COVID-19 Disease and Ophthalmology: An Update

Management of COVID-19 in Ophthalmology

From its outbreak in early 2020, the new SARS-CoV-2 infection has deeply affected the entire eye care system for several reasons. Since the beginning of the COVID-19 pandemic, ophthalmologists were among the "high-risk category" for contracting the SARS-CoV-2 infection based on the notion that the eye was suspected to be a site of inoculation, infection, and transmission. Clinical ophthalmologists have been required to learn and promptly recognize the ocular manifestations associated with the COVID-19 disease, with its treatments and vaccinations. Restriction measures, lockdown periods, guidelines to prevent SARS-CoV-2 infection transmission, and the use of telemedicine and artificial intelligence modalities have induced profound modifications. These changes, which are most likely to be irreversible, influence routine clinical practice, education, and research, thus giving rise to a "new ophthalmology in the COVID era". This book chapter aims to provide several notions regarding COVID-19 in ophthalmology, including the SARS-CoV-2 virus infection and transmission modalities; the ocular manifestation associated with the COVID-19 disease; the drugs and vaccines used for COVID-19; the precautions adopted in the ophthalmic practice to limit the spread of the virus; the consequences of the pandemic on the ophthalmic patients, clinicians, and the entire eye care system; and, the future of ophthalmology in the era of "COVID new normal".

Ophthalmic manifestations in patients recovered from COVID-19 in Mexico

INTRODUCTION AND OBJECTIVES

Although the ophthalmic manifestations appear to be associated with the coronavirus disease 2019 (COVID-19), there is not enough evidence. Hence, the aim of this study was to determine the various types and frequency of ophthalmic manifestations in patients recovered from SARS-CoV-2 infection in Mexico.

MATERIAL AND METHODS

This retrospective, observational and descriptive study included all patients recovered from SARS-CoV-2 infection attending the tertiary level hospital of Mexican Social Security Institute (IMSS) from June 2020 to June 2022. During the hospital admission of patients, the demographic data such age, name, gender was recorded. Ophthalmologic examination was performed under torchlight by an ophthalmologist in the Department of Ophthalmology from IMSS. Data was compiled and statistically analyzed using Fisher's exact test and Spearman correlation.

RESULTS

A total of 3,081 SARS-CoV-2-positive patients were recorded, of which 318 (10.32%) met the inclusion criteria. Of them, 21 (6.60%) had ophthalmic manifestations and the female-to-male ratio was 1.6:1. The mean age (±SD) was 47.95 ± 15.27 years and the median (interquartile range) time from the diagnosis of COVID-19, as defined by positive SARS-CoV-2 RT-PCR testing, to detection of the ophthalmic manifestation was 31 (142) days. The most common ocular manifestation was orbital mucormycosis (23.80%). Interestingly, the presence of ophthalmic manifestations was not associated with severe COVID-19 (p = 0.665).

CONCLUSIONS

The ophthalmic manifestations are infrequent in patients recovered from severe COVID-19. Nevertheless, further large sample studies are needed to confirm these findings.

Cataract Surgery during the COVID-19 Pandemic: Insights from a Greek Tertiary Hospital

Background: COVID-19 has affected everyday clinical practice, having an impact on the quality of healthcare provided, even in eye clinic departments. The aim of this study is to evaluate the consequences of this worldwide pandemic on cataract surgery in a Greek tertiary university hospital. Methods: A total of 805 patients were included in this study. The number of cataract surgeries (CS), the type, the unilateral or bilateral appearance as well as the stage of cataract were recorded for the months between January and June 2019 (pre-COVID period) and compared with the same period in 2021 (during the pandemic outbreak) in the Department of Ophthalmology of Thessaloniki General Hospital G. Papanikolaou. Results: A significant reduction in the number of CS as well as a significant increase in advanced and/or bilateral cataracts in 2021 compared to the pre-COVID period were observed. Conclusions: The COVID-19 pandemic has affected equally the value of ophthalmic interventions as well as the patients’ quality of life, being a powerful reminder of the significant physical and psychological benefits of CS, especially for older adults and patients with comorbidities.

