s total COVID-19 cases.1 Three ophthalmologists from Wuhan Central Hospital have been fallen prey in line of duty, and Dr Guangfa Wang, a pulmonologist, was reported to afflict by SARS-CoV-2 through vulnerable ocular exposure.2 These reports have amplified concerns about the course of dissemination.
The major source for COVID-19 infection is aerosol-generating procedures and direct contact. However, the oculo-pathogenic potential of human coronaviruses, and the role of ocular surface for transmission, and are not well addressed.
The SARS-CoV-2, a Beta coronavirus is transmitted through the angiotensin-converting enzyme 2 (ACE2) receptor, expressed in the cornea, conjunctiva,3 retina, and aqueous.4 The abundance of ACE2 receptors on the ocular surface makes them a prospective target of COVID-19. However, the accumulation of SARS-CoV-2 in ophthalmic secretions remains unclear. Probably due to direct inoculation by the aerosolized viral particles, transmission from the nasopharynx through the nasolacrimal duct.
In animal studies, coronaviruses have been associated with anterior uveitis, retinitis, vasculitis, and optic neuritis.5 Seventeen percent of human coronavirus NL 63 (HCoV-NL63) are found to be associated with conjunctivitis.1
Around “0.8%” of “1,099” COVID-19 patients in China had reported conjunctival congestion.1 Another recent case series also stated that “31.6%” of the COVID-19 hospitalized patients developed ocular symptoms comprising conjunctival hyperemia, chemosis, and epiphora. The reverse-transcriptase polymerase chain reaction (RT-PCR) for SARS-CoV-2 from the conjunctival swab along with the nasopharyngeal swabs had positive results in “16.7%” of them. The patients with ocular symptoms had a higher total leukocyte count, C-reactive protein, procalcitonin, and lactate dehydrogenase compared with patients without any signs of ophthalmological complications.6
Ophthalmology examination findings are consistent with follicular conjunctivitis of the bulbar conjunctiva, a follicular reaction involving the palpebral conjunctiva, watery discharge, and mild eyelid edema.1 Isolated chemosis may indicate third-spacing in a severely ill patient. The ocular manifestations of COVID-19 have been described in three original studies and a few case reports (Table 1) to date. There is no reporting of diplopia, keratitis, subconjunctival hemorrhage, and pseudomembrane formation in COVID-19 patients.
About one-third of hospitalized COVID-19 patients require intensive care support. The importance of eye care in these severely ill patients is paramount. Impaired blinking reflex causes drying of ocular surface which leads to the breakdown of corneal epithelium, thereby resulting in exposure keratopathy. Subsequent contamination from the respiratory secretions, and venous stasis, and conjunctival edema due to intermittent positive-pressure ventilation aggravate the situation.
Ting et al.7 have reported a case of the white cornea with presumed infection in a severely ill patient of COVID-19. Ensuring eye care through taping, use of the moist chamber, frost suture, 1% chloramphenicol ointment, 6–8 hourly checking of eyes, avoidance of aspiration of secretion over the face if the eyes are not covered, and early detection of the dull cornea may be useful to prevent this.7 Thus, incorporation of prevention, identification, and treatment of ocular complications as a component of the critical care bundle for COVID-19 is the need of the hour.
In the absence of significant pain, dimness of vision, patients can be treated with periodic application of cold compresses, preservative-free artificial tears, and lubricating ocular ointment. The use of topical antibiotics may be considered for preventing the bacterial superinfection depending on symptoms and customized risk factors (e.g., contact lens user).
Currently, antiviral, antimalarial, antiparasitic drugs, and other therapeutic agents, particularly targeted to prevent the “cytokine storm” associated in the critical cases, are being evaluated under controlled clinical settings for potential adverse interactions with other therapeutic agents and ocular toxicity (Table 2).
