Can the Coronavirus Disease 2019 (COVID-19) Affect the Eyes? A Review of Coronaviruses and Ocular Implications in Humans and Animals

Toward Nanotechnology-Enabled Approaches against the COVID-19 Pandemic

The COVID-19 outbreak has fueled a global demand for effective diagnosis and treatment as well as mitigation of the spread of infection, all through large-scale approaches such as specific alternative antiviral methods and classical disinfection protocols. Based on an abundance of engineered materials identifiable by their useful physicochemical properties through versatile chemical functionalization, nanotechnology offers a number of approaches to cope with this emergency. Here, through a multidisciplinary Perspective encompassing diverse fields such as virology, biology, medicine, engineering, chemistry, materials science, and computational science, we outline how nanotechnology-based strategies can support the fight against COVID-19, as well as infectious diseases in general, including future pandemics. Considering what we know so far about the life cycle of the virus, we envision key steps where nanotechnology could counter the disease. First, nanoparticles (NPs) can offer alternative methods to classical disinfection protocols used in healthcare settings, thanks to their intrinsic antipathogenic properties and/or their ability to inactivate viruses, bacteria, fungi, or yeasts either photothermally or via photocatalysis-induced reactive oxygen species (ROS) generation. Nanotechnology tools to inactivate SARS-CoV-2 in patients could also be explored. In this case, nanomaterials could be used to deliver drugs to the pulmonary system to inhibit interaction between angiotensin-converting enzyme 2 (ACE2) receptors and viral S protein. Moreover, the concept of "nanoimmunity by design" can help us to design materials for immune modulation, either stimulating or suppressing the immune response, which would find applications in the context of vaccine development for SARS-CoV-2 or in counteracting the cytokine storm, respectively. In addition to disease prevention and therapeutic potential, nanotechnology has important roles in diagnostics, with potential to support the development of simple, fast, and cost-effective nanotechnology-based assays to monitor the presence of SARS-CoV-2 and related biomarkers. In summary, nanotechnology is critical in counteracting COVID-19 and will be vital when preparing for future pandemics.

Evaluation of Conjunctival Swab PCR Results in Patients with SARS-CoV-2 Infection

PURPOSE

The study objective was to identify severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA in conjunctival swabs from patients with confirmed SARS-CoV-2 infection.

METHODS

Forty patients who tested positive by real-time reverse transcription (rRT)-polymerase chain reaction (PCR) of nasopharyngeal and oropharyngeal swabs were enrolled. Conjunctival swabbing was used to collect the tear and conjunctival secretions of patients.

RESULTS

Conjunctival swab rRT-PCR was positive for three patients and negative for 37 patients. Ten of the patients (25%) were diagnosed with conjunctivitis during the ophthalmic examination. Of these patients, one was found positive by conjunctival swab rRT-PCR, and nine were found negative. The difference between patients who tested positive or negative using conjunctival swab rRT-PCR was without statistical significance in terms of the presence of conjunctivitis (p = .720).

CONCLUSION

The rate of positivity from conjunctival swab rRT-PCR was 7.5% in patients with confirmed SARS-CoV-2 infection.

Coronavirus Disease 2019: Associated Multiple Organ Damage

A 56-year-old man presented a particularly severe and multisystemic case of coronavirus disease 2019 (COVID-19). In addition to the common lung and quite common pulmonary embolism and kidney injuries, he presented ocular and intestinal injuries that, to our knowledge, have not been described in COVID-19 patients. Although it is difficult to make pathophysiological hypotheses about a single case, the multiplicity of injured organs argues for a systemic response to pulmonary infection. A better understanding of physiopathology should feed the discussion about therapeutic options in this type of multifocal damage related to severe acute respiratory syndrome coronavirus 2.

Conjunctivitis as a Sentinel of SARS-CoV-2 Infection: a Need of Revision for Mild Symptoms

COVID-19 has been declared a pandemic by the World Health Organization on March 11, and since then, more than 3 million cases and a quarter million deaths have occurred due to it. Lately, there is a growing evidence for an ophthalmologic symptom (conjunctivitis) to be connected with the disease. This seems to happen in early stages of the infection by SARS-CoV-2, and thus, it is of major importance to understand the mechanism through which the virus can facilitate such a symptom. Here, we are proposing a molecular mechanism through which the novel coronavirus could act in order to affect the eye and use it as another, secondary but alternative, point of entry to the host organism.