Emergency Vitrectomies for Retinal Detachment Before and During the Coronavirus Pandemic - A Retrospective Single Centre Analysis

Background While the corona pandemic and the resulting containment measures affect the number of elective surgical procedures, the impact on emergency surgical interventions is less tangible. This analysis quantifies the frequency of emergency vitrectomies for retinal detachment and investigates underlying factors.

Methods Retrospective identification of patients who underwent primary emergency vitrectomies for retinal detachment at the Cantonal Hospital of Lucerne between 01.01.2018 – 31.12.2020. Parameters were collected, including demographics, date of hospitalisation, reported onset of symptoms, pre-operative best corrected visual acuity (BCVA), involvement of the macula, and canton of residence.

Results Overall, a total of 665 patients with 683 eyes underwent emergency surgery for primary retinal detachment in the time span of 01.01.2018 – 31.12.2020. Median monthly number of surgeries was 20. During the first Swiss national lockdown (16.03.2020 – 19.04.2020), a minimum of 9 vitrectomies was recorded in March 2020. A maximum of 36 vitrectomies was conducted in August 2020. The mean age of patients was 61.5 years. Of the 665 patients, 133 (20.0%) were residents of the canton of Ticino. Median pre-operative BCVA was 0.25 over all three years, and no significant reduction in pre-operative BCVA was observed during or after the lockdown. The proportion of eyes with involvement of the macula was 52.2%. In 2018, this proportion (47.6%) was significantly lower than in 2019 and 2020 (Chi ² test, p < 0.001). However, cases with macular involvement in post lockdown months were not more frequent. Median time in days from reported symptom onset to hospitalisation was 5 days. In April 2020, the proportion of patients with > 14 days symptom duration was significantly higher (Chi ² test, p < 0.001). During the lockdown, there was a significant reduction in cases from Ticino. Also, patients from Ticino showed proportionally longer symptom duration after the lockdown.

Conclusion A significant reduction in the number of emergency vitrectomies was observed for the initial period of the coronavirus pandemic. Delayed emergency presentation is not assumed, since there was no increase in severity (i.e. macular involvement) or prolonged symptoms in the months following the lockdown. More protracted symptoms were only observed in patients from Ticino. The initial low numbers were generally made good later in the year.

Analysis of microvascular and neurodegenerative complications of mild COVID-19

Purpose

To examine retinal and corneal neurodegenerative and retinal microvascular changes in patients after mild or asymptomatic COVID-19 disease compared to age-matched controls.

Methods

Thirty-five (35) patients after PCR-proven SARS-CoV-2 infection and 28 age-matched controls were enrolled. Swept-source optical coherence tomography (OCT), OCT angiography, and in vivo corneal confocal microscopy were performed in both groups. Corneal subbasal nerve plexus was quantified. Vessel density for superficial (SCP) and deep capillary plexus (DCP) and structural OCT parameters were recorded.

Results

Significantly lower nerve branch density (P = 0.0004), nerve fiber area (P = 0.0001), nerve fiber density (P = 0.0009), nerve fiber length (P < 0.0001), and total nerve branch density (P = 0.002) values were observed in patients after COVID-19 compared to healthy controls. VD of the temporal SCP was significantly different between the two groups (P = 0.019). No other SCP and DCP vessel density parameter differed significantly between the two groups.

Conclusions

Our results suggest that peripheral neurodegenerative changes may occur even after mild or asymptomatic SARS-CoV-2 infection. No relevant microvascular changes were seen with OCT angiography and structural OCT parameters did not show any signs of optic neuropathy in post-COVID patients. In vivo confocal microscopy seems to be an important tool in monitoring peripheral neuropathy in patients after COVID-19.

