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Recently, the American Academy of Ophthalmologists issued an update on COVID-19 for eye specialists. Here, we try to share and explain the important points from this update.

QUICK-FACTS

1. Conjunctivitis: where the eye becomes red or sore from infection has been reported in several COVID-19 reports suggesting that the virus may be caught through aerosol contact with the eye.a. In a Journal of Medical Virology study of 30 patients hospitalized for COVID-19 in China, 1 had conjunctivitis. That patient—and not the other 29—had SARS-CoV-2 in their eye secretions. This suggests that COVID-19 can infect the conjunctiva and cause conjunctivitis, and virus particles are present in eye secretions.b. In a larger study published in the New England Journal of Medicine, researchers reported “conjunctival congestion” where the “whites” of the eye is red and swollen in 9 of 1,099 patients (0.8%) with laboratory-confirmed COVID-19 from 30 hospitals across China.
2. Conjunctivitis with fever and respiratory symptoms could be COVID-19 especially if there has been recent travel abroad to areas with known outbreaks (China, Iran, Italy, Japan and South Korea), or with family members recently returned from one of these countries.
3. Given the information above: our hands can transmit virus particles when we rub our eyes and vice versa. The public health message of washing our hands with soap and avoiding touching our face is relevant and specifically, avoiding rubbing our eyes with unclean hands.
4. The wearing of masks may give us a false sense of security because if we rub our eyes with virus-laden hands, we may still be able to catch COVID-19, even with our masks on.
5. Disinfection of surfaces with alcohol and bleach-based disinfectants is effective as the virus that causes COVID-19 is likely susceptible to these disinfectants.
6. Protective eyewear also becomes an additional requirement over and above masks, gloves and protective gowns when attending to persons with confirmed COVID-19.

Background

The SARS-CoV-2 virus which causes COVID-19 belongs to a family of viruses called the coronavirus. This is the same family of viruses that caused SARS and MERS. Although initial thinking is that it is less fatal than SARS coronavirus or MERS coronavirus; authorities cannot be certain of exactly how fatal COVID-19 really is. What we do know is that it is a highly transmissible infection. And because it is highly contagious, even though it seems to be less fatal, COVID-19 related deaths have already exceeded that of SARS and MERS. The rapid transmission and escalating number of deaths globally has prompted the WHO to declare COVID-19 a “global pandemic”.

WHO Situation Report on COVID-19 as of 13^th March 2020

Globally

• 132 758 confirmed (7499 new) 4955 deaths (342 new)

China

• 80 991 confirmed (11 new) 3180 deaths (07 new)

Outside of China

• 51 767 confirmed (7488 new) 1775 deaths (335 new)
• 122 countries/territories/ areas (5 new)

Situation in Singapore as of 13^th March 2020

What do people with COVID-19 infection experience?

Typically, they will have a respiratory illness with cough, shortness of breath and fever.  Symptoms can appear as soon as 2 days or as long as 14 days after exposure. A March 10 study in the Annals of Internal Medicine found that the mean incubation period for SARS-CoV-2 was 5 to 7 days. More than 97% of those who developed symptoms did so within 11.5 days of exposure, findings that further support current 14-day quarantine recommendations. Conjunctivitis which is sore or red eyes has also been seen in some patients.

Is there treatment for COVID-19?

At this time, there is no vaccine to prevent infection, and no medication known to be effective in treatment.

How does it spread?

How COVID-19 spreads is based on what we know about other similar coronaviruses. Spread from  person-to-person is believed to be through respiratory droplets produced when an infected person coughs or sneezes. Spread can also occur when people touch an object or surface with virus and then touch their mouth, nose or eyes. Virus has also been detected in stool samples from infected patients, this may mean the possibility of catching it through faeces is possible.

In a study posted March 10 on MedRxIV, scientists found that the virus could survive up to 24 hours on cardboard, up to 4 hours on copper and up to 2 to 3 days on plastic and stainless steel. This study has not yet been peer-reviewed; meaning that the results are not fully validated and may be subject to changes. There are no changes in recommendations related to use of masks on the basis of this study, but it does emphasize the importance of handwashing and cleaning surfaces and materials possibly contaminated by respiratory secretions from infected patients.

How is the eye involved in COVID-19?

