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Viewpoint
September 22/29, 2020

Ophthalmology and COVID-19

Author Affiliations
  • 1Department of Ophthalmology, Johns Hopkins University School of Medicine, Baltimore, Maryland
  • 2Editor, JAMA Ophthalmology
JAMA. 2020;324(12):1143-1144. doi:10.1001/jama.2020.17595

While common ophthalmic diseases, such as age-related macular degeneration or cataract or glaucoma, have minimal clinical relevance to other areas of medicine, coronavirus disease 2019 (COVID-19) and ophthalmology have had immediate connections and importance for hospital epidemiology and infection control experts, public health officials, and the general population. In the first preliminary study of characteristics of ocular findings among 38 patients hospitalized with COVID-19 in Hubei province, China, Wu et al1 reported conjunctivitis in 12 (38%). Virus material also was detected on swabs of the conjunctiva among 2 of 11 patients (18%) tested for COVID-19 in this manner.

The ocular findings these investigators detected, such as epiphora, conjunctival congestion, or chemosis, appeared to be more common in patients with more severe systemic manifestations. These findings may have been related to the other respiratory complications and management that these patients were receiving. However, it is not uncommon for viral infections such as COVID-19 to have an associated conjunctivitis, and perhaps these ocular findings are related to why Dr Li Wenliang, a Chinese ophthalmologist in Wuhan, was one of the first physicians to alert the public to the possibility of a new epidemic. He may have recognized the conjunctivitis among people with symptoms of COVID-19, and he potentially became infected from contact with these patients’ eyes.

These findings meant that all health care workers needed to consider not only respiratory transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) from the nose and mouth but ocular transmission as well. Hospital epidemiologists and infection control specialists throughout the world began to recommend personal protective equipment, to help prevent both respiratory transmission and ocular transmission.2 This prompted ophthalmologists to recommend protective measures specific to their specialty that considered the possibility of these routes of infection. Guidance came from various ophthalmology societies, including the American Academy of Ophthalmology,3 as well as from physicians from hospitals and institutions who wanted to share their opinions on how to cope with the early days of the pandemic.4

While these recommendations were based on the knowledge that transmission through the conjunctiva could occur, not all of the recommendations were based on scientific studies that confidently proved their benefits. For example, most if not all of these guidelines specific to ophthalmology practices suggested using a protective shield at the slit lamp biomicroscope to try to reduce droplet transmission from sporadic coughs and sneezes by patients with presumably asymptomatic infection. Ideally, the patient, ophthalmologist, or both would move away from the slit lamp biomicroscope when sensing an oncoming sneeze or cough. However, if they did not move away, recent Video evidence in a simulation of this situation suggested that these slit lamp biomicroscope shields might not fully protect an individual from contamination during an examination.5 For another example, during the height of the pandemic in a quality improvement study in Turkey, investigators found that, despite following guidelines for cleaning rooms among 22 asymptomatic patients plus 9 companions, when evaluating 7 samples taken at the beginning and end of the day from the slit lamp biomicroscope breath shields as well as phoropter surfaces, SARS-CoV-2 viral material was found in 2 of 7 postexamination samples from the end of the day.6

With crisis, though, comes opportunity to pursue ophthalmic research to improve public health. For example, ophthalmologists recently showed how researchers could use big data to guide triage of ophthalmic clinic appointments wherein the algorithm developed balanced the glaucoma progression risk against the morbidity risk from COVID-19 exposure during ophthalmic care.7 Perhaps this tool can be expanded when balancing the risk of progression of diabetic retinopathy, the neovascular form of age-related macular degeneration. In another recent epidemiologic investigation, Zeng et al8 noted at the beginning of the pandemic in Hubei province in China that among 276 patients admitted to a hospital with laboratory-confirmed COVID-19, the proportion of patients who reported routinely wearing eyeglasses was lower than in the general population.

These findings suggest a hypothesis that eyeglasses may be acting as a barrier that could reduce the frequency with which people touch their eyes. In an accompanying Invited Commentary, Maragakis9 appropriately cautioned that some may conclude that everyone should wear eyeglasses, goggles, or a face shield in public to protect themselves from COVID-19 because a single observation does not necessarily imply cause and effect. There are potential ascertainment and selection biases of the cohort evaluated, and possible confounding variables wherein wearing eyeglasses is associated with another factor, and it is that other factor, not wearing eyeglasses, that confers some protection.