Blood and saliva contamination on protective eyewear during dental treatment

Objectives

Dental treatments are inherently associated with the appearance of potentially infective aerosols, blood and saliva splashes. The aim of the present study was to investigate the quantitative contamination of protective eyewear during different dental treatments and the efficacy of the subsequent disinfection.

Materials and methods

Fifty-three standardized protective eyewear shields worn by students, dentists and dental assistants during different aerosol-producing dental treatment modalities (supragingival cleaning, subgingival periodontal instrumentation, trepanation and root canal treatment and carious cavity preparation; within all treatments, dental evacuation systems were used) were analysed, using common forensic techniques. For detection of blood contamination, luminol solution was applied onto the surface of safety shields. A special forensic test paper was used to visualize saliva contamination. Further analysis was conducted after standardized disinfection using the same techniques. Statistical analysis was performed using SPSS.

Results

Macroscopically detectable contamination was found on 60.4% of protective eyewear surfaces. A contamination with blood (median 330 pixels, equivalent to 0.3% of the total surface) was detected on all shields after dental treatment. Between various dental treatments, the contamination with blood tend to be statistically significant (p = 0.054). Highest amount of blood was observed after professional tooth cleaning (median 1,087 pixels). Significant differences of saliva contamination were detected between the different measurements (p < 0.001) with contamination only after dental treatment. Due to the low variance and right-skewed distribution for saliva contamination, no statistical analysis between different treatments could be performed. After disinfection, 0.02% blood contamination and no saliva contamination were detected.

Conclusions

Disinfection is effective against blood and saliva contamination. Macroscopically, clean protective eyewear contains up to 12% surface contamination with blood. Based on the results, it may be concluded that protective eyewear is essential for each dental practitioner.

Clinical relevance

As standard for infection prevention in the dental practice, disinfection of protective eyewear after each patient is necessary.

COVID-19 and the Eye: Ocular Manifestations, Treatment and Protection Measures

The novel pandemic coronavirus disease 2019 (COVID-19) leading to health and economic problems worldwide is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Although COVID-19 mainly occurs as a lower respiratory tract infection, there is multiorgan involvement in infected patients. The disease is transmitted from person to person through air droplets or contact with contaminated surfaces. SARS-CoV-2 leads to this systemic involvement by attaching to angiotensin-converting enzyme 2 (ACE2) receptors located on several human cells. Since SARS-CoV-2 RNA has been found in tears of infected patients, ocular surface may allow the virus to transmit to nasopharynx via the nasolacrimal duct. This narrative review aims to sum up all segmental ocular complications, ocular adverse effects of COVID-19 treatment, and preventive measures suggested to minimize the SARS-CoV-2 transmission between patients and ophthalmologists by reviewing currently available literature.

Risk of SARS-CoV-2 virus transmission from donor corneal tissue: A review

Since the outbreak of respiratory coronavirus disease (COVID-19) caused by the coronavirus SARS-CoV-2, there is an ongoing discussion about whether the virus could be transmitted through corneal transplantation from donor to recipient. The purpose of this review was to summarize the current knowledge in the scientific community to provide aid in risk evaluation for potential virus transfer by corneal transplants. Literature was searched in PubMed.gov for relevant articles on coronavirus in conjunction with cornea processing, cornea transplantation and eye banking. Further, guidelines of health authorities and eye banking associations were reviewed. Studies have shown that SARS-CoV-2 RNA can be detected in ocular swabs and/or fluid of patients with COVID-19. However, the risk of SARS-CoV-2 virus transmission through these ocular tissues or fluid of patients is judged differently. To date, per literature and official guidelines, no evidence of viable virus in ocular tissue and no cases of transmission of SARS-CoV-2 via tissue preparations have been reported.

Quantitative assessment of retinal changes in COVID-19 patients

CLINICAL RELEVANCE

The SARS-COV 2 virus, which is responsible for the COVID-19 pandemic, acts on the angiotensin converting enzyme 2 (ACE-2) receptor in the host cell. Ocular effects may occur because of the ACE-2 receptor in the retina.