COVID-19 and the Ocular Surface: A Review of Transmission and Manifestations

PURPOSE

The outbreak of coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has reached pandemic proportions within an unprecedented span of time. It is controversial whether the virus can be transmitted via tears and its ocular implications have not been widely studied. In this article, the current evidence related to ocular transmission and ocular manifestations is reviewed.

RESULTS

Several mechanisms for the ocular transmission of the virus are proposed with highlight on the nasolacrimal system as a conduit between the eye and the respiratory tract, and the role of the lacrimal gland in hematogenous spread. Ocular surface manifestations such as conjunctivitis are more commonly reported.

CONCLUSION

The exact pathophysiology of ocular transmission of the virus remains incompletely understood, although there is preliminary evidence of SARS-CoV-2 being detected in ocular secretions. The ocular tropism of the virus and its potential to cause localized ocular disease are worth considering.

Preventing SARS-CoV-2 transmission in rehabilitation pools and therapeutic water environments

SARS-CoV-2 is mainly transmitted by respiratory droplets and contact with contaminated surfaces. It can be retrieved in faeces but there is no evidence of faecal–oral transmission, which is the main route of contamination in recreational waters. Standard cleaning and disinfecting procedures, microbiological control and health rules aim to prevent infectious risk regardless of the micro-organisms. In the context of progressive lockdown exit and hospital activities recovery, we assessed the risk of SARS-CoV-2 transmission in rehabilitation pools and therapeutic water environments in order to provide specific recommendations to control the spread of SARS-CoV-2 while ensuring essential rehabilitation care for patients.

Ocular manifestations of coronavirus disease 2019

Purpose

Coronavirus disease 2019 (COVID-19) is an ongoing global public health problem, and most of the COVID-19 research is focused mainly on the respiratory system because of life-threatening results. However, manifestations in other organs should not be ignored since they can also be a mode of transmission. We sought to describe the ocular manifestations of COVID-19 and investigate the association between ocular involvement and clinical presentation and laboratory outcomes.

Methods

This cross-sectional study was conducted between March 1, 2020, and April 30, 2020. Ninety-three sequentially hospitalized and clinically confirmed COVID-19 patients were included in the study. The systemic and ocular symptoms, clinical findings, and laboratory outcomes were recorded.

Results

Of the 93 COVID-19 patients, 54 (58.1%) were male, and 39 (41.9%) were female. Mean age of the patients was 39.4 ± 21.9 (min 7, max 88) years. Twenty patients (n 21.5%) had at least one ocular abnormality. Most common findings included hyperemia (n = 20), epiphora (n = 9), increased secretion (n = 6), chemosis (n = 3), follicular conjunctivitis (n = 2), and episcleritis (n = 2). The most common symptom was photophobia (n 15). Patients with ocular involvement were more likely to have higher neutrophil counts (p = 0.001), and increased CRP (p < 0.001), PCT (p = 0.001), and ESR levels (p < 0.001). Mean lymphocyte count was statistically lower in patients with ocular manifestations (p = 0.001). Mean age and number of patients with fever over 37.3 °C in the ocular involvement group was found to be higher (p < 0.001, p = 0.006, respectively).

Conclusion

Older age, high fever, increased neutrophil/lymphocyte ratio, and high levels of acute phase reactants seemed to be risk factors for ocular involvement.

COVID-19: Specific and Non-Specific Clinical Manifestations and Symptoms: The Current State of Knowledge

Coronavirus disease 2019 (COVID-19), due to the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), has become an epidemiological threat and a worldwide concern. SARS-CoV-2 has spread to 210 countries worldwide and more than 6,500,000 confirmed cases and 384,643 deaths have been reported, while the number of both confirmed and fatal cases is continually increasing. COVID-19 is a viral disease that can affect every age group-from infants to the elderly-resulting in a wide spectrum of various clinical manifestations. COVID-19 might present different degrees of severity-from mild or even asymptomatic carriers, even to fatal cases. The most common complications include pneumonia and acute respiratory distress syndrome. Fever, dry cough, muscle weakness, and chest pain are the most prevalent and typical symptoms of COVID-19. However, patients might also present atypical symptoms that can occur alone, which might indicate the possible SARS-CoV-2 infection. The aim of this paper is to review and summarize all of the findings regarding clinical manifestations of COVID-19 patients, which include respiratory, neurological, olfactory and gustatory, gastrointestinal, ophthalmic, dermatological, cardiac, and rheumatologic manifestations, as well as specific symptoms in pediatric patients.

