key: cord-1031300-pytu6sy0
authors: Sun, Xufang; Zhang, Xian; Chen, Xuhui; Chen, Liwen; Deng, Chaohua; Zou, Xiaojing; Liu, Weiyong; Yu, Huimin
title: The infection evidence of SARS-COV-2 in ocular surface： a single-center cross-sectional study
date: 2020-02-26
journal: nan
DOI: 10.1101/2020.02.26.20027938
sha: c10661c9b35e068691b879661bcebeba3bd6aad9
doc_id: 1031300
cord_uid: pytu6sy0

Purpose: The aim of this study was to identify whether SARS-COV-2 infected in ocular surface. Methods: Cross-sectional study of patients presenting for who received a COVID-19 diagnosis, from December 30, 2019 to February 7, 2020, at Tongji hospital, Tongji medical college, Huazhong University of Science and Technology. Demographics, temperature was recorded, blood routine test (Rt), chest Computed Tomography (CT) were took intermittently, and SARS-COV-2 real-time reverse-transcriptase-polymerase-chain-reaction (RT-PCR) assay were arranged for the nasopharyngeal and conjunctival swab samples. Results: A total of 102 patients (48 Male [50%] and 54 Female [50%]) with clinical symptoms, Rt, and chest Computed Tomography (CT) abnormalities were identified with a clinical diagnosis of COVID-19. Patients had a mean [SD] gestational age of 57.63 [14.90] years. Of a total of 102 patients identified, 72 patients (36 men [50%] and 36 women [50%]; mean [SD] age, 58.68 [14.81] years) confirmed by laboratory diagnosis with SARS-COV-2 RT-PCR assay. Only two patients (2.78%) with conjunctivitis was identified from 72 patients with a laboratory confirmed COVID-19. However, SARS-COV-2 RNA fragments was found in ocular discharges by SARS-COV-2 RT-PCR only in one patient with conjunctivitis. Conclusions: Although we suspect the incidence of SARS-COV-2 infection through the ocular surface is extremely low, the nosocomial infection of SARS-CoV-2 through the eyes after occupational exposure is a potential route. The inefficient diagnostic method and the sampling time lag may contribute to the lower positive rate of conjunctival swab samples of SARS-COV-2. Therefore, to lower the SARS-COV-2 nosocomial infection, the protective goggles should be wore in all the health care workers.

A novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) associated with severe human infected disease (COVID-19) outbroke starting from Wuhan city, in China. 1 Most recently, Wang D et al reported 138 hospitalized SARS-COV-2 pneumonia cases with a hospital-associated transmission rate of 41%, among whom 70% were medical staffs. 2 To date, nearly 80, 000 people have been infected by COVID-19, including over 3000 medical staffs. Therefore, in order to curb the spread of SARS-COV-2, and reduce the nosocomial infection, the exact routes of transmission need to be further studied and confirmed.

Although primarily affecting the respiratory tract, it also involves extra-pulmonary sites, including the digestive tract and other organs. 3 SARS-CoV-2 infected patients develop respiratory illness, with the first symptoms of fever, cough and fatigue that quickly progress to pneumonia. COVID- 19 were also contributed to extra-pulmonary manifestations in a number of patients at the onset of the illness, such as headache, diarrhoea, nausea and vomiting, 4 or even presented with asymptomatic infection. 8 Despite the intensive work that has been focused on an understanding of the transmission of SARS-CoV-2, the spread mode of the SARS-CoV-2 is unclear.

To our knowledge, limited investigations have been conducted to date into the clinical features of SARS-COV-2 in ocular surface. A few of COVID-19 patients with conjunctivitis, or even as the first symptom, make the early diagnosis and effective protection a great difficulty. A recent research has demonstrated that SARS-COV-2 can be detected in the conjunctival sac of patients with COVID-19 patients or suspected. 5 However, none of these patients had ocular symptoms. We therefore conducted a study to describe the clinical spectrum of ocular symptoms and laboratory test in conjunctival swab samples, we found a rare case of nosocomial SARS-COV-2 infection with conjunctivitis in a nurse, which suggests that ocular transmission may be a potential route of nosocomial transmission of the SARS-COV-2.