BACKGROUND

To investigate the impact of COVID-19 on the retinal layers and optic disc parameters in previously confirmed COVID-19 patients using spectral domain optical coherence tomography (SD-OCT).

METHODS

This study included 60 eyes of 60 subjects; 35 of them were in the COVID-19 group and the remaining 25 were in the control group. Patients with the diagnosis of COVID-19 that had a negative result after treatment were included in the study. Macular and peripapillary retinal nerve fiber layer (RNFL) thickness measurements, each retinal layer thickness of all participants were done 14-30 days after COVID-19 symptom onset, following the negative result of real time reverse transcriptase-polymerase chain reaction test using SD-OCT.

RESULTS

The mean value of central macular thickness was significantly higher in the COVID-19 group than the control group (p = 0.02). The mean values of the ganglion cell layer and inner nuclear layer thickness in the COVID-19 group were significantly thinner than control group (p = 0.04 and p = 0.04, respectively). Even though mean RNFL thickness measurements in all sections in the COVID-19 group was thinner than controls, there were no significant differences between groups (p > 0.05 for all).

CONCLUSION

In the early recovery phase, changes in the macula, ganglion cell layer and inner nuclear layer could be seen. These patients should be followed up closely for the recognition of new pathologies that could be seen in the late recovery phase.

Persistent Retinal Microvascular Impairment in COVID-19 Bilateral Pneumonia at 6-Months Follow-Up Assessed by Optical Coherence Tomography Angiography

The purpose of this study was to evaluate the long-term evolution of retinal changes in COVID-19 patients with bilateral pneumonia. A total of 17 COVID-19 patients underwent retinal imaging 6 months after hospital discharge with structural optical coherence tomography (OCT) and optical coherence tomography angiography (OCTA). The parafoveal retinal nerve fiber layer (RNFL) and ganglion cell layer (GCL) were significantly thinner in COVID-19 patients at 6 months compared to 0 months (p = <0.001 in both cases). In the optic nerve analysis, a significantly thinner RNFL was observed (p = 0.006) but persisted significantly thickened, compared to controls (p = 0.02). The vascular density (VD) at 6 months persisted significantly decreased when compared to the control group, and no significant differences were found with the 0 months evaluation; in addition, when analyzed separately, women showed a worsening in the VD. Moreover, a significantly greater foveal area zone (FAZ) (p = 0.003) was observed in COVID-19 patients at 6 months, compared to 0 months. The cotton wool spots (CWSs) observed at baseline were no longer present at 6 months, except for one patient that developed new ones. This study demonstrates that some of the previously known microvascular alterations resulting from COVID-19, persist over time and are still evident 6 months after hospital discharge in patients who have suffered from bilateral pneumonia.

Ophthalmic manifestations associated with SARS-CoV-2 in newborn infants: a preliminary report

COVID-19, caused by severe acute respiratory syndrome coronavirus (SARS-CoV-2), affects people of all ages. The virus can cause multiple systemic infections, principally in the respiratory tract, as well as microvascular damage. Ocular manifestations of COVID-19 are uncommon in adults and children. We describe ophthalmic manifestations in newborns detected by slit-lamp examination, fundus examination, and fluorescein angiography. All patients showed edema and hemorrhagic conjunctivitis; fundus examinations revealed cotton wool spots and vitreous hemorrhage, and microvascular damage manifested as patchy choroidal filling, peripapillary hyperfluorescence, delayed retinal filling and venous laminar flow, and boxcarring on fluorescein angiography.

Impact of COVID-19 at the Ocular Level: A Citation Network Study

BACKGROUND

The main objective of this study was to use citation networks to analyze the relationship between different publications on the impact of COVID-19 at an ocular level and their authors. Furthermore, the different research areas will be identified, and the most cited publication will be determined.