The COVID-19 pandemic: Important considerations for contact lens practitioners

A novel coronavirus (CoV), the Severe Acute Respiratory Syndrome Coronavirus - 2 (SARS-CoV-2), results in the coronavirus disease 2019 (COVID-19). As information concerning the COVID-19 disease continues to evolve, patients look to their eye care practitioners for accurate eye health guidance. There is currently no evidence to suggest an increased risk of contracting COVID-19 through contact lens (CL) wear compared to spectacle lens wear and no scientific evidence that wearing standard prescription spectacles provides protection against COVID-19 or other viral transmissions. During the pandemic there will potentially be significant changes in access to local eyecare. Thus, it is imperative CL wearers are reminded of the steps they should follow to minimise their risk of complications, to reduce their need to leave isolation and seek care. Management of adverse events should be retained within optometric systems if possible, to minimise the impact on the wider healthcare service, which will be stretched. Optimal CL care behaviours should be the same as those under normal circumstances, which include appropriate hand washing (thoroughly with soap and water) and drying (with paper towels) before both CL application and removal. Daily CL cleaning and correct case care for reusable CL should be followed according to appropriate guidelines, and CL exposure to water must be avoided. Where the availability of local clinical care is restricted, practitioners could consider advising patients to reduce or eliminate sleeping in their CL (where patients have the appropriate knowledge about correct daily care and access to suitable lens-care products) or consider the option of moving patients to daily disposable lenses (where patients have appropriate lens supplies available). Patients should also avoid touching their face, including their eyes, nose and mouth, with unwashed hands and avoid CL wear altogether if unwell (particularly with any cold or flu-like symptoms).

Guidelines: Anaesthesia in the context of COVID-19 pandemic

OBJECTIVES

The world is currently facing an unprecedented healthcare crisis caused by the COVID-19 pandemic. The objective of these guidelines is to produce a framework to facilitate the partial and gradual resumption of intervention activity in the context of the COVID-19 pandemic.

METHODS

The group has endeavoured to produce a minimum number of recommendations to highlight the strengths to be retained in the 7 predefined areas: (1) protection of staff and patients; (2) benefit/risk and patient information; (3) preoperative assessment and decision on intervention; (4) modalities of the preanaesthesia consultation; (5) specificity of anaesthesia and analgesia; (6) dedicated circuits and (7) containment exit type of interventions.

RESULTS

The SFAR Guideline panel provides 51 statements on anaesthesia management in the context of COVID-19 pandemic. After one round of discussion and various amendments, a strong agreement was reached for 100% of the recommendations and algorithms.

CONCLUSION

We present suggestions for how the risk of transmission by and to anaesthetists can be minimised and how personal protective equipment policies relate to COVID-19 pandemic context.

Coronavirus Disease 2019 (COVID-19) From the Point of View of Neurologists: Observation of Neurological Findings and Symptoms During the Combat Against a Pandemic

Some respiratory viruses have long been known to cause neurological involvement. A novel coronavirus, leading to severe acute respiratory syndrome, also called coronavirus disease 19 (COVID-19), seems to be a new member of neuroinvasive viruses. While severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) keeps on spreading around the world rapidly, reports about the neurological manifestations associated with SARS-CoV-2, increases day by day. It is reported that a variety of symptoms and syndromes such as headache, dizziness, confusion, ataxia, epilepsy, ischemic stroke, neuropathic pain and myopathy are common especially in more severe COVID-19 patients. It is also suggested that the development of neurological complications is strongly associated with a poor outcome. On the other hand, hyposmia can be the unique symptom in COVID-19 carriers and this can serve as a marker for identifying the otherwise asymptomatically infected patients. It is thought that SARS-CoV-2 may cause neurological symptoms through direct or indirect mechanisms. Nevertheless, neuroinvasion capability of SARS-CoV2 is confirmed by the presence of the virus, in the cerebrospinal fluid of a COVID-19 patient with encephalitis, and this is proven by gene sequencing. In conclusion, during the COVID-19 pandemic, it is crucial to be aware of the possible neurological complications of the disease. Therefore, in this review, we aimed to report neurological manifestations associated with SARS-CoV-2 and possible underlying pathophysiological mechanisms. Due to the high homology of SARS-CoV-2 with other human coronaviruses such as SARS-CoV or Middle East Respiratory Syndrome (MERS)-CoV, reviewing the neurological involvement also associated with these coronaviruses will provide an idea about the long-term complications of COVID-19.

