Indian Journal of Health Sciences and Biomedical Research KLEU

ORIGINAL ARTICLE
Year
: 2022  |  Volume : 15  |  Issue : 1  |  Page : 46--49

Ocular manifestations in SARS COVID admitted patients: A hospital-based study


Nagbhushan Chougule, Mitali Vijay Mangoli, Avaneet Kumar, V Bindushree Reddy, Arvind L Tenagi 
 Department of Ophthalmology, JNMC, Belagavi, Karnataka, India

Correspondence Address:
Dr. Mitali Vijay Mangoli
Department of Ophthalmology, JNMC, Belagavi, Karnataka
India

Abstract

CONTEXT: Ongoing COVID-19 Pandemic. AIMS: The aim of this study is to assess the ocular manifestations of coronavirus disease (COVID-19) admitted in KLES Dr. Prabhakar Kore Hospital and MRC, KAHER, Belagavi, Karnataka, India. SETTINGS AND DESIGN: This is a cross-sectional study. SUBJECTS AND METHODS: It was a cross-sectional study, which included 100 patients who tested positive for COVID-19 (reverse transcriptase-polymerase chain reaction) and were admitted from August 2020 to September 2020 in KLES Dr. Prabhakar Kore and MRC Hospital, KAHER, Belagavi, Karnataka, India. Approval from the ethical committee was obtained, and informed consent was taken from all the patients included in this study. STATISTICAL ANALYSIS USED: Statistical analysis was performed using statistical software R and Microsoft Excel. Categorical variables were given in the form of frequency (%). RESULTS: A variety of ocular symptoms which included conjunctival congestion and dry eyes were noted. Of the 100 patients assessed, 43 patients had new-onset ocular symptoms. In these 43 patients, the history of onset of ocular complaints and the day of onset of COVID symptoms was analyzed, and it was found that 35 patients (81.39%) complained of their ocular symptoms at the same time as they started experiencing the symptoms of COVID. CONCLUSIONS: Severe acute respiratory syndrome coronavirus-2 is thought to be transmitted from person to person mainly through respiratory droplets or close contact. The ocular surface is exposed to the outside environment, which may be a potential gateway for pathogens such as viruses to invade the human body. Furthermore, eye rubbing is another high-risk factor for virus transmission, which has been confirmed in adenovirus-induced conjunctivitis. It is important for all health-care workers to be updated about these symptoms in this regard.



How to cite this article:
Chougule N, Mangoli MV, Kumar A, Reddy V B, Tenagi AL. Ocular manifestations in SARS COVID admitted patients: A hospital-based study.Indian J Health Sci Biomed Res 2022;15:46-49


How to cite this URL:
Chougule N, Mangoli MV, Kumar A, Reddy V B, Tenagi AL. Ocular manifestations in SARS COVID admitted patients: A hospital-based study. Indian J Health Sci Biomed Res [serial online] 2022 [cited 2022 Jul 6 ];15:46-49
Available from: https://www.ijournalhs.org/text.asp?2022/15/1/46/336294


Full Text



 Introduction



One of the most significant events of current times that have affected the entire humanity is the emergence of novel coronavirus severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), causing coronavirus disease 2019 (COVID-19). The first cases, which presented as pneumonia of unknown origin, were identified in Wuhan, the capital city of Hubei province in China and now this disease is recognized as a pandemic.

Coronaviruses (CoVs) are a diverse group of viruses that mainly affect birds and mammals. In contrast to common CoVs, novel CoVs, such as SARS-CoV-2 and Middle East respiratory syndrome CoV (MERS-CoV), and SARS-CoV-2 are highly pathogenic, especially in the elderly and immunocompromised patients.[1]

During 2003 SARS outbreak, a study detected SARS-CoV-2 in tear samples in SARS patients in Singapore.