MATERIALS AND METHODS

The publications were searched within the Web of Science database, using "ocular", "SARS-CoV-2", "ophthalmology", "eyesight", and "COVID-19" as keywords for the period between January 2020 and January 2021. The Citation Network Explorer and the CiteSpace software were used to analyze the different publications.

RESULTS

A total of 389 publications with 890 citations generated on the web were found. It must be highlighted that July was the month with the largest number of publications. The most cited ones were "Characteristics of Ocular Findings of Patients with Coronavirus Disease 2019 (COVID-19) in Hubei Province, China" by Wu et al., which was published in May 2020. Three groups covering the different research areas in this field were found using the clustering functions: ocular manifestations, teleophthalmology, and personal protective equipment.

CONCLUSIONS

The citation network has shown a comprehensive and objective analysis of the main studies on the impact of COVID-19 in ocular disease.

Preventive Practices of Ophthalmologists During COVID-19 Pandemic

PURPOSE

To explore ophthalmologists' preventive practices, and their perceived seriousness and perceived risk of transmission of coronavirus disease 2019 (COVID-19).

METHODS

In a cross-sectional study, a semi-structured questionnaire was distributed online among ophthalmologists. Questions about COVID-19 infection, perceived seriousness, perceived risk of transmission, and recommended COVID-19 preventive practices were asked. Based on the adoption of a preventive measure and its frequency, a maximum preventive score of 25 was computed.

RESULTS

Among 126 respondents, the mean±SD age was 45.3±10.9 years, and 57.9% worked in a tertiary care hospital. Regarding preventive practices, 96.8% of ophthalmologists wore face masks, 89.6% avoided talking during the slit lamp examination, and 72.2% wore gloves during the ophthalmic examination. Availability of plastic barriers and regular disinfection of slit lamps were reported by 78.6% and 43.7% of ophthalmologists, respectively. The mean preventive score increased with increasing age (p=0.001), and was higher for males (18.96±4.60) compared to females (17.81±4.96). The mean score for perceived severity was higher (p<0.0001) among ophthalmologists with more than 10 years of experience (8.76±1.58) than those with experience of 10 years or less (7.49±1.86). Out of 29 ophthalmologists who had been tested for COVID-19, 11 were found to be positive, giving an overall incidence of COVID-19 infection of 8.7%.

CONCLUSION

The ophthalmologists were generally compliant with recommended preventive measures. Some preventive measures, such as the wearing of gloves and regular disinfection of slit lamps, need improvement. We recommend creating awareness of and monitoring for COVID-19 infection control measures in healthcare settings.

Ocular Involvement of SARS-CoV-2 in a Polish Cohort of COVID-19-Positive Patients

The coronavirus SARS-CoV-2 responsible for the current human COVID-19 pandemic has shown tropism toward different organs with variable efficiency, eyes included. The purpose of this study has been to investigate the presence of detectable SARS-CoV-2 infection in ocular swabs in patients affected by COVID-19. A consecutive series of 74 COVID-19-positive patients (age 21-89) were enrolled at two Polish COVID-19 hospitals for 4 months and were characterized by PCR for the presence of the SARS-CoV-2 genetic material in nasopharyngeal (NP) and ocular swabs, while their respiratory and ocular symptoms were noted. Almost 50% of them presented with severe/critical respiratory involvement, and some degree of eye disease. No tight correlation was observed between the presence of ocular and respiratory symptoms. Three male patients presenting with severe/critical lung disease tested positive in ocular swab, however with mild/moderate ocular symptoms. In conclusion, our study lends further support to the view that overt ocular infection by the SARS-CoV-2 virus is not such a frequent occurrence.