Ocular Manifestations of COVID-19 (SARS-CoV-2): A Critical Review of Current Literature

The novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), emerged in China in the city of Wuhan in December of 2019 and since then more than 5,000,000 people have been infected, with approximately 338,000 deaths worldwide. The virus causes the coronavirus disease 2019 (COVID-19), which is characterized by fever, myalgia and cough, with severe acute respiratory syndrome being the most fearsome complication. Nevertheless, the vast majority of cases present mild symptoms or none. Central nervous system and cardiovascular manifestations have been reported. The range of ocular manifestations, either as a result of the infection or as a result of the treatment, has not yet been discussed. In this study, a systematic review of current literature relevant to COVID-19 was performed with focus on modes of transmission, ocular manifestations related to infection and medications, as well as the control of infection in ophthalmic practice.

COVID-19 and the eye: how much do we really know? A best evidence review

To identify and classify available information regarding COVID-19 and eye care according to the level of evidence, within four main topics of interest: evidence of the virus in tears and the ocular surface, infection via the conjunctival route, ocular manifestations, and best practice recommendations. A structured review was conducted in PubMed, ScienceDirect, LILACS, SciELO, the Cochrane Library and Google Scholar on COVID-19 and ophthalmology. The Oxford Centre for Evidence Based Medicine 2011 Levels of Evidence worksheet was used for quality assessments. 1018 items were identified in the search; 26 records were included in the qualitative synthesis, which encompassed 6 literature reviews, 10 case series or cross-sectional studies, 4 case reports, and 6 intervention descriptions. Seventeen out of 26 records (65%) were categorized as level 5 within the Oxford CBME methodology grading system, the rest were level 4. The evidence generated on COVID-19 and ophthalmology to date is limited, although this is understandable given the circumstances. Both the possible presence of viral particles in tears and conjunctiva, and the potential for conjunctival transmission remain controversial. Ocular manifestations are not frequent and could resemble viral infection of the ocular surface. Most recommendations are based on the strategies implemented by Asian countries during previous coronavirus outbreaks. There is a need for substantive studies evaluating these strategies in the setting of SARS-CoV-2. In the meantime, plans for applying these measures must be implemented with caution, taking into account the context of each individual country, and undergo regular evaluation.

Detection of SARS-CoV-2 in Human Retinal Biopsies of Deceased COVID-19 Patients

PURPOSE

To report the presence of viral ribonucleic acid (RNA) of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in human retina in deceased patients with confirmed novel coronavirus disease 2019 (COVID-19).

PATIENTS AND METHODS

Fourteen eyes of 14 deceased patients with confirmed COVID-19 disease were enucleated during autopsy. A sample of human retina was secured and fixed in RNAlater™. Real-time reverse transcriptase-polymerase chain reaction (RT-PCR) was performed to detect three different viral RNA sequences (RdRp-gene, E-gene and Orf1 gene) of SARS-CoV-2.

RESULTS

In three out of 14 eyes SARS-CoV-2 viral RNA was detected in the retina of deceased COVID-19 patients. As analysis for three different sequences (RdRp-gene, E-gene and Orf1 gene) revealed positive results in RT-PCR, the existence of SARS-CoV-2 viral RNA in human retina is proven according to the standards of the World-Health-Organization.

CONCLUSION

Viral RNA of SARS-CoV-2 is detectable in the retina of COVID-19 patients.

Potential Drugs Targeting Early Innate Immune Evasion of SARS-Coronavirus 2 via 2'-O-Methylation of Viral RNA

The severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) causing the COVID-19 respiratory disease pandemic utilizes unique 2'-O-methyltransferase (2'-O-MTase) capping machinery to camouflage its RNA from innate immune recognition. The nsp16 catalytic subunit of the 2'-O-MTase is unusual in its requirement for a stimulatory subunit (nsp10) to catalyze the ribose 2'-O-methylation of the viral RNA cap. Here we provide a computational basis for drug repositioning or de novo drug development based on three differential traits of the intermolecular interactions of the SARS-CoV-2-specific nsp16/nsp10 heterodimer, namely: (1) the S-adenosyl-l-methionine-binding pocket of nsp16, (2) the unique "activating surface" between nsp16 and nsp10, and (3) the RNA-binding groove of nsp16. We employed ≈9000 U.S. Food and Drug Administration (FDA)-approved investigational and experimental drugs from the DrugBank repository for docking virtual screening. After molecular dynamics calculations of the stability of the binding modes of high-scoring nsp16/nsp10-drug complexes, we considered their pharmacological overlapping with functional modules of the virus-host interactome that is relevant to the viral lifecycle, and to the clinical features of COVID-19. Some of the predicted drugs (e.g., tegobuvir, sonidegib, siramesine, antrafenine, bemcentinib, itacitinib, or phthalocyanine) might be suitable for repurposing to pharmacologically reactivate innate immune restriction and antagonism of SARS-CoV-2 RNAs lacking 2'-O-methylation.

Haemorrhagic conjunctivitis with pseudomembranous related to SARS-CoV-2

Purpose

To describe the multiplicity of ocular manifestations of COVID-19 patients, we report a case of pseudomembranous and hemorrhagic conjunctivitis related with SARS-CoV-2 pneumonia in a patient of intensive care unit (ICU).

Observations

A 63-year-old male was admitted in intensive care unit (ICU), seven days after the beginning of an influenza-like symptoms, to manage an acute respiratory syndrome related with SARS-CoV-2. Chest scan showed interstitial pneumonia with “crazy paving” patterns. At day 19, ocular examination at the patient's bed described petechias and tarsal hemorrhages, mucous filaments and tarsal pseudomembranous. Conjunctival scrapings and swabs did not identify any bacteria or virus. To our knowledge, we described the first case of pseudomembranous conjunctivitis in a COVID-19 patient.

Conclusion and importance

Considering that SARS-CoV-2 is present in tears and conjunctival secretions, external ocular infections could be factors of infectious spreading. Physicians should be aware of late (>2 weeks) ocular complications in COVID-19 patients to prevent sequelae.

Neurological involvement in SARS-CoV-2 infection: A clinical systematic review

OBJECTIVE

Reports of neurological involvement during Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) infection course are increasingly described. The aim of this review is to provide a clinical approach of SARS-CoV-2 neurological complications based on the direct or indirect (systemic/immune-mediated) role of the SARS-CoV-2 in their genesis.

METHODS

A review of the current literature has been carried out up to May 20th 2020 according to the PRISMA guidelines. All case series and reports of adult neurological manifestations associated to SARS-CoV-2 published in English were considered. Review and fundamental research studies on Coronaviruses neuroinvasive potential were analyzed to support pathogenic hypothesis and possible underlying mechanisms. Clinical patterns were subdivided into three groups according to putative underlying mechanisms: direct invasion of central or peripheral nervous system, systemic disorders leading to acute CNS injuries and post-infectious neurological syndromes (PINS).

RESULTS

Sixteen case series and 26 case reports for a total of 903 patients were identified presenting with neurological involvement during SARS-CoV-2 infection. Hypo/anosmia and dys/ageusia were found in 826 patients and mainly attributed to direct viral invasion. Cerebrovascular complications occurred in 51 patients and related to viral infection associated systemic inflammation. PINS were described in only 26 patients. A wide heterogeneity of these reports emerged concerning the extension of the clinical examination and ancillary exams performed.

CONCLUSIONS

Neurological complications of SARS-CoV-2 are mainly related to olfactory and gustatory sensory perception disorders through possible direct nervous system invasion while cerebrovascular disease and PINS are rare and due to distinct and indirect pathophysiological mechanisms.

All India Ophthalmological Society - Indian Journal of Ophthalmology consensus statement on preferred practices during the COVID-19 pandemic

The COVID-19 pandemic has taken tragic proportions and has disrupted lives globally. In the wake of governmental lockdowns, ophthalmologists need practical and actionable guidelines based on advisories from national health departments on how to conduct their duties during nationwide lockdowns and after these are lifted. In this paper, we present a preferred practice pattern (PPP) based on consensus discussions between leading ophthalmologists and health care professionals in India including representatives from major governmental and private institutions as well as the All India Ophthalmological Society leadership. In this document, the expert panel clearly defines the range of activities for Indian ophthalmologists during the ongoing lockdown phase and precautions to be taken once the lockdown is lifted. Guidelines for triage, governmental guidelines for use of personal protective equipment from ophthalmologists' point of view, precautions to be taken in the OPD and operating room as well as care of various ophthalmic equipment have been described in detail. These guidelines will be applicable to all practice settings including tertiary institutions, corporate and group practices and individual eye clinics and should help Indian ophthalmologists in performing their professional responsibilities without being foci of disease transmission.