Recent studies also suggest that ocular transmission is possible, as the virus was shown to replicate in conjunctival tissue and conjunctival secretions have tested positive for SARS-CoV-2 RNA using reverse transcriptase-polymerase chain reaction (RT-PCR).[2] It is also suggested in some studies that ocular symptoms could be the initial symptoms of an individual suffering from the infection.[2] Ocular manifestations were mostly reported during the middle phase of the disease and in patients with severe pneumonia. More severe ocular manifestations as anterior uveitis, retinitis, and optic neuritis have been only documented in animal models.[3] Furthermore, retinal disorders, such as retinal vasculitis, retinal degeneration, and blood–retinal barrier breakdown, had been demonstrated in experimental animal models of CoV infection. However, ocular complications of SARS-CoV infection have not been widely reported and viral loads in ocular tissue are still to be investigated.[4] Considering that the virus is present in the body fluids of patients, tear fluid is a type of body fluid, and SARS-CoV-2 is similar to SARS-CoV, it is speculated that there may be a risk of tear and conjunctival transmission.[5]

Several urgent questions need to be addressed, including (a) what are the detailed profiles of COVID-19-related ocular symptoms and diseases? (b) What are the clinical characteristics of COVID-19 patients with conjunctival congestion? and (c) Can COVID-19 spread through the ocular route or present as the primary infected site? To answer these questions, it is essential to perform ocular screening among patients with COVID-19. To our knowledge, comprehensive ophthalmological data on COVID-19 are still missing.[6]

Very few studies are conducted on the ocular manifestations of COVID-19 in India. It is important to completely understand the signs and symptoms of this disease and its modes of transmission so as to identify new cases. This will in turn help in curbing the transmission of the virus. Therefore, this study is conducted so as to get a broad picture regarding the various ocular manifestations of COVID.[7]

This study will help us to get a better understanding of the disease and guide us to take appropriate measures while examining the patients.

 Subjects and Methods



The study was conducted at KLES Dr. Prabhakar Kore Hospital and MRC, Belagavi, Karnataka, India. This was a cross-sectional observational study conducted on 100 COVID-19 patients (RT-PCR positive) admitted in the hospital from April 2020 to June 2020. Study diagnosis and classification of COVID-19 cases were done based on the guidelines provided by the Ministry of Health and Family Welfare and the Directorate General of Health Services, India. The study was conducted in accordance with the ethical standard of the institutional research committee and adhered to the tenets set forth in the Helsinki declaration. Ethical clearance details - Ethical clearance was obtained from JNMC Institutional Ethical Committee, Ref: MDC/DOME/427 Dated 18/9/2020.

Ocular history and examination have been done by an ophthalmology resident doctor posted in the ward wearing complete personal protective equipment. Appropriate distance was maintained so as to prevent exposure of the infection.

The complete assessment was documented and was entered in Microsoft Excel.

Statistical analysis was performed using statistical software R and Microsoft Excel. Categorical variables were given in the form of frequency (%).

 Results



Of the 100 patients assessed, 43 patients had new-onset ocular symptoms.

In these 43 patients, the history of onset of ocular complaints, and the day of onset of COVID symptoms was analyzed, and it was found that 35 patients (81.39%) complained of their ocular symptoms at the same time as they started experiencing the symptoms of COVID. However, some of them were tested positive at a later date.

Thirty-four patients of 43 (79.06%) were diagnosed with conjunctivitis. Eight of 43 (18.60%) complained of mucoid discharge. One patient (2.32%) developed steroid-induced maculopathy which was evaluated after treatment was taken for 2 weeks.

On further evaluation of the patients with conjunctival congestion, eight patients (23.52%) also had associated complaints of watering. There was no chemosis or any evidence of corneal defects seen in any of the patients.

The remaining 57 patients had symptoms of diminution of vision which were due to the development of cataract (17.54), age-related macular degeneration (5.26%), glaucoma (14.03%), hypertensive retinopathy (35.08%), Branched Retinal Vein Occlusion (BRVO, 5.26%) and diabetic retinopathy, and both nonproliferative (28.07%) as well as proliferative (3.50%). The development of these retinal vascular diseases may or may not be due to viral infection. We have not assessed that in our study.

