UPDATE: What ophthalmologists need to know about COVID-19

With issues surrounding COVID-19 grabbing headlines across the country and around the globe, ophthalmologists must understand the risks to be informed and positioned to provide quality care for their patients.

Currently, the potential risk in the office remains fairly minimal. However, the U.S. Centers for Disease Control and Prevention (CDC) reported the potential public health threat posed by COVID-19 to be high, both globally and in the United States.

Travelers entering the United States also will face new protocols as cases of novel coronavirus grow around the world.

The U.S. government announced over the weekend it is expanding travel restrictions from Iran and heightening a travel advisory for certain regions of South Korea and Italy.

Related: Ophthalmologists at ground level of COVID-19 fight

Transmission and systemic manifestations

There is growing evidence the COVID-19 virus is transmitted human-to-human among close contacts. The route of transmission of COVID-19 is not yet fully known, but it is thought to be mainly respiratory.

Coronaviruses are a large family of viruses producing illnesses ranging from the common cold to more severe diseases. Coronaviruses are zoonotic, which means they are transmitted between animals and humans.

A novel coronavirus (nCoV) is a new strain that has not been previously identified in humans. Symptom onset include fever, cough, fatigue, and shortness of breath.1 ore throat has also been reported in some patients early in the clinical course of the disease. Less commonly reported symptoms include nausea, diarrhea, headache, and sputum production with or without blood. In more severe cases, COVID-19 infection can cause pneumonia, SARS, kidney failure, and death.

According to the World Health Organization, the global number of confirmed cases of COVID-19 has surpassed 100 000

The CDC reported 164 confirmed cases in the United States, with 11 total deaths and 19 states reporting cases, as of March 7. This includes both confirmed and presumptive positive cases reported to CDC. It does not include people who returned to the U.S. via State Department-chartered flights.

Thirty-six of the 60 cases are travel associated, 18 are likely person-to-person transmission, and 110 cases are under investigation, which means that state and local public health officials are still investigating how these people were infected.

The CDC is no longer reporting the number of patients under investigation for COVID-19 or patients who have tested negative for the virus.

“With more and more testing done at states, these numbers would not be representative of the testing being done nationally,” said Nancy Messonnier, MD, director of the Center for the National Center for Immunization and Respiratory Diseases (NCIRD) at the CDC.

Possible early ocular signs

Evidence shows that some coronavirus infections can occasionally cause conjunctivitis in humans. In fact, in 2004 another coronavirus, NL-63, was first identified in a baby with bronchiolitis and conjunctivitis.²

In 28 cases subsequently confirmed in French children with coronavirus NL-63, 17 percent had conjunctivitis.³ Although in the initial clinical reports of 150 patients with COVID-19 conjunctivitis has not been observed clinically, it cannot be excluded because it is known a coronavirus has been recognized to cause conjunctivitis.²

As of Feb. 10, information emerged identifying the conjunctiva as an alleged route of exposure. COVID-19 may enter the body through the eyes and spread via the superficial conjunctival blood vessels to the entire body.¹

As these patients may present with a viral conjunctivitis, it is important for eyecare professionals to inquire about travel history, family history, and systemic flu-like symptoms. COVID-19 may cause other ocular signs and symptoms, including photophobia, irritation, conjunctival injection, and a watery discharge. These signs are predominantly self-limiting but may require supportive care.

Ocular tears and discharge are a potential contamination source, and the eye is likewise a route of exposure.¹

Monitoring the situation

There are several annual meetings that often attract a global audience, and organizations are taking a cautious approach with the cloud of COVID-19 looming.

The European Society of Cataract and Refractive Surgeons (ESCRS) held its winter annual meeting Feb. 21-24 in Morocco. It monitored the situation in the days and weeks leading up to the event to ensure the health and safety of its delegates.

The ESCRS also offered some precautions recommended by the WHO:

• Do not travel if you have a fever and cough

• Wash your hands frequently and thoroughly with water and soap

• When sneezing or coughing, cover mouth and nose with a tissue (not your hands!) or sneeze or cough in the crook of your arm; discard tissue immediately into a closed bin and clean your hands • Avoid touching eyes, nose and mouth

• Avoid direct contact with sick people

• If you have fever, cough and difficulty breathing, seek medical care early

In the United States, there are several high-profile shows this year, including the ARVO 2020, May 3-7 in Baltimore; American Society of Cataract and Refractive Surgery and American Society of Ophthalmic Administrators Annual Meeting, May 15-19 in Boston; American Society of Retina Specialists Annual Meeting, July 24-28 in Seattle; and the American Academy of Ophthalmology (AAO) Annual Meeting, Nov. 14-17 in Las Vegas.

Vision Expo East, scheduled to be held March 26-29, will be consolidated with Vision Expo West in Las Vegas, Sept. 23-26. 

Ashley Mills, CEO of The Vision Council, orgnaizers of the event, said it was a difficult decision for the organization.

"Ultimately The Vision Council’s Board of Directors believes the safety and well-being of our members, exhibitors, attendees and staff must come first," she said. "Furthermore, we want to be respectful to the exhibitors and attendees who would not be able to attend Vision Expo East due to travel restrictions.”

Yancy Weinrich, COO of Reed Exhibitions, added that “Vision Expo East is a pivotal event that brings together a diverse industry to celebrate advances in eyewear, eyecare, technology and fashion.

"Over the past year, our Vision Expo staff and the entire show community worked tirelessly to plan a completely reimagined show that we were looking forward to unveiling in March. This will now take place September 23-26th in Las Vegas and we’re excited for the show at that date.”

Regarding its annual meeting in Seattle, in a statement, ASRS officials said "leadership is actively monitoring developments concerning COVID-19 and staying abreast of updates from health organizations responsible for tracking and responding to the virus, including the Centers for Disease Control and Prevention (CDC), World Health Organization (WHO), Washington State Department of Health, and King County Public Health. In addition, we are closely monitoring all travel alerts issued by the U.S. Department of Homeland Security. As our meeting approaches, we will rely on these authorities to provide us guidance and take appropriate steps, if necessary, to ensure the safety of our participants."

In the meantime, ASRS officials are encouraging members to monitor the CDC website for additional information and recommendations for protecting themselves from an infection.

In a statement, AAO said, “it is monitoring the situation and advice from health authorities, and keeping our members and employees informed.

The Academy meeting (AAO) is still nine months away and it is too soon to know what impact it will have on attendance.”

Conclusion

During this time of limited but rapidly expanding information, eyecare providers need to stay highly vigilant to recognize early manifestation of COVID-19, including the consideration of viral conjunctivitis as a possible early presentation of the disease. Watching 24-hour news coverage of the situation can cause a twinge of fear. Yet society is not on the brink of doom. Taking modest and sensible precautions should keep most people safe. Still, all healthcare personnel, including ophthalmologists, should be aware of the disease and on the lookout.

References:

1. Centers for Disease Control and Prevention. About Coronavirus Disease 2019 (COVID-19). Available at:  https://www.cdc.gov/coronavirus/2019-ncov/about/index.html. Accessed 3/4/20.
2. World Health Organization.  Available at: https://www.who.int/health-topics/coronavirus. Accessed 3/4/20.
3. van der Hoek L , Pyrc K , Jebbink MF , et al. Identification of a new human coronavirus. Nat Med. 2004 Apr;10(4):368-73.