All rights reserved. No reuse allowed without permission. the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint (which was not peer-reviewed) is Serum was collected in a serum separator tube and then centrifuged in accordance with CDC guidelines. Laboratory-confirmed cases were identified with the criteria of at least one positive result from a respiratory specimen using RT-PCR assays. All patients invited to participate in the study provided consent for the nasopharyngeal and conjunctival swab samples with synthetic fiber swabs.

Then, these swab samples were detected via real-time RT-PCR assays as previously described. 7 forward primer 5′-ACTTCTTTTTCTTGCTTTCGTGGT-3′;

reverse primer 5′-GCAGCAGTACGCACACAATC-3′; and the probe 5′CY5-CTAGTTACACTAGCCATCCTTACTGC-3′BHQ1.

The statistical analysis was performed using SPSS software version 22.0 (SPSS Inc, All rights reserved. No reuse allowed without permission.

the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint (which was not peer-reviewed) is Only two patients (2.78%) with conjunctivitis were identified from 72 patients with a laboratory confirmed COVID-19. However, SARS-CoV-2 was found in ocular discharges by RT-PCR only in one patient, the symptoms and laboratory test were shown in Fig. 2 . Briefly, a 29-year-old nurse working in the Emergency Department at Tongji hospital, Wuhan City, China was referred to the Department of Ophthalmology at Tongji Hospital on February 1st, 2020 due to excessive tearing and redness in both eyes (Fig. 3A) . No other systemic symptoms except for a moderate fever of 38.2℃ was reported on January 31st, 2020. The ocular examination revealed conjunctival congestion and watery discharges in both eyes with normal best corrected visual acuity, normal corneal epithelium, quiescent anterior chamber and no tenderness or enlargement of the preauricular lymph node. We therefore excluded the possibility of conventional conjunctivitis, such as bacterial conjunctivitis, hemorrhagic conjunctivitis, allergic conjunctivitis, according to her clinical symptom and sign. She clarified medical N95 respirators continuously wore during operation, while occasionally worked with a dislocated eye mask touching her eyelids.

Considering the occupational exposure by SARS-COV-2, SARS-COV-2 related assay were arranged. Surprising, the chest CT showed multiple peripheral ground-glass opacities in both lungs (Fig. 3D-F) . The conjunctival and oropharyngeal swabs tested All rights reserved. No reuse allowed without permission. the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint (which was not peer-reviewed) is . https://doi.org/10.1101/2020.02.26.20027938 doi: medRxiv preprint for SARS-COV-2 were both positive. The blood Rt showed a normal total white blood cells with elevated monocyte counts. On the basis of her epidemiologic characteristics, clinical manifestations, chest images, and laboratory findings, this patient was diagnosed with SARS-COV-2 infected acute viral conjunctivitis and pneumonia.

Before admission, the patient reported persistent a 4-day history of conjunctivitis and a 3-day history of fever. Ganciclovir eye drops was used to control her conjunctivitis, the patient's conjunctivitis vital signs remained stable during her home quarantine, apart from the development of intermittent fevers, accompanied by periods of cough from day 4 to 9 post of illness (Fig. 2) . Although, SARS-COV-2 RT-PCR assay for the nasopharyngeal and conjunctival swab were negative 5 days after the conjunctivitis taken a turn for the better, a fever reappear, and the Chest Radiographs showed that her pneumonia aggravated at day 10 post illness. Then, she was arranged to the hospital treated according to the guidance of CDC, and then discharged 11 days post hospitalization, accompanied with a slight cough. the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint (which was not peer-reviewed) is In the current study, we found that two patients (2.78%) with conjunctivitis was identified from 72 patients with a laboratory confirmed COVID-19. However, SARS-CoV-2 was found in ocular discharges by RT-PCR only in one COVID-19 patient. Although the incidence of conjunctivitis is extremely low, these results demonstrated that SARS-CoV-2 have shown a capacity to use the eye as a portal of entry and cause ocular disease. To our knowledge, several anatomical and mucosal immune properties permitted the eye as both a potential site of virus infected site as well as a gateway for respiratory infection. [12] [13] In coincidence with our result, SARS-CoV was detected by RT-PCR in tear samples from three probable cases. 14 Resemble as SARS-CoV, entry of SARS-CoV-2 via the host functional receptor is mediated by ACE2. 15 Moreover, Sun and colleagues 16 found that ACE2 expressed in human cornea and conjunctival tissues, which providing strong evidence for our diagnosis.