Below [Table 1] and [Table 2] give a summary of the distribution of anterior and posterior segments in the study.{Table 1}{Table 2}

 Discussion



Very few studies describing the characteristic ocular findings of COVID-19 infection are available. The precise incidence of ocular manifestations relative to COVID-19 is still unclear.

In our study, we found that 43% of patients developed ocular symptoms 2–3 days after the development of symptoms due to COVID. As seen in most other studies based on ocular manifestations, the common symptom and sign associated with COVID was conjunctival congestion and mucoid discharge. The severity of these symptoms did not correlate with the severity of the infection. In the course of this study, we also found that the demographic details of the patients did not have any specific pattern. The age and gender of the patients did not increase the odds of developing the ocular symptoms.

Although diminution of vision was a common complaint seen in the patients, it could not be attributed to the COVID infection as most of these cases developed diminution of vision before they got infected with the virus. The common anterior segment findings seen in our study were conjunctival congestion (14%), followed by conjunctival congestion with mucoid discharge (7%). The duration of conjunctival congestion ranged from 2 to 24 days. Conjunctival congestion appeared 2–3 days after the onset of symptoms due to the infection.[6] Other clinical findings such as follicles, papillae, and concretions which are seen in various types of conjunctivitis were seen in only 1% of the cases. This self-limiting type of conjunctivitis could be due to the presence of innate ocular defense mechanisms which are found in the tear film and also due to the mechanical obstruction to the droplets by the eyelids.

A few studies showed that there were significant changes in the posterior segment, mainly the retinal vasculature, in patients infected with COVID.

However, in our study, the fundus findings were that of hypertensive retinopathy (9%) and diabetic retinopathy (6%) either in one or both the eyes. These changes could be due to the existing comorbidities and their direct association to the COVID infection cannot be established. There was no evidence of any other chronic eye diseases nor any symptoms associated with intraocular diseases (such as iritis, choroiditis, and retinal disease), which suggests that the possibility of endophthalmitis is very small.

The present study has a few limitations, the first being that the sample size of this study was relatively small. Our study also excluded the patients who had severe infection and hence the assessment of ocular manifestations in those patients was not done. Ideally, a conjunctival swab test should have been performed to determine if the virus is being transmitted through conjunctival secretions, and this was also not done in our study. The study also lacks a control group, therefore, no comparison can be made.

 Conclusions



SARS-CoV-2 is thought to be transmitted from person to person mainly through respiratory droplets or close contact. The ocular surface is exposed to the outside environment, which may be a potential gateway for pathogens such as viruses to invade the human body. Furthermore, eye rubbing is another high-risk factor for virus transmission, which has been confirmed in adenovirus-induced conjunctivitis.

Our study aims at helping in better understanding of the COVID-19-related eye diseases by better identification of symptoms, signs, and assessment of clinical outcomes. We have also tried to provide a clue regarding hand-eye contact and ocular manifestations. This will also help us in early detection, diagnosis, and prompt treatment, especially if the initial symptoms of COVID-19 are suspected to be ocular in certain cases, if not all. It is important for all health-care workers to be updated about these symptoms in this regard.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Chen L, Liu M, Zhang Z, Qiao K, Huang T, Chen M, et al. Ocular manifestations of a hospitalised patient with confirmed 2019 novel coronavirus disease. Br J Ophthalmol 2020;104:748-51.
2Douglas KA, Douglas VP, Moschos MM. Ocular manifestations of COVID-19 (SARS-CoV-2): A critical review of current literature. In vivo 2020;34:1619-28.
3Daruich A, Martin D, Bremond-Gignac D. Ocular manifestation as first sign of coronavirus disease 2019 (COVID-19): Interest of telemedicine during the pandemic context. J Fr Ophtalmol 2020;43:389-91.
4Feng Y, Park J, Zhou Y, Armenti ST, Musch DC, Mian SI. Ocular manifestations of hospitalized COVID-19 patients in a tertiary care academic medical center in the United States: A cross-sectional study. Clin Ophthalmol 2021;15:1551-6.
5Xia 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.
6Chen 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.
7Wu 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.