The refractory non-infective uveitis patients may require systemic immunosuppression. In the current scenario before starting systemic immunosuppression, screening for SARS-CoV-2 may be beneficial. Management of COVID-19 patients with systemic immunosuppression is a challenging task, and the use of systemic corticosteroids in SARS-CoV-2 positive patients is still debatable. However, individualized treatment by a multidisciplinary approach comprising rheumatologists, ophthalmologists, and intensivists is necessary.
|1.||Zhou et al.||Retrospective cohort study (n = 67)||Wuhan||SARS-CoV-2 detected in the conjunctival sac of patients with COVID-19.||https://doi.org/10.1101/2020.02.11.20021956|
|2.||Sun et al.||Cross-sectional study (n = 102)||Wuhan||Nosocomial infection of SARS-CoV-2 through the eyes is a potential route.||https://doi.org/10.1101/2020.02.26.20027938|
|3.||Xia et al.||Prospective case series study (n = 30)||Hangzhou||SARS-CoV-2 detected in the tears and conjunctival secretions of COVID-19 patients with conjunctivitis.||https://doi.org/10.1002/jmv.25725.|
|4.||Casalino et al.||Case report||Milan||A patient of COVID-19 presenting with unilateral conjunctivitis in Italy.||https://doi.org/10.1038/s41433-020-0909-x|
|5.||Li et al.||Case series (n = 4)||Wuhan||Healthcare workers with COVID-19 presented with conjunctivitis.||https://doi.org/10.3760/cma.j.issn.2095-0160.2020.0002|
|6.||Li et al.||Case series (n = 2)||Wuhan||Conjunctivitis as the first symptom in COVID-19 patients.||https://doi.org/10.3760/cma.j.issn.115989-20200303-00133|
|7.||Ye et al.||Case series (n = 30)||Wuhan||Three cases of binocular conjunctivitis reported in patients with neuropathic corneal pain (NCP) and positive viral nucleic acid were detected in the conjunctiva sacs of 2 of other 27 NCP patients.||https://doi.org/10.3760/cma.j.cn112142-20200214-00063|
|Drugs||Ocular side effects||Toxic dosage|
|Hydroxychloroquine||Vortex keratopathy, maculopathy||>6.5 mg/kg/day with normal renal function|
|Ivermectin||Foreign body sensation, eyelid edema, anterior uveitis, blurred vision, conjunctival hemorrhage||>200 μg/kg|
|Ritonavir/lopinavir||Blurring of vision, toxic epidermal necrolysis||>800 mg/200 mg twice daily|
|Favipiravir||Blurring of vision, ocular pain, toxic epidermal necrolysis, Stevens–Johnson syndrome||Human data not available|
|Remdesivir||Safety and efficacy not established||Human data not available|
|Methylprednisolone||Ocular hypertension, posterior subcapsular cataract, open-angle glaucoma||>10 mg/day|
In conclusion, ocular surface infection is a potentially dangerous route of transmission, and healthcare professionals should be cautious in this regard. Further research on ophthalmological manifestation, viral transmission through ocular secretions, long-term complications of these patients is the need of the hour.
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4. Siedlecki J, Brantl V, Schworm B, Mayer WJ, Gerhardt M, Michalakis S, et al. COVID-19: ophthalmological aspects of the SARS-CoV 2 global pandemic. Klin Monbl Augenheilkd 2020;237(5):675–680. DOI: 10.1055/a-1164-9381. [Epub ahead of print].
5. Seah I, Agrawal R. Can the coronavirus disease 2019 (COVID-19) affect the eyes? A review of coronaviruses and ocular implications in humans and animals. Ocul Immunol Inflamm 2020;28(3):391–395. DOI: 10.1080/09273948.2020.1738501.
6. Wu P, Duan F, Luo C, Liu Q, Qu X, Liang L, et al. Characteristics of ocular findings of patients with coronavirus disease 2019 (COVID-19) in Hubei Province, china. JAMA Ophthalmol 2020;138(5):575–578. DOI: 10.1001/jamaophthalmol.2020.1291.
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