Furthermore, Dr. Guangfa Wang, a member of the national expert panel on pneumonia, reported that he was infected by SARS-COV-2 during the inspection in Wuhan, through unprotected eye exposure. 17 Similarly, an anesthesiologist with insufficient eye protection confirmed with COVID-19 and also presented conjunctivitis as the initial symptom. The laboratory test revealed that the nasopharyngeal swab was positive while the conjunctival swab was negative. 5 On the contrary, our case All rights reserved. No reuse allowed without permission. the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint (which was not peer-reviewed) is There are several limitations need to be considered. First, the conjunctival scraping test should be done as early as possible if we find ocular symptoms in a suspected one.

The mean time for conjunctival sampling in our study are 18.15 days, in which exceeded the optimal detection time. Second, how to increase the positive rate. The most commonly used chest CT examination has certain limitations for the special suspected groups, such as pregnant women. In addition, we found that 2~3 repeated tests did in suspected patients of nasopharyngeal swabs before the SARS-CoV-2 was All rights reserved. No reuse allowed without permission. the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint (which was not peer-reviewed) is . https://doi.org/10.1101/2020.02.26.20027938 doi: medRxiv preprint obtained, which may be related to the false-negative result of RT-PCR. Therefore, the low viral load in the ocular surface and the lower positive rate of RT-PCR makes early diagnosis of SARS-CoV-2 a challenge. Recently, Doan 21 reported that the influenza virus and rubella virus found in patients' conjunctival sac or tears by the next generation sequencing rapidly, which provides us with a feasible direction for future study.

In conclusion, we suspect the incidence of SARS-COV-2 infection through the ocular surface is extremely low in the general population, however, considering the common feature of the positive cases which are occupational exposure accompanied with conjunctivitis in the early stage, the higher viral aerosol load in the hospital and more opportunities to contact with COVID-19 patients, we highlight that ocular transmission is a potential important way of occupational exposure for medical staff.

Therefore, To lower the risk of SARS-COV-2 nosocomial infection, the protective goggles should be wore in all the health care workers, especially who work in the Fever Outpatient and Infection Wards. Patients with conjunctivitis in the epidemic area should also be treated seriously to rule out the COVID-19. Moreover, to date, the lower positive rate of conjunctival sac may be ascribed to the lower viral concentration, the sampling time lag, and the inefficient detection methods. Our study highlights the need for further research into the efficient detection methods of SARS-COV-2.

All authors report no relevant conflicts of interest, financial or otherwise.

A Novel Coronavirus from Patients with Pneumonia in China

Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China

Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China

Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study

Ophthalmologic evidence against the interpersonal transmission of 2019 novel coronavirus through conjunctiva

World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects

Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China

Transmission of 2019-nCoV Infection from an Asymptomatic Contact in Germany

The digestive system is a potential route of 2019-nCov infection: a bioinformatics analysis based on single-cell transcriptomes

First Case of 2019 Novel Coronavirus in the United States

Clinical characteristics of 2019 novel coronavirus infection in China

Ocular manifestations of feline viral diseases

Ocular tropism of respiratory viruses

Tears and conjunctival scrapings for coronavirus in patients with SARS

The novel coronavirus 2019 (2019-nCoV) uses the SARS-coronavirus receptor ACE2 and the cellular protease TMPRSS2 for entry into target cells

2019-nCoV transmission through the ocular surface must not be ignored. The Lancet

Respiratory tract samples, viral load, and genome fraction yield in patients with Middle East respiratory syndrome

Middle East respiratory syndrome coronavirus (MERS-CoV) causes transient lower respiratory tract infection in rhesus macaques

Metagenomic DNA Sequencing for the Diagnosis of Intraocular Infections