The Eyes Have It: Novel Coronavirus in Eye Can be Communicable

One-third of patients in a series of 38 hospitalized for coronavirus disease 2019 (COVID-19) were found to have symptoms consistent with conjunctivitis. Two of the patients yielded positive RT-PCR tests for the SARS-CoV-2 virus from both conjunctival and nasopharyngeal swabs, and 1 patient manifested the excessive tearing of epiphora as the first symptom of the viral illness.

"Because unprotected eyes were associated with an increased risk of transmission SARS-CoV-1 (in 2003 SARS outbreak), in support of our current results, our results might suggest that SARS-CoV-2 might be transmitted through the eye," warns Ping Wu, MD, Department of Ophthalmology, The First College of Clinical Medical Science, Yichang Central People's Hospital, China, and colleagues.

The investigators undertook their study after noting that there has been little previous evaluation of ocular signs and symptoms in patients infected with SARS-CoV-1 or with SARS-CoV-2, and no reported direct evidence that coronavirus causes conjunctivitis or other ocular diseases.

Ocular manifestations consistent with conjunctivitis, including conjunctival hyperemia, chemosis, epiphora and increased secretions, were found in 12 of the 38 patients. The symptoms appeared more likely to occur in patients with more severe COVID-19, as 6 of the 12 patients were deemed critical, 2 were severely ill and 4 had moderate severity. Applying univariate analysis, the researchers found that the patients with ocular symptoms were also more likely to have higher white blood cell and neutrophil counts; and higher levels of procalcitonin, C-reactive protein and lactate dehydrogenase than patients without ocular symptoms.

Moderate severity of COVID-19 was defined has having fever and/or respiratory symptoms and lung involvement demonstrated by chest CT. Severe illness was characterized by dyspnea with 30 or more respirations per minute, blood oxygen saturation of 93% or less, blood oxygen saturation of not more than 93%, and arterial partial pressure of oxygen to fraction of oxygen inspiration ratio of 300 or less. Patients were classified as critical if they experienced respiratory failure, shock, or with multiple organ failure/dysfunction.

"Our investigation suggests that among patients with COVID-19, 31.6% (95% CI, 17.5-48.7) have ocular abnormalities, with most among patients with more severe systemic manifestations or abnormal findings on blood test," Wu and colleagues report. "These results suggest that ocular symptoms commonly appear in patients with severe pneumonia."

In commentary accompanying the published report, Alfred Sommer, MD, MHS, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, commends the researchers for bringing "necessarily preliminary but valuable insights from the front line."

"The primary importance of this finding is epidemiologic: it confirms other reports that the virus can invade the conjunctiva, which might, in turn, serve as a source of its spread," Sommer points out.

Sommer notes that effective containment of the virus requires an understanding of its mode of transmission and implementing rapid and vigorous interventions to stop it. "Unfortunately, this is a lesson we keep forgetting," he observed.

Sommer also reminds that it was an ophthalmologist caring for patients in Wuhan, Li Wenliang, MD, who was the first to attempt to alert the public and call for action on the new illness—meeting harsh government action and dying of COVID-19.