Retinal Microvascular Impairment in COVID-19 Bilateral Pneumonia Assessed by Optical Coherence Tomography Angiography

The purpose of this study was to evaluate the presence of retinal and microvascular alterations in COVID-19 patients with bilateral pneumonia due to SARS-COV-2 that required hospital admission and compare this with a cohort of age- and sex-matched controls. COVID-19 bilateral pneumonia patients underwent retinal imaging 14 days after hospital discharge with structural optical coherence tomography (OCT) and optical coherence tomography angiography (OCTA) measurements. Vessel density (VD) and foveal avascular zone (FAZ) area were evaluated in the superficial, deep capillary plexus (SCP, DCP), and choriocapillaris (CC). After exclusion criteria, only one eye per patient was selected, and 50 eyes (25 patients and 25 controls) were included in the analysis. COVID-19 patients presented significantly thinner ganglion cell layer (GCL) (p = 0.003) and thicker retinal nerve fiber layer (RNFL) compared to controls (p = 0.048), and this RNFL thickening was greater in COVID-19 cases with cotton wool spots (CWS), when compared with patients without CWS (p = 0.032). In both SCP and DCP, COVID-19 patients presented lower VD in the foveal region (p < 0.001) and a greater FAZ area than controls (p = 0.007). These findings suggest that thrombotic and inflammatory phenomena could be happening in the retina of COVID-19 patients. Further research is warranted to analyze the longitudinal evolution of these changes over time as well as their correlation with disease severity.

Systemic diseases and the cornea

There is a number of systemic diseases affecting the cornea. These include endocrine disorders (diabetes, Graves' disease, Addison's disease, hyperparathyroidism), infections with viruses (SARS-CoV-2, herpes simplex, varicella zoster, HTLV-1, Epstein-Barr virus) and bacteria (tuberculosis, syphilis and Pseudomonas aeruginosa), autoimmune and inflammatory diseases (rheumatoid arthritis, Sjögren's syndrome, lupus erythematosus, gout, atopic and vernal keratoconjunctivitis, multiple sclerosis, granulomatosis with polyangiitis, sarcoidosis, Cogan's syndrome, immunobullous diseases), corneal deposit disorders (Wilson's disease, cystinosis, Fabry disease, Meretoja's syndrome, mucopolysaccharidosis, hyperlipoproteinemia), and genetic disorders (aniridia, Ehlers-Danlos syndromes, Marfan syndrome). Corneal manifestations often provide an insight to underlying systemic diseases and can act as the first indicator of an undiagnosed systemic condition. Routine eye exams can bring attention to potentially life-threatening illnesses. In this review, we provide a fairly detailed overview of the pathologic changes in the cornea described in various systemic diseases and also discuss underlying molecular mechanisms, as well as current and emerging treatments.

Corneal transplantation during COVID-19 pandemic: need for special considerations-A live review

Corneal blindness is the fourth leading cause of blindness worldwide, with 10 million people having bilateral corneal blindness, nearly 80% of all corneal blindness cases are avoidable and are reversible. Corneal transplantation (CT) is the most frequently performed type of transplant across the world. This review was conducted with the objective of identifying if it is safe to harvest the cornea from the patients died due to COVID-19 and preventing the chances of transmission from donor to the recipient or healthcare worker handling the harvested cornea. A total of 45 articles were found with the keywords and out of all, only 16 fulfilled the inclusion criteria. RT-PCR is the technique of choice for detection of virus in the corpse and the sample analyzed was a pharyngeal swab. Available literature states unavailability of sufficient evidence-based studies proving presence of virus in the cornea or tear of COVID affected patients There is no proven consensus on presence of Virus in cornea. It is important to follow preferred practice guidelines so as to restart eye banking and do at least the emergency surgeries without having risk of disease transmission and keeping ourselves safe.

Ocular Manifestations of COVID-19: A Systematic Review and Meta-analysis

Several studies have reported the characteristics of Coronavirus disease 2019 (COVID-19), yet there is a gap in our understanding of the ocular manifestations of COVID-19. In this systematic review and meta-analysis, we investigated the prevalence of ocular manifestations in COVID-19 patients. We searched Pubmed, Embase, Scopus, Web of Science, and medRxiv from December 1, 2019 to August 11, 2020. Two independent reviewers screened the articles, abstracted the data, and assessed the quality of included studies in duplicate. Thirty-eight studies were eligible after screening of 895 unique articles, with a total of 8,219 COVID-19 patients (55.3% female; n = 3,486 out of 6,308 patients). Using data extracted from cross-sectional studies, we performed random-effects meta-analyses to estimate the pooled prevalence of ocular symptoms along with 95% confidence interval (CI). The prevalence of ocular manifestations was estimated to be 11.03% (95% CI: 5.71-17.72). In the studies that reported the details of observed ocular symptoms, the most common ocular manifestations were dry eye or foreign body sensation (n = 138, 16%), redness (n = 114, 13.3%), tearing (n = 111, 12.8%), itching (n = 109, 12.6%), eye pain (n = 83, 9.6%) and discharge (n = 76, 8.8%). Moreover, conjunctivitis had the highest rate among reported ocular diseases in COVID-19 patients (79 out of 89, 88.8%). The results suggest that approximately one out of ten COVID-19 patients show at least one ocular symptom. Attention to ocular manifestations, especially conjunctivitis, can increase the sensitivity of COVID-19 detection among patients.

Study of the Etiology of Acute Respiratory Infections in Children Under 5 Years at the Dr. Agostinho Neto Hospital, Praia, Santiago Island, Cabo Verde

Background: Acute respiratory infections are one of the major causes of morbidity and mortality in children under 5 years in developing countries and are a challenge for the health system of these countries. In Cabo Verde, despite the lack of recent studies, data indicate that it affects thousands of children, being the fourth leading cause of infant mortality in 2013. The aim of this study was to identify and describe the etiological agents associated with acute respiratory tract infections in children under 5 years old, and their associated risk factors, such as clinical symptoms or socio-demographic characteristics. Methods: Naso-pharyngeal samples were collected from children under 5 years attending at Dr. Agostinho Neto Hospital (Praia, Santiago Island, Cabo Verde) with suspected ARI at different time-points during 2019. Samples were analyzed using FilmArray® Respiratory Panel v. 2.0 Plus to identify etiological agents of ARI. A questionnaire with socio-demographic information was also collected for each participant. Data analyses were carried out using the IBM SPSS version 25 (IBM Corporation, Armonk, NY) and R 3.5.1 statistical software. Results: A total of 129 naso-pharyngeal samples were included in the study. Seventeen different etiologic agents of respiratory infections were identified. HRV/EV was the most frequent agent detected, followed by FluA H3 and RSV. Coinfection with two or more pathogens was detected in up to 20% of positive samples. The results were analyzed in terms of age-group, sex, period of the year and other social and demographic factors. Conclusion: Viruses are the main causative agents of ARI in children <5 years attending at the pediatrics service at the Dr. Agostinho Neto Hospital in Praia city, Santiago Island, Cabo Verde. Some factors are described in this study as statistically associated with the presence of an infectious agent, such as having one or more children sharing the bedroom with an adult and the presence of some clinical symptoms. The data addresses the need for studies on respiratory tract infections in Cabo Verde.

Ocular manifestations of COVID-19: a literature review

Coronavirus disease 2019 (COVID-19) caused by the highly pathogenic SARS-Cov-2 virus, was declared as a pandemic by the World Health Organization (WHO) in March 2020. Its main clinical manifestations are related to airway involvement; however, there is extrapulmonary impairment in some cases. Given this context, this literature review aims to identify the ophthalmological conditions caused by infection with the novel coronavirus. Although ocular findings do not include the standard clinical presentation of the disease, there are reports of some ophthalmological changes in COVID-19 patients, and conjunctivitis is the most common among these.