In summary, ophthalmology and COVID-19 represent a unique moment in medicine. As Sommer, who has extensive experience as an ophthalmic epidemiologist involved in international ophthalmology studies for almost a half century, stated in an Invited Commentary,10 viral outbreaks can be devastating and “have killed off virtually entire populations… medical interventions, (principally vaccines) and stringent public health measures have often altered the outcome, but not necessarily in predictable ways.” The publications cited in this Viewpoint are only a sampling of efforts to begin to address COVID-19 in JAMA Ophthalmology. In concert with JAMA and the JAMA Network of specialty journals, it is hoped editors, advisors, staff, reviewers, and authors will do all they can to help facilitate scientific dissemination of knowledge that can address this pandemic for patients, health care workers, and all of humankind.

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Article Information

Corresponding Author: Neil M. Bressler, MD, Department of Ophthalmology, Johns Hopkins University School of Medicine, 600 N Wolfe St, Maumenee 752, Baltimore, MD 21287 (nmboffice@jhmi.edu).

Conflict of Interest Disclosures: None reported.

References
1.
Wu  P, Duan  F, Luo  C,  et al.  Characteristics of ocular findings of patients with coronavirus disease 2019 (COVID-19) in Hubei Province, China.   JAMA Ophthalmol. 2020;138(5):575-578. doi:10.1001/jamaophthalmol.2020.1291PubMedGoogle ScholarCrossref
2.
Sommer  A.  Humans, viruses, and the eye-an early report from the COVID-19 front line.   JAMA Ophthalmol. 2020;138(5):578-579. doi:10.1001/jamaophthalmol.2020.1294PubMedGoogle ScholarCrossref
3.
Parke  DW  II.  Ophthalmology after coronavirus disease 2019 (COVID-19): transition back to patient care.   JAMA Ophthalmol. 2020;138(6):599-600. doi:10.1001/jamaophthalmol.2020.2004PubMedGoogle ScholarCrossref
4.
Jun  ISY, Hui  KKO, Songbo  PZ.  Perspectives on coronavirus disease 2019 control measures for ophthalmology clinics based on a Singapore center experience.   JAMA Ophthalmol. 2020;138(5):435-436. doi:10.1001/jamaophthalmol.2020.1288PubMedGoogle ScholarCrossref
5.
Felfeli  T, Mandelcorn  ED.  Assessment of simulated respiratory droplet spread during an ophthalmologic slitlamp examination.   JAMA Ophthalmol. Published online August 18, 2020. doi:10.1001/jamaophthalmol.2020.3472PubMedGoogle Scholar
6.
Aytoğan  H, Ayintap  E, Özkalay Yilmaz  N.  Detection of coronavirus disease 2019 viral material on environmental surfaces of an ophthalmology examination room.   JAMA Ophthalmol. Published online August 3, 2020. doi:10.1001/jamaophthalmol.2020.3154PubMedGoogle Scholar
7.
Bommakanti  NK, Zhou  Y, Ehrlich  JR,  et al; SOURCE Consortium.  Application of the sight outcomes research collaborative ophthalmology data repository for triaging patients with glaucoma and clinic appointments during pandemics such as COVID-19.   JAMA Ophthalmol. Published online July 17, 2020. doi:10.1001/jamaophthalmol.2020.2974PubMedGoogle Scholar
8.
Zeng  W, Wang  X, Li  J,  et al  Association of daily wear of eyeglasses and susceptibility to COVID-19 infection.   JAMA Ophthalmol. Published online September 11, 2020. doi:10.1001/jamaophthalmol.2020.3906Google Scholar
9.
Maragakis  LL.  Does wearing eye protection mitigate COVID-19 risk in public, non-healthcare settings?   JAMA Ophthalmol. Published online September 11, 2020. doi:10.1001/jamaophthalmol.2020.3909Google Scholar
10.
Sommer  A.  Humans, viruses, and the eye—an early report from the COVID-19 front line.   JAMA Ophthalmol. 2020;138(5):578-579. doi:10.1001/jamaophthalmol.2020.1294PubMedGoogle ScholarCrossref
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    1 Comment for this article
    Macular Degeneration as a Risk Factor for COVID-19 Severity
    Andrew Kanter, MD, MPH | Dept of Biomedical Informatics/Columbia University
    Research done by one of my colleagues at Columbia University points to macular degeneration, a proxy for complement-activation disorders, as a risk factor for COVID-19 morbidity and mortality (1).

    Reference

    1. https://www.nature.com/articles/s41591-020-1021-2
    CONFLICT OF INTEREST: None Reported
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