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Ophthalmology

Characteristics of Ocular Findings of Patients With Coronavirus Disease 2019 (COVID-19) in Hubei Province, China

Educational Objective
To understand the ocular manifestations and conjunctival viral prevalence in patients with COVID-19

1 Credit CME

JAMA Ophthalmology

Published Online: March 31, 2020

Brief Report

Article Information and Disclosures

Fang Duan, MD²;

Chunhua Luo, MD¹;

Qiang Liu, MD¹;

Xingguang Qu, MD¹;

Liang Liang, MD¹;

Author Affiliations

¹Department of Ophthalmology, The First College of Clinical Medical Science, Yichang Central People’s Hospital, China Three Gorges University, Yichang, China
²Zhongshan Ophthalmic Center, State Key Laboratory of Ophthalmology, Sun Yat-Sen University, Guangzhou, China

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Key Points

Question What are the ocular manifestations and conjunctival viral prevalence in patients from Hubei province, China, with coronavirus disease 2019 (COVID-19)?

Findings In this case series including 38 patients with COVID-19, 12 patients had ocular manifestations, such as epiphora, conjunctival congestion, or chemosis, and these commonly occurred in patients with more severe systemic manifestations. Reverse transcriptase–polymerase chain reaction results were positive for severe acute respiratory syndrome coronavirus 2 in 28 nasopharyngeal swabs and 2 conjunctival swabs, and more significant changes in blood test values appeared in patients with ocular abnormalities.

Meaning These data may assist ophthalmologists and others to understand the ocular manifestations of COVID-19, thus enhancing the diagnosis and prevention of the transmission of the disease.

Abstract

Importance While the outbreak of coronavirus disease 2019 (COVID-19) has resulted in more than 100 000 infected individuals in China and worldwide, there are few reports on the association of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) with ocular abnormalities. Understanding ocular manifestations of patients with COVID-19 by ophthalmologists and others may facilitate the diagnosis and prevention of transmission of the disease.

Objective To investigate ocular manifestations and viral prevalence in the conjunctiva of patients with COVID-19.

Design, Setting, and Participants In this case series, patients with COVID-19 treated from February 9 to 15, 2020, at a hospital center in Hubei province, China, were retrospectively reviewed for ocular manifestations. During the period of treatment, the ocular signs and symptoms as well as results of blood tests and reverse transcriptase–polymerase chain reaction (RT-PCR) from nasopharyngeal and conjunctival swabs for SARS-CoV-2 were noted and analyzed.

Main Outcomes and Measures Ocular signs and symptoms as well as results of blood tests and RT-PCR for SARS-CoV-2.

Results Of the 38 included patients with clinically confirmed COVID-19, 25 (65.8%) were male, and the mean (SD) age was 65.8 (16.6) years. Among them, 28 patients (73.7%) had positive findings for COVID-19 on RT-PCR from nasopharyngeal swabs, and of these, 2 patients (5.2%) yielded positive findings for SARS-CoV-2 in their conjunctival as well as nasopharyngeal specimens. A total of 12 of 38 patients (31.6%; 95% CI, 17.5-48.7) had ocular manifestations consistent with conjunctivitis, including conjunctival hyperemia, chemosis, epiphora, or increased secretions. By univariate analysis, patients with ocular symptoms were more likely to have higher white blood cell and neutrophil counts and higher levels of procalcitