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Table of Contents
Year : 2021  |  Volume : 3  |  Issue : 1  |  Page : 11

Ocular symptoms and clinical profile associated with COVID-19

1 Rangaraya Medical College, Kakinada, Andhra Pradesh, India
2 GSL Medical College and General Hospital, Rajahmundry, Andhra Pradesh, India

Date of Submission11-Jan-2021
Date of Acceptance17-Feb-2021
Date of Web Publication07-Apr-2021

Correspondence Address:
Dr. Tarun Kumar Suvvari
Rangaraya Medical College, Kakinada, Andhra Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/pajo.pajo_75_21

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Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a highly contagious pathogen, led to the coronavirus disease 2019 (COVID-19) pandemic. Ocular secretions can be one of the possible causes of SARS-CoV-2 transmission, and it should not be ignored. In the group of severe COVID-19 complications, ocular manifestations are underreported, and elucidation of ocular signs among COVID-19 patients is necessary. According to many research studies, conjunctivitis and sore eyes were the most reported ocular symptoms. Many studies have limitations such as low sample size or lack of proper findings, and much more studies need to be performed for a better inference.

Keywords: Conjunctivitis, COVID-19, ocular symptoms, SARS-CoV-2, sore eyes

How to cite this article:
Suvvari TK, Kumar Kandula VD. Ocular symptoms and clinical profile associated with COVID-19. Pan Am J Ophthalmol 2021;3:11

How to cite this URL:
Suvvari TK, Kumar Kandula VD. Ocular symptoms and clinical profile associated with COVID-19. Pan Am J Ophthalmol [serial online] 2021 [cited 2023 Oct 1];3:11. Available from: https://www.thepajo.org/text.asp?2021/3/1/11/313167

  Introduction Top

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a highly contagious pathogen, led to the pandemic coronavirus disease 2019 (COVID-19).[1] In the previous SARS outbreak in 2003, SARS-CoV was found in tears of SARS patients, which indicated the possible route of transmission of SARS-CoV through ocular secretions.[2],[3] During the early COVID-19 pandemic, concern on SARS-CoV-2 transmission through eye secretions was raised among physicians.[3]

In the previous studies, it was reported that ocular diseases such as retinitis, optic neuritis, and anterior uveitis were caused by coronaviruses in animals.[3] In the past pandemics, SARS and Middle East Respiratory Syndrome (MERS), no significant ocular symptoms were reported.[3],[4],[5] According to a few studies, it was found that some coronaviruses can cause conjunctivitis in humans.[4],[5]

While manifestations of COVID-19 are still being studied, numerous clinical manifestations and widespread clinical complications have been reported so far. From several studies, it is well known that COVID-19 involves multisystemic manifestations, and ocular involvement is not an exception.

  Ocular Manifestations and COVID-19 Top

In the pool of serious and life-threatening complications, ocular manifestations are underreported and not being considered as serious noticeable symptoms. However, throwing some light on the most important sense organ is truly a requirement.[3] Even though transmission through respiratory droplets is the most potential route, several studies conducted on SARS-CoV, which is genetically similar to SARS-CoV-2, showed the viral RNA presence in the tear samples.[6] In a cross-sectional, observational study done by Abrishami et al. (data collected from 142 patients), they observed ocular manifestations in more than half of the patients with conjunctival hyperemia (50.7%) and chemosis (60.7%) being the most common among them.[7] In the study by Ma et al., it was stated that almost 49 (23%) of 216 children, they examined reported manifestations such as conjunctival discharge, eye rubbing, and conjunctival congestion.[8]

In another study by Pardhan et al.,[9] they noticed sore eyes as the most significant ocular manifestation in COVID-19 patients, with 16% reporting it as one of the symptoms when compared to the pre-COVID-19 state (5%). They have compared the anterior eye symptom incidence among study participants before COVID-19 and during the COVID-19. Ocular Surface Disease Index and Salisbury Eye Evaluation Questionnaire were used as references, and questions were adapted. The ocular symptoms last for 1-“2 weeks in 41%, less than a week in 39%, and over 2 weeks in 20% of the study participants.[9] In this study, 65% of the patients experienced ocular symptoms within 1 week than other symptoms indicative of COVID-19; similarly, 16% of patients have experienced within 2 weeks.[9] Conjunctivitis was also reported among the study participants, but as many ocular manifestations such as mucous discharge and gritty eyes were associated with the term conjunctivitis, it was misleading. In a study by Ping et al., 33% of the COVID-19 patients experienced ocular manifestations such as conjunctivitis, chemosis, epiphora, and increased eye secretion, which was frequently noticed in severe COVID-19 patients.[10]

