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Review Article

Indian J Med Res 151, May 2020, pp 411-418

DOI: 10.4103/ijmr.IJMR_1369_20
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COVID-19 pandemic from an ophthalmology point of view

Parul Chawla Gupta1, Praveen Kumar-M2 & Jagat Ram1

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Departments of 1Ophthalmology & 2Pharmacology, Postgraduate Institute of Medical Education & Research,
Chandigarh, India

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.

Key words Chloroquine - contact lens - coronavirus - eye donation - eye shields - hydroxychloroquine - ophthalmologist

Introduction can affect both the upper and lower respiratory tracts
through aerosols, faeces and contaminated surfaces5-8.
On December 31, 2019, the Government of China
However, no transmission through breast milk has
sounded the World Health Organization of a group
been documented9. A potentially fatal form of it is
of patients being admitted to hospitals with atypical known as severe acute respiratory syndrome (SARS)10.
pneumonia with likely origin due to a virus from the It is produced by a highly contagious RNA virus
Huanan seafood marketplace in Wuhan city, situated termed as SARS coronavirus 2 (SARS-CoV-2), with
in the province of Hubei in China1. Initially, the virus the tremendous capability of survival attributed to its
was thought to have an animal-to-human transmission, rapid mutation rates as compared to DNA viruses11.
but the enormous spread among humans due to the As of May 20, 2020, SARS-CoV-2 had affected
massive human migration on account of the Chinese 5,054,252 people in 213 countries/territories and two
New Year proved this fact untrue with the evidence international conveyances, with 327,938 mortalities
of human-to-human transmission2-4. Coronavirus located majorly within the USA, Russia, Spain, Brazil,
disease 2019 (COVID-19) is a new infection that the UK and Italy12. India had 112,028 people affected

© 2020 Indian Journal of Medical Research, published by Wolters Kluwer - Medknow for Director-General, Indian Council of Medical Research
411
 412 INDIAN J MED RES, MAY 2020

with 3,434 total deaths, with the maximum being in curtail the incidence of coronavirus infection in both
the State of Maharashtra13. This review highlights the medical personnel and patients.
risk ophthalmologists have due to close proximity with
Guidelines for ophthalmologists to prevent the
patients and suggests ways to prevent this transmission.
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spread of COVID-19
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Medical personnel at high-risk Ocular involvement in patients with proven SARS-

Ophthalmologists are at a high-risk due to the CoV-2 infection
following three important reasons: presence of virus The symptoms of COVID-19 may vary from
in the tear fluid, proximity of encounter and deceiving being completely asymptomatic to having fever,
symptoms. cough, breathlessness, muscle aches, fatigue and loss
Presence of virus in the tear fluid of smell or taste26. Non-specific symptoms include
headache, blood in vomitus or diarrhoea27. A few
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SARS-CoV-2 via its surface spike glycoprotein COVID-19 patients present with conjunctival redness
binds to the angiotensin-converting enzyme 2 (ACE2) or conjunctivitis21.
receptors. These ACE2 receptors are found distributed
in various human organs, including the surface of the In a series of 38 patients from Hubei province
cornea and the conjunctiva, and these act as potential in China, those with ophthalmic symptoms were
entry points14,15. Coronavirus was spotted in the more susceptible to have leucocytosis with increased
conjunctival discharge of COVID-19-positive patients neutrophil numbers and much higher enzymes such
having conjunctivitis16. Loon et al17 have isolated as procalcitonin, C-reactive protein and lactate
virus from the tears of coronavirus-infected patients dehydrogenase than patients with no ophthalmic
by reverse transcription-polymerase chain reaction manifestations. Ocular features were seen in one-third
(RT-PCR). While examining the patient, the risk of of the involved patients and they demonstrated signs
tears contaminating the fingers of the examiner as well of conjunctivitis, including conjunctival hyperaemia,
as the instruments, is fairly high18. chemosis or increased tearing. Fundus was not
evaluated in any of these patients. However, none of
Proximity of encounter them complained of any decrease in vision. Nearly 91.7
Because of the proximity (20-30 cm) to the per cent of the patients of the one-third in this study
patients, examining a patient in the clinic (conjunctival tested positive for SARS-CoV-2 using RT-PCR from
discharge, tears and nasal/oral secretions) can pose a nasopharyngeal swabs and of these, 16.7 per cent tested
hazard to ophthalmologists19-21. The patients visiting positive from both conjunctival and nasopharyngeal
ophthalmology clinics are predominantly elderly swabs28.
and they suffer from old age-related diseases such In another study by Guan et al26, among 1,099
as cataracts, macular degenerations and glaucoma22. patients from mainland China, 0.8 per cent (9 patients)
Hence, nosocomial infections are an essential concern had symptoms of conjunctival congestion. In a case
both for the doctor and the patient23. report of a 30 yr old patient of confirmed COVID-19,
Deceiving symptoms bilateral follicular conjunctivitis with tearing, redness
and moderate and tender preauricular lymphadenopathy
Eye care professionals can also be caught was documented on the day 14 of illness with the
unaware because conjunctivitis may be one of subsequent resolution on day 19. The fundus picture
the first signs of COVID-19 at presentation, even taken through a non-mydriatic fundus camera as
precluding the emergence of additional symptoms well as macular optical coherence tomography was
such as dry cough and anosmia24. The American unremarkable. The virus load in the swabs obtained
Academy of Ophthalmology (AAO) has released from the conjunctiva was considerably lesser than that
an advisory alerting eye specialists to put on face obtained from the nasopharyngeal swabs29.
and eye shields while examining patients with fever,
breathlessness or any history of international travel Ocular symptoms/signs as first indicators of SARS-
CoV-2 infection
or travel to and from any hotspot25. With these
reasons in the background, it is especially important In a prospective contact tracing study in China, the
to have practical and useful guidelines, directed at first symptom of a 22 yr old index patient of COVID-19
eye care specialists, tailored to the local needs to was itchy eyes30. In another study which included
 GUPTA et al: COVID-19 PANDEMIC & OPHTHALMOLOGY 413