COVID-19: Ophthalmological Aspects of the SARS-CoV 2 Global Pandemic

PURPOSE

To perform a systematic analysis of articles on the ophthalmological implications of the global COVID-19 pandemic.

METHODS

PubMed.gov was searched for relevant articles using the keywords "COVID-19", "coronavirus", and "SARS-CoV-2" in conjunction with "ophthalmology" and "eye". Moreover, official recommendations of ophthalmological societies were systematically reviewed, with a focus on the American Academy of Ophthalmology (AAO) and the Royal College of Ophthalmologists (RCOphth).

RESULTS

As of April 16, 2020, in total, 21 peer-reviewed articles on the ophthalmological aspects of COVID-19 were identified. Of these, 12 (57.1%) were from Asia, 6 (28.6%) from the United States of America, and 3 (14.3%) from Europe. There were 5 (23.8%) original studies, 10 (47.6%) letters, 3 (14.2%) case reports, and 3 (14.2%) reviews. These articles could be classified into the topics "Modes and prevention of (ocular) transmission", "Ophthalmological manifestations of COVID-19", "Clinical guidance concerning ophthalmological practice during the COVID-19 pandemic", and "Practical recommendations for clinical infrastructure". Practical recommendations could be extracted from official statements of the AAO and the RCOphth.

CONCLUSION

Within a short period, a growing body of articles has started to elucidate the ophthalmological implications of COVID-19. As the eye can represent a route of infection (actively via tears and passively via the nasoacrimal duct), ophthalmological care has to undergo substantial modifications during this pandemic. In the eye, COVID-19 can manifest as keratoconjunctivitis.

Ocular manifestation as first sign of Coronavirus Disease 2019 (COVID-19): Interest of telemedicine during the pandemic context

We report here the case of a 27-year-old man who consulted by telemedicine during the Coronavirus disease 2019 (COVID-19) pandemic, due to foreign body sensation and left eye redness. Examination revealed unilateral eyelid edema and moderate conjunctival hyperemia. A few hours later, the patient experienced intense headache and developed fever, cough and severe dyspnea. A nasopharyngeal swab proved positive for SARS-CoV-2. This case demonstrates that conjunctivitis can be the inaugural manifestation of the COVID-19 infection. It illustrates the interest of telemedicine in ophthalmology during the COVID-19 pandemic, since moderate conjunctival hyperemia can be the first sign of a severe respiratory distress.

COVID-19 pandemic from an ophthalmology point of view

Coronavirus disease 2019 (COVID-19) is caused by a highly contagious RNA virus termed as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Ophthalmologists are at high-risk due to their proximity and short working distance at the time of slit-lamp examination. Eye care professionals can be caught unaware because conjunctivitis may be one of the first signs of COVID-19 at presentation, even precluding the emergence of additional symptoms such as dry cough and anosmia. Breath and eye shields as well as N95 masks, should be worn while examining patients with fever, breathlessness, or any history of international travel or travel from any hotspot besides maintaining hand hygiene. All elective surgeries need to be deferred. Adults or children with sudden-onset painful or painless visual loss, or sudden-onset squint, or sudden-onset floaters or severe lid oedema need a referral for urgent care. Patients should be told to discontinue contact lens wear if they have any symptoms of COVID-19. Cornea retrieval should be avoided in confirmed cases and suspects, and long-term preservation medium for storage of corneas should be encouraged. Retinal screening is unnecessary for coronavirus patients taking chloroquine or hydroxychloroquine as the probability of toxic damage to the retina is less due to short-duration of drug therapy. Tele-ophthalmology and artificial intelligence should be preferred for increasing doctor-patient interaction.

The Ocular Surface and the Coronavirus Disease 2019: Does a Dual 'Ocular Route' Exist?

Coronavirus disease 2019 (COVID-19) is an important health problem that was defined as a pandemic by the World Health Organization on 11 March 2020. Although great concern has been expressed about COVID-19 infection acquired through ocular transmission, its underlying mechanism has not currently been clarified. In the current work, we analyzed and elucidated the two main elements that should be taken into account to understand the "ocular route", both from a clinical and molecular point of view. They are represented by the dynamism of the ocular surface system (e.g., the tear film turnover) and the distribution of ACE2 receptors and TMPRSS2 protein. Although it seems, at the moment, that there is a low risk of coronavirus spreading through tears, it may survive for a long time or replicate in the conjunctiva, even in absence of conjunctivitis signs, indicating that eye protection (e.g., protective goggles alone or in association with face shield) is advisable to prevent contamination from external droplets and aerosol.

Effect of COVID-19 related lockdown on ophthalmic practice and patient care in India: Results of a survey

Purpose:

In early 2020, the World Health Organization declared the outbreak of the disease COVID-19, caused by a new variant of coronavirus 2019-nCoV as a global pandemic. The government of India ordered a nationwide lockdown for 21 days, limiting movement of people as a preventive measure. This survey was designed and conducted during the lockdown period to assess its effect on ophthalmic practice and patient care in India.

Methods:

An online survey was sent across to practicing Indian ophthalmologists across through various social media platforms. All valid responses were tabulated and analyzed.

Results:

A total of 1260 ophthalmologists responded to the survey. Most of the respondents (775/1260; 61.5%) were in private practice and 14.8% (187/1260) were affiliated to ophthalmic institutes. At the time of taking the survey, 72.5% of the respondents (913/1260) were not seeing any patients due to the lockdown. Of those who were still examining patients, 82.9% (287/347) were only seeing emergency cases, based on their own clinical judgement. The proportion of ophthalmologists in ophthalmic institutes, government and municipal hospitals (126/253;49.8%) who were still seeing patients was significantly higher (P < 0.0001) than those in private practice (174/775;22.4%). Apart from emergencies such as trauma, retinal detachment, and endophthalmitis (81.8%), other surgeries that were still being performed included intravitreal injections (9.1%) and cataract surgeries (5.9%). Approximately, 77.5% (976/1260) of the respondents had begun telephonic/e-mail/video consultations or consultations over social media applications since the lockdown began. In addition, 59.1% (745/1260) felt that ophthalmologists were potentially at a higher risk of contracting COVID-19 compared to other specialties while examining patients. When asked about the resumption of practice upon easing off of the restrictions, 57.8% (728/1260) of the respondents said they were unsure of when to resume elective surgeries; furthermore, 62.8% (791/1260) were unsure about the preferred screening strategy or precautionary approach prior to resuming surgeries and were awaiting guidelines.

Conclusion:

Our survey shows that majority of ophthalmologists in India were not seeing patients during the COVID-19 lockdown, with near-total cessation of elective surgeries. Emergency services were still being attended to by 27.5% of ophthalmologists who responded. A large proportions of ophthalmologists had switched over to telephonic advice or other forms of telemedicine to assist patients. Most of the responding ophthalmologists were unclear about when and how to resume surgeries upon easing off of the COVID-19 related restrictions. Regulatory bodies should take note of this and issue appropriate guidelines regarding the same.

Conjunctivitis can be the only presenting sign and symptom of COVID-19

Five cases of non-remitting conjunctivitis turned out to be the sole presenting sign and symptom of COVID-19. These patients tested positive on RT-PCR of naso-pharyngeal swabs and developed no fever, malaise, or respiratory symptoms throughout the course of their illness. They all fully recovered. In the current efforts to fight the spread of this virus, authors want to emphasize that atypical clinical presentations of COVID-19 can occur and a high level of suspicion should be maintained. Ocular involvement and transmission of SARS-CoV-2 should never be overlooked. In fact, conjunctival mucosae are susceptible to respiratory viruses and remain an important point of entry. For this reason, eye protection in the form of goggles or a face shield should be considered essential for all healthcare providers, even when taking care of patients who are not showing typical symptoms of COVID-19.

Protective measures for COVID-19 for healthcare providers and laboratory personnel

In the COVID-19 pandemic, which affects the whole world, healthcare professionals (HCP) are at high risk of transmission due to their direct contact with patients with COVID-19. Therefore, how to ensure the triage of the patient with acute respiratory symptoms should be determined in advance, the contact distance should be arranged to be at least 2 m, COVID-19 suspect or diagnosed patient should be instructed to wear a surgical mask. During the care of these patients, HCP should wear their personal protective equipment (PPE) in accordance with the procedure and should not neglect hand hygiene. The samples of the patient with known or suspected COVID-19, patient should also be known to be risky in terms of contamination, and a risk assessment should be performed for the procedures to be performed in laboratories. The PPE should be used in accordance with the procedure to be performed. The protection of the HCP, who sacrifice at the risk of life, is possible only by complying with infection control and precautions.