Regarding the retinal involvement in the COVID-19 patients, a cross-sectional study by Pirraglia et al. involving 46 COVID-19 patients does not show any significant retinal manifestations; only two patients have shown bilateral conjunctivitis and chorioretinitis (opportunistic origin).[11] In a study in China, 535 cases were analyzed, 5% reported conjunctival congestion, and the average duration of conjunctival congestion was 5.9 ± 4.5 days.[1] Other symptoms such as increased photophobia, dry eye, conjunctival secretion, ocular pain, and tearing were observed in patients with conjunctival congestion. Conjunctival congestion incidence was high in patients with more hand-eye touches. Ofloxacin, ganciclovir, and tobramycin were eye drops commonly used by patients suffering from conjunctival congestion. In the patients with conjunctival congestion, 62.9% have bilateral lung involvement in chest computed tomography, and conjunctival congestion has appeared after initial symptoms in most patients.[12]

In an online survey-based study by Boccardo on mask-associated ocular symptoms (self-reported), 18.3% responded that they had experienced mask-associated dry eye, and 26.7% felt that their symptoms worsened due to face mask. A higher incidence of mask-associated dry eye was found in females and retail workers. There was no significant association found between age, pre-existing ocular discomfort, refractive correction, and mask-associated dry eye.[13] In a study by Sezgin Akçay et al., the ocular clinical profile was evaluated in 1083 patients by dividing into inpatients and outpatients. 58.6% of them were male, and the mean age of the study population was 44.2 years. Among inpatients, more people have comorbidities along with past ophthalmic diseases and received medications/surgeries. Major ocular symptoms reported among inpatients were sore eye or burning sensation, itching, and red eye. 28 patients (14 inpatients and 14 outpatients) reported significant symptoms such as ocular discharge, eyelid edema, and red eye.[14]

In a meta-analysis on ocular symptoms, 1533 COVID-19 patients were evaluated, and 11.2% of them reported ocular manifestations. Conjunctivitis was the most common ocular manifestation noticed. Prodromal ocular symptoms were reported in 12.5% of patients with COVID-19. The nonspecificity of the ocular symptoms is a major concern in the meta-analysis. These types of manifestations are known to be common in intensive care exposure and severe pneumonia patients.[15],[16] Most of the studies that reported ocular manifestations missed several details. Only a few successfully addressed the location, nature, and duration of the symptoms. For instance, in many studies, it was unclear whether these symptoms were preexisting or newly developed. However, some symptoms such as dry eyes are most common among the general population.[17]

COVID-19 can be transmitted through tears by ocular shedding of SARS-CoV-2. Ophthalmologists should wear eyeglasses, and patients should be educated/encouraged not to use wearing contact lenses, applying cosmetics during this pandemic time. Ophthalmologists should deliver essential ophthalmic care with necessary infection control. Ophthalmologists should be vigilant for unusual manifestations and infectious reactions as they can lead to short-term or long-term complications. As conjunctivitis and sore eyes were commonly reported ocular manifestations in many studies, patients with those symptoms must be screened, and special care should be taken while treating them because they can be carriers of the virus.