Novel Insights into the Transmission of SARS-CoV-2 Through the Ocular Surface and its Detection in Tears and Conjunctival Secretions: A Review

SARS-CoV-2 is a highly transmissible virus that spreads mainly via person-to-person contact through respiratory droplets, or through contact with contaminated objects or surfaces from an infected person. At present we are passing through a phase of slow and painful understanding of the origin, epidemiological profile, clinical spectrum, and risk profile of the virus. To the best of our knowledge there is only limited and contradictory evidence concerning SARS-CoV-2 transmission through other routes. Importantly, the eye may constitute not only a potential site of virus replication but also an alternative transmission route of the virus from the ocular surface to the respiratory and gastrointestinal tract. It is therefore imperative to gain a better insight into the potential ophthalmological transmission route of the virus and establish directions on best practice and future models of care for ophthalmological patients. This review article critically evaluates available evidence on the ophthalmological mode of viral transmission and the value of earlier identification of the virus on the eye. More evidence is urgently needed to better evaluate the need for protective measures and reliable ocular diagnostic tests to diminish further pandemic spread.

An Ophthalmic Insight into Novel Coronavirus 2019 Disease: A Comprehensive Review of the Ocular Manifestations and Clinical Hazards

PURPOSE

To discuss the ocular manifestations provoked by novel coronavirus 2019 (COVID-19) disease in humans, the natural history of the disease in the eye, and its treatment.

METHODS

We designed a narrative review of the ocular manifestations of COVID-19 based on the literature published till July 30, 2020. The databases were PubMed, Scopus, Cochrane Library, Google Scholar, and ScienceDirect. The inclusion criteria were (1) all types of clinical studies and (2) the topic was COVID-19 and its association to the eye regarding the current guidelines.

RESULTS

From 168 abstracts screened, 61 papers fully filled the inclusion criteria after the full-text screening. The 61 records include 13 case reports, 17 prospective (case series or cross-sectional) studies, 8 retrospective studies, 12 literature reviews (one systematic review), and 11 letters to the editor. The majority of the papers agreed that ophthalmic manifestations due to COVID-19 were few and rarely encountered. The main ocular pathology seemed to be conjunctivitis, where the viral polymerase chain reaction also happened to be most detectable. Posterior segment or neuro-ophthalmic manifestations were scarce. Viral genome detection in the eye as well as viral portal of entry to the globe is still vague.

CONCLUSION

The exact incidence of ocular manifestations in COVID-19 disease is uncertain. Conjunctivitis is the most prevalent ocular manifestation. It is still a debate whether the eye is a portal of entry for infection.

Peripapillary Retinal Vascular Involvement in Early Post-COVID-19 Patients

The ability of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2's) to cause multi-organ ischemia and coronavirus-induced posterior segment eye diseases in mammals gave concern about potential sight-threatening ischemia in post coronavirus disease 2019 patients. The radial peripapillary capillary plexus (RPCP) is a sensitive target due to the important role in the vascular supply of the peripapillary retinal nerve fiber layer (RNFL). Eighty patients one month after SARS-CoV-2 infection and 30 healthy patients were selected to undergo structural OCT (optical coherence tomography) and OCTA (optical coherence tomography angiography) exams. Primary outcome was a difference in RPCP perfusion density (RPCP-PD) and RPCP flow index (RPCP-FI). No significant difference was observed in age, sex, intraocular pressure (IOP) and prevalence of myopia. RPCP-PD was lower in post SARS-CoV-2 patients compared to controls. Within the post-COVID-19 group, patients with systemic arterial hypertension had lower RPCP-FI and age was inversely correlated to both RPCP-FI and RPCP-PD. Patients treated with lopinavir + ritonavir or antiplatelet therapy during admission had lower RPCP-FI and RPCP-PD. RNFL average thickness was linearly correlated to RPCP-FI and RPCP-PD within post-COVID-19 group. Future studies will be needed to address the hypothesis of a microvascular retinal impairment in individuals who recovered from SARS-CoV-2 infection.

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.