Quoting from the American Academy of Ophthalmologists update:

“Two recent reports suggest the virus can cause conjunctivitis. Thus, it is possible that SARS-CoV-2 is transmitted by aerosol contact with the conjunctiva of the eye. In a Journal of Medical Virology study of 30 patients hospitalized for COVID-19 in China, 1 had conjunctivitis. That patient—and not the other 29—had SARS-CoV-2 in their ocular secretions. This suggests that SARS-CoV-2 can infect the conjunctiva and cause conjunctivitis, and virus particles are present in ocular secretions. In this larger study published in the New England Journal of Medicine, researchers documented “conjunctival congestion” in 9 of 1,099 patients (0.8%) with laboratory-confirmed COVID-19 from 30 hospitals across China.”

What does this mean to us?

The information above adds to the growing knowledge about this very new infection called COVID-19.

1. Conjunctivitis or “sore eyes” which is a relatively common condition, can be a feature of COVID-19 infection in a very small number of cases: about 0.8% of all COVID infections in the larger published study. Whether, we will see this in more numbers, making conjunctivitis a more widely seen feature of COVID-19 remains something to watch. But we need to be aware that “sore eyes” can be a feature and be vigilant toward this, especially when there are accompanying features of cough, running nose, breathing difficulty and fever.
2. Regular “sore eyes” has always been contagious and transmitted through rubbing our eyes with hands that have come into contact with viruses or bacteria causing these “sore eyes”. This latest update has found COVID-19 causing virus in the tear samples taken from a COVID-19 patient with “sore eyes”. This suggests that, COVID-19 may be transmitted through the eyes as well and can be caught through rubbing our eyes with dirty hands. Hand washing and avoiding rubbing our eyes and touching our face with unclean hands is relevant and cannot be over-emphasised.
3. The wearing of masks may give us a false sense of security because if we rub our eyes with virus-laden hands, we may still be able to catch COVID-19, even with our masks on.
4. For carers at home, or healthcare workers involved in the care of COVID-19 patients, protecting the mouth and nose alone may not be sufficient. Protecting the eyes either with googles or shields is recommended when caring for these patients.

Environmental cleaning and disinfection is important

In Bozhou, China, in a photo from February, workers spray disinfectant to protect against the novel coronavirus. STR/AFP VIA GETTY IMAGES

A letter published in the Journal of the American Association of Medicine (JAMA)  by our Singapore researchers at the National Center for Infectious Disease on March 4^th  showed that patients with the coronavirus extensively contaminate their bedrooms and bathrooms, highlighting the need to routinely clean high-touch surfaces, basins and toilet bowls. This study collected samples from patients’ rooms on five days over a two-week period and testing them for the coronavirus.

The researchers were able to demonstrate that twice-a-day cleaning of surfaces and daily cleaning of floors with a commonly used disinfectant killed the virus.

We will do well to take lessons from this study, which although was carried out at the NCID, in a clinical environment, should also be relevant to our homes and workplaces. Regular cleaning of surfaces with household disinfectants, especially the high-touch surfaces could help reduce the risk and likelihood of infection.

The National Environmental Agency has provided a list of household disinfectants that have been shown to be effective against coronaviruses. Because the COVID-19 is new, no study has been published on the virus. This assessment is thus based on published scientific studies on coronaviruses, a group to which the COVID-19 virus would belong.

https://www.nea.gov.sg/our-services/public-cleanliness/environmental-cleaning-guidelines/guidelines/interim-list-of-household-products-and-active-ingredients-for-disinfection-of-covid-19

To summarize,  it seems that patients with the new Coronavirus can have virus particles in their tears. Conjunctivitis, or sore eyes, may be another feature of COVID-19, especially in combination with fever and respiratory symptoms in a very small number of people. Above all, as we still know relatively little about this virus, being careful is wise. This finding on COVID-19 affecting the eyes while not conclusive, should be a reminder that masks alone may give us a false sense of security, we need to take on the public health advice to practice good hygiene, especially with hand washing and avoid touching our face, including our eyes.

https://www.moh.gov.sg/docs/librariesprovider5/2019-ncov/covid-19-pss-educational-material_final.pdf

1. Lu H, Stratton CW, Tang YW. Outbreak of pneumonia of unknown etiology In Wuhan, China: The mystery and the miracle.J Med Virol.2020;10.1002/jmv.25678. doi:10.1002/jmv.25678. (Epub ahead of print, 2020 Jan 16).
2. Zhang L, Shen FM, Chen F, Lin Z. Origin and evolution of the 2019 novel coronavirus. Clin Infect Dis. 2020; ciaa112. doi:10.1093/cid/ciaa112. (Epub a head of print, 2020 Feb 3).
3. Chodash, J. (2020). Alert: Important Coronavirus updates for ophthalmologists. [online]. Available at: https://www.aao.org/headline/alert-important-coronavirus-contex.[ Accessed 13^th March 2020].