  Conclusion Top

Sore eyes and conjunctivitis were the most common ocular manifestations reported in several studies; however, most of the findings were not proper for a better conclusion. Hence, there is a need for concern on ocular manifestations, and more multicentric cohort studies must be done to understand the impact of COVID-19 on eyes.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Pal M, Berhanu G, Desalegn C, Kandi V. Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2): An update. Cureus 2020;12:e7423.  Back to cited text no. 1
Loon SC, Teoh SC, Oon LL, Se-Thoe SY, Ling AE, Leo YS, et al. The severe acute respiratory syndrome coronavirus in tears. Br J Ophthalmol 2004;88:861-3.  Back to cited text no. 2
Hu K, Patel J, Patel BC. Ophthalmic Manifestations of Coronavirus. StatPearls. Available from: https://www.ncbi.nlm.nih.gov/books/NBK556093/. [Last accessed on 2021 Jan 11].  Back to cited text no. 3
Seah I, Agrawal R. Can the coronavirus disease 2019 (COVID-19) affect the eyes? A review of coronaviruses and ocular implications in humans and animals. Ocul Immunol Inflamm 2020;28:391-5.  Back to cited text no. 4
Li JO, Lam DS, Chen Y, Ting DS. Novel coronavirus disease 2019 (COVID-19): The importance of recognising possible early ocular manifestation and using protective eyewear. Br J Ophthalmol 2020;104:297-8.  Back to cited text no. 5
Xia J, Tong J, Liu M, Shen Y, Guo D. Evaluation of coronavirus in tears and conjunctival secretions of patients with SARS-CoV-2 infection. J Med Virol 2020;92:589-94.  Back to cited text no. 6
Abrishami M, Tohidinezhad F, Daneshvar R, Omidtabrizi A, Amini M, Sedaghat A, et al. Ocular manifestations of hospitalized patients with COVID-19 in northeast of Iran. Ocul Immunol Inflamm 2020;28:739-44.  Back to cited text no. 7
Ma N, Li P, Wang X, Yu Y, Tan X, Chen P, et al. Ocular manifestations and clinical characteristics of children with laboratory-confirmed COVID-19 in Wuhan, China. JAMA Ophthalmol 2020;138:1079-86.  Back to cited text no. 8
Pardhan S, Vaughan M, Zhang J, Smith L, Chichger H. Sore eyes as the most significant ocular symptom experienced by people with COVID-19: A comparison between pre-COVID-19 and during COVID-19 states. BMJ Open Ophthalmol 2020;5:e000632.  Back to cited text no. 9
Wu P, Duan F, Luo C, Liu Q, Qu X, Liang L, et al. Characteristics of ocular findings of patients with coronavirus disease 2019 (COVID-19) in Hubei Province, China. JAMA Ophthalmol 2020;138:575-8.  Back to cited text no. 10
Pirraglia MP, Ceccarelli G, Cerini A, Visioli G, d'Ettorre G, Mastroianni CM, et al. Retinal involvement and ocular findings in COVID-19 pneumonia patients. Sci Rep 2020;10:17419.  Back to cited text no. 11
Chen L, Deng C, Chen X, Zhang X, Chen B, Yu H, et al. Ocular manifestations and clinical characteristics of 535 cases of COVID-19 in Wuhan, China: A cross-sectional study. Acta Ophthalmol 2020;98:e951-9.  Back to cited text no. 12
Boccardo L. Self-reported symptoms of mask-associated dry eye: A survey study of 3,605 people. Cont Lens Anterior Eye 2021. DOI: 10.1016/j.clae.2021.01.003.  Back to cited text no. 13
Sezgin Akçay Bİ°, Kardeş E, Kıray G, Ayaz B, Karakuş Hacıoğlu G, Pala E. Evaluation of ocular symptoms in COVID-19 subjects in in-patient and out-patient settings. Int Ophthalmol 2021;1-8. DOI: 10.1007/s10792-021-01728-x.  Back to cited text no. 14
Ezra DG, Chan MP, Solebo L, Malik AP, Crane E, Coombes A, et al. Randomised trial comparing ocular lubricants and polyacrylamide hydrogel dressings in the prevention of exposure keratopathy in the critically ill. Intensive Care Med 2009;35:455-61.  Back to cited text no. 15
Hartford JB, Bian Y, Mathews PM, De Rojas J, Garg A, Rasool N, et al. Prevalence and risk factors of exposure keratopathy across different intensive care units. Cornea 2019;38:1124-30.  Back to cited text no. 16
The epidemiology of dry eye disease: Report of the Epidemiology Subcommittee of the International Dry Eye Work Shop. Ocul Surf 2007;5:93-107.  Back to cited text no. 17


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