key: cord-0819048-f1e6hs11 authors: Dockery, Dominique M.; Rowe, Susannah G.; Murphy, Marjorie A.; Krzystolik, Magdalena G. title: The Ocular Manifestations and Transmission of COVID-19; Recommendations for Prevention date: 2020-05-08 journal: J Emerg Med DOI: 10.1016/j.jemermed.2020.04.060 sha: 1d40163aa648a837209bf31d0c3b54b8a38e6969 doc_id: 819048 cord_uid: f1e6hs11 Abstract Background Coronavirus disease-2019 (COVID-19), caused by a novel coronavirus termed severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), has been linked to ocular signs and symptoms in several case reports. Research has demonstrated that SARS-CoV-2 is spread primarily through close contact via respiratory droplets, but there is the possibility for ocular transmission with the conjunctiva as a conduit as well as a source of infection. Discussion Ocular manifestations of SARS-CoV-2 include follicular conjunctivitis and have been repeatedly noted as an initial or subsequent symptom of COVID-19 positive patients. Particularly in patients with ocular manifestations, there is evidence that the virus may present in tears based on the detection of SARS-CoV-2 in conjunctival swab samples via reverse transcription polymerase chain reaction (RT-PCR). The virus may therefore be transmittable from the ocular surface to a new host via contact with the ocular mucosa, tears, or subsequent fomites. Conclusions All healthcare professionals should ask patients about ocular symptoms consistent with SARS-CoV-2, use eye protection such as goggles or face shields as part of the standard personal protective equipment (PPE) for high-risk patients in addition to wearing of masks both by the patient and provider, and should consider tears to be potentially infectious. appears to be via large respiratory droplets (2), the eyes may serve as a source of infection as 29 well as an entryway for transmission. 30 Belser and colleagues previously described an anatomical theory for ocular transmission 32 of respiratory disease via the nasolacrimal system. (3) They suggested that the ocular mucosal 33 immune system, composed of the conjunctiva, cornea, lacrimal glands, and lacrimal drainage 34 system, clears fluid from the eye and transports it to the inferior meatus of the nose. Therefore, if 35 a respiratory droplet is deposited on the surface of the eye, the virus-containing fluid can then 36 enter the respiratory system through the nose, gaining access to the lungs. Respiratory syncytial 37 virus (RSV) is one respiratory illness that has been demonstrated to be primarily spread through 38 the eyes and nose. The eyes, in addition to the nose and upper respiratory system, are home to 39 various receptors that have been linked to viral binding in RSV infection. Therefore, the eyes are 40 a portal of entry for RSV, and the use of eye protection has been demonstrated to reduce the 41 Additional data supporting this theory includes the presence of a viral load in the tear 43 fluid of patients with a variety of respiratory illnesses. This theory has been studied in animal 44 models including mice, ferrets, rabbits, and cotton rats. The viruses tested in these species included adenoviruses and influenza viruses, and the animal models used intrastromal 46 inoculation or dropwise inoculation onto the cornea. After inoculation, viral loads were detected 47 in tear samples from all animals. These animals were also found to have clinical signs of presentation in addition to cough, sore throat, and coryza. Ocular swabs were collected starting 107 on day three of hospital admission and were continued with almost daily frequency until day 27. 108 The conjunctivitis was noted to resolve at day 20 and the patient continued to have daily viral 109 SARS-CoV-2 RNA detection in ocular samples until day 21. Furthermore, this patient had a 110 subsequent positive ocular swab on day 27, which was days after SARS-CoV-2 was undetectable 111 by a nasopharyngeal swab. This suggests that tears can be a potential source of infection early on 112 in the disease course and that the conjunctiva may sustain viral replication for an extended period 113 of time. Although the reported incidence of both ocular symptoms and positive conjunctival 116 swabs for SARS-CoV-2 has been fairly low to date, it is important to note that conjunctival 117 swabs from these small case series may have had insufficient tear material to detect the virus in 118 the samples, thus accounting for the low incidence of positive swabs. However, a paucity of 119 evidence is not enough to rule out the possibility of ocular transmission. Suspected COVID-19 120 patients could also have experienced ocular symptoms that are being underreported. In order to 121 increase the accuracy of ocular data collection in patients presenting with COVID-19 symptoms, A Novel Coronavirus from Patients with Pneumonia in Early Transmission Dynamics in Wuhan, China Ocular Tropism of Respiratory Viruses Can the Coronavirus Disease The Severe Acute Respiratory Syndrome Risk Factors for SARS Transmission from Patients Requiring Intubation: A Multicentre Investigation in Toronto The severe acute respiratory syndrome coronavirus 181 in tears Characteristics of Ocular Findings of Patients with 183 Ophthalmologic evidence against the interpersonal 186 transmission of 2019 novel coronavirus through conjunctiva The infection evidence of SARS-CoV-2 in ocular 188 surface: a single-center cross-sectional study Evaluation of coronavirus in tears and conjunctival secretions 190 of patients with SARS-CoV-2 infection Ocular manifestations of a hospitalised patient with 192 confirmed 2019 novel coronavirus disease SARS-CoV-2 Isolation From Ocular Secretions of a 194 Patient With COVID-19 in Italy with Prolonged Viral RNA Detection American Academy of Ophthalmology Eye protection for preventing transmission of respiratory viral infections to 200 healthcare workers