COVID-19: Preliminary Clinical Guidelines for Ophthalmology Practices

The zoonotic Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) and its resultant human coronavirus disease (COVID-19) recently appeared as a global health threat that can cause severe respiratory infection and terminal respiratory distress. By the first week of April, more than 1.3 million people had been globally infected and more than 70,000 had lost their lives to this contagious virus. Clinical manifestations occur shortly after exposure, or a few days later. There is controversy regarding the transmission of the virus through the tear and conjunctiva; however, there are reports that the ocular surface might be a potential target for COVID-19. The ease of transmission of this virus at close proximity presents a risk to eyecare workers. Several recommendations have been issued by local and national organizations to address the issue of safe ophthalmic practice during the ongoing COVID-19 pandemic. These guidelines have numerous similarities; however, subtle differences exist. The purpose of this paper was to discuss measures, with a specific focus on standard precautions, to prevent further dissemination of COVID-19 at Eye Clinics. We have proposed procedures to triage suspected cases of COVID-19, considering emergency conditions.

Eyes Have It: From COVID-19 Perspective

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.

Extrapulmonary Features of COVID-19: A Concise Review

Typical manifestations of coronavirus disease (COVID-19) involve the upper and lower respiratory tract. But as the pandemic surges, we are encountering numerous case reports and series of extrapulmonary presentations of COVID-19 in the outpatient department. Abundant retrospective data have also cited various extrapulmonary complications in the hospitalized COVID-19 patients. This knowledge needs to be condensed and disseminated in order to improve COVID-19 surveillance and to reduce the accidental exposure of healthcare workers. Our review suggests that gastrointestinal tract, cardiovascular system, nervous system, renal system, and manifestations due to hematological abnormalities are common masqueraders to watch out for.

Evaluation of Patients Presenting to the Ophthalmology Department of a Tertiary Hospital for Nonemergency Reasons During the Covid-19 Pandemic

OBJECTIVE

To evaluate changes in the demographic and diagnostic distribution of patients presenting to the ophthalmology department during the COVID-19 pandemic, compared to the pre-pandemic period

METHODS

The study included patients who made outpatient appointments in our ophthalmology department. The COVID-19 group (CovG) comprised patients who presented between April 15 and May 15, 2020, the 30-day period with the highest daily number of new cases in Turkey. The control group (CG) was obtained by randomization through a computer program from among 2 245 patients who applied in the same period of the previous year. The patients’ presenting complaint(s), diagnostic(s) and demographic information’s were collected from a database, with all identifying information concealed. For patients who presented more than once, their initial complaint and diagnoses were analyzed

RESULTS

The study included a total of 400 patients: 200 in the CovG and 200 in the CG. Mean ages in the CovG and CG were 41.23 ± 14.48 and 48.20 ± 17.49 years, respectively (p < 0.001). The female to male patient ratio was 0.53 in the CovG and 0.83 in the CG (p = 0.032). There were fewer university graduates compared to other education levels among the patients who presented during the pandemic (p = 0.013). During the COVID-19 pandemic, there was no increase in presentation frequency for any ocular disease compared to the previous year. The only statistical decrease in patient application complaints was observed in reading difficultness (11 % in CovG vs. 37 % in CG; p < 0.001). Presentations due to dry eye (DE) and allergic conjunctivitis (AC) were similar to the same period of the year (p = 0.303 and p = 0.550, respectively). At least 1 chronic ocular disease was present in 25 % of the CovG and 45.5 % of the CG (p < 0.001). A statistically significant decrease was observed in CovG for age-related macular degeneration and glaucoma in the diagnoses made at the end of the examination (p = 0.001 and p < 0.001, respectively).

CONCLUSION

During the first peak of the COVID-19 pandemic in Turkey, the most common outpatient presentations to the ophthalmology department were for the diagnoses of DE and AC. During peak pandemic period, elderly patients, women and academically trained patients significantly reduced their visits to the Eye Clinic. The reduction in presentation of patients with glaucoma and age-related macular degeneration may be due to the longterm treatment planning for these patients and the social isolation measures issued for the older population. These patients should be encouraged to use video consultation / telemedicine in eye patients at risk of vision loss.