534 COVID-19-confirmed patients, 25 patients be used to communicate with the patients. Tele-
(4.68%) had conjunctival congestion and of them, ophthalmology services can be used for patient
three patients had it as the first symptom. The mean consults or for patients requiring urgent follow
duration of the congestion was 4.9±2.6 days. Dry eye up36,37. The governments in different countries have
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(112, 20.97%), blurred vision (68, 12.73%) and foreign recommended telemedicine in lieu of in-hospital
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body sensation (63, 11.80%) were the most frequently visits. Lives can be saved by social distancing in
occurring ophthalmic symptoms in these patients. pandemic areas38. Mode of communication can be
Other symptoms included itching and photophobia. audio, video or text.
Approximately more than 60 per cent of patients
had a history of hand-eye touch31. Other studies also There are mobile apps for visual acuity and
demonstrated conjunctival congestion in 4.76 per cent perimetry39,40. Home monitoring of intraocular
and 2.78 per cent of the total COVID-19 patients, pressure using finger tension and of metamorphopsia
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respectively32,33. In a contrary study of 17 patients, using Amsler grid should be done41. Drug dosage
tear samples were negative for SARS-CoV-2, even modifications can be done during teleconsultation.
though nasopharyngeal swabs were positive. One of Informed consent of the patient needs to be taken
the 17 patients demonstrated eye signs even though during tele-consults or video visits. Doctor-patient
SARS-CoV-2 could not be established in tears. interaction can also be enhanced through the Internet
This study concluded that viral spread through tears with the assistance of artificial intelligence42,43.
irrespective of the stage of infection is less34. Screening at entrance to hospital: For any patient
Other coronaviruses are responsible for causing visiting the eye hospital, at the entry point, a history of
a wide spectrum of ophthalmic signs and symptoms travel in the past 14 days from an area in the red zone
such as conjunctivitis, uveitis and posterior segment should be enquired about44. Thermal scanning should
vision-impairing conditions such as retinitis and be done at the main entrance. The patient and the
optic neuritis. However, uveitis and other posterior attendants should be asked to wear a three-ply mask.
segment manifestations have not been documented35. If the patient has fever or any of the aforementioned
An illustrated depiction of all eye-related symptoms is symptoms, he/she should be taken to the dedicated
given in Figure 1. COVID-19 hospital45-47.
Guidelines at the place of practice Triaging: Triaging: Initially, telephonic triaging can be
practised, and only those patients who require emergent
Non-pharmacological interventions, hygiene ophthalmic check-up should be called to the hospital.
practices and personal protective equipment (PPE) to Triaging should be able to segregate the patients into
limit the virus circulation along with postponement of the following three groups: (i) patients who can be
non-emergency surgeries should be followed in both seen in the main stream (patients without symptoms
public and private ophthalmology clinics21. Some of and a history of travel to hotspots); (ii) patients who
the important points are discussed below:
have to be sent to COVID-19 managing hospital;
Opting for tele-ophthalmology: Only e-mails, phone and (iii) indeterminate group. The indeterminate
calls, messages and social media platforms should group should be evaluated for the need for urgent eye

Fig. 1. Ophthalmological signs and symptoms of coronavirus disease 2019. Chemosis, conjunctival congestion, follicles, tearing, itching,
dry eye, blurred vision, photophobia and preauricular lymphadenopathy are major signs.
 414 INDIAN J MED RES, MAY 2020

consultation. If urgent, they would need to be examined scratch-resistant goggles/face-shield, disposable

in a separate isolation room with PPE. waterproof gown, preferably nitrile gloves, and
impermeable shoe covers) should be worn by
Emergent conditions: Patients with sudden-onset of
surgeons while operating on COVID-19-confirmed
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painful or painless vision loss, or sudden-onset squint,

patients. Proper technique of donning and doffing of
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or sudden-onset floaters or severe lid oedema and

PPE and their disposal should be followed50. Separate
children with the aforementioned conditions as well as
colour-coded bins/bags should be kept as per the
those with unilateral white reflex should be attended
Biomedical Waste Rules 2016 and amended by the
to on an emergent basis21. For patients presenting with
Central Pollution Control Board51.
conjunctivitis, allergic or toxic conjunctivitis should
be ruled out. Circumcorneal congestion can point Instrument sanitation should be done after seeing
towards serious ocular conditions such as uveitis or every patient. Sanitation of the floor, doorknobs and bed
corneal ulcers. The final treatment can be targeted rails should be done using freshly prepared one per cent
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towards the most common causes of conjunctivitis sodium hypochlorite preferably after every two hours46. The
i.e., viral/bacterial, which consists of a topical air conditioning should have fresh air exchange and should
fluoroquinolone and lubricants. Topical steroids should be fitted with standard filters. Temperature and humidity
be avoided as it would require frequent follow up for should be maintained as per guidelines. Negative pressure
intraocular pressure monitoring48. The latest guidelines is preferred in rooms requiring aerosolization procedures
by the All India Ophthalmological Society have given such as intubation/extubation, suction and nebulization52.
subspecialty-wise classification of procedure on A summary of potential strategies in hygiene practices,
the basis of priority: emergency, urgent and routine personal protective equipment and non-pharmacological
procedures46. interventions is documented in Figure 2.
Management at outpatient department (OPD): Special topics of interest in COVID-19 era
Children <10 yr and elderly >65 yr should be Contact lens (CL) practice
discouraged from visiting the hospital unless they
are patients themselves. The waiting areas should be A contact lens specialist should keep away from
decongested and intercoms or call notifications on touching his/her face and mucus membrane-covered
phones can be used to call each patient for examination49. areas such as nose, mouth and eyes53. CLs should be
adequately cleaned, and disposable CLs should not be
Special referral tests such as refraction used longer than what is recommended. Individuals
perimetry, optical coherence tomography, fundus should be told to discontinue CL wear if they have any
fluorescein angiography, corneal topography, specular symptoms of COVID-1954,55.
microscopy, ultrasound and ultrasound biomicroscopy
should be deferred until these are critical for making Corneal donation guidelines
a diagnosis. Fundus evaluation, if required, can be The Eye Bank Association of America (EBAA): The
done using non-mydriatic fundus cameras. Indirect Eye Bank Association of America has laid down
ophthalmoscopy should be preferred in place of the guidelines for eye donation56. According to these, eye
slit lamp for examination as it has a larger working banks should avoid corneal donation from donors
distance. Indirect ophthalmoscopy can also be used for who in the last 28 days were positive for the novel
evaluating the central fundus in case of non-availability coronavirus or those who came in contact with a
of non-mydriatic fundus cameras. positive case or a suspect or those who had an acute
Management at operation theatre (OT) level: All respiratory illness with fever >38°C with any one of
elective surgeries should be postponed. Surgeries the symptoms of COVID-19 or those who had acute
under general anaesthesia should be avoided as respiratory distress syndrome/pneumonia/ground-glass
extubation leads to aerosol generation. Since nasal opacities on computed tomography. Cornea from
secretions have been shown to contain SARS-CoV-2; a donor who has tested negative for the disease and
has been diagnosed with another aetiology which
procedures which act as nasal simulants such as nasal
explains the symptoms or findings can be considered
endoscopy should be avoided34. Topical anaesthesia
for transplant57.
should be preferred over regional anaesthesia. Pre-
operative testing for COVID-19 should be done Global Alliance of Eye Bank Associations (GAEBA):
for all patients46. Full PPE (N95 mask, fog and Because there is no evidence till date that coronaviruses
 GUPTA et al: COVID-19 PANDEMIC & OPHTHALMOLOGY 415
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Fig. 2. A summary of potential strategies in hygiene practices, personal protective equipment and non-pharmacological interventions for the
prevention of infection among the ophthalmologists and patients visiting ophthalmology clinics.

can be transmitted by avascular tissue (cornea) Guidelines for cornea and eye banking should be
transplantation even though it has been proved to be followed58.
present in tears and conjunctival discharges of patients
Retinal screening before starting chloroquine therapy
positive for the novel coronavirus, any efforts to
procure tissue are precautionary, hence, the guidelines Chloroquine (CQ) and hydroxychloroquine (HCQ)
include that any potential donor with confirmed or have been demonstrated to have considerable efficacy
suspected coronavirus infection should not donate against the SARS-CoV-259. CQ and HCQ have been
if the death has occurred less than 14 days since the used by the physicians since long for diseases such
resolution of symptoms or awaiting test results for as systemic lupus erythematosus (SLE) as well as
suspected coronavirus infection. Moreover, if the donor rheumatic disorders60. Retinal toxicity is rarely seen
has been in contact with a confirmed or suspected case before 10 or more years of use at a dose of <5 mg/kg
of coronavirus infection less than 14 days from the first real weight as advocated by the AAO guidelines61.
day of contact, the donation should be avoided57. Rheumatologists have been routinely using HCQ as
a part of the therapeutic regimen for SLE, myeloma
Eye Bank Association of India (EBAI): The Eye
and small-cell carcinoma of the lung. These regimens
Bank Association of India57 has given an advisory
extend from a few weeks to months. Visual loss has not
for the resumption of eye banking activities through
been documented in any of the studies except in two
the Hospital Cornea Retrieval Programme in the
patients who showed subtle alterations in the parafoveal
non-containment area of the red zones as demarcated
ellipsoid zone on optical coherence tomography62-64.
by the government. Because the virus may be present
in tears and mucus membranes, it is risky for those Marmor60 has concluded that ophthalmic retinal
healthcare personnel who are deployed for recovery screening is unnecessary for coronavirus patients
of the donated ocular tissue. They should wear full taking CQ or HCQ as antiviral drug therapy for a
PPE (cap, gloves, N95 mask, face shield, gown and time period less than two weeks, as the probability of
shoe covers) before enucleating the donor eyeball. toxic damage to the retina is extremely less even on
 416 INDIAN J MED RES, MAY 2020

using large dosages. Other drugs such as remdesivir, 8. World Health Organization. WHO Director-General’s remarks
CQ, oseltamivir, interferon 1β, tocilizumab and at the media briefing on 2019-nCoV on 11 February 2020.
convalescent serum, as well as anti-mRNA vaccines, Available from: https://www.who.int/dg/speeches/detail/
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are under trial47.
Sj32S5aMfaURMPpSpx6kqHsrJYCAzwc87vjF9AWfsygSxegOxz5e3FbD7ohHzTFC7/g1/iY6b1fgM1dwHV5bdUkgkLXb6GtqgJ2+

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For correspondence: Dr Jagat Ram, Department of Ophthalmology, Postgraduate Institute of Medical Education & Research,
Chandigarh 160 012, India
e-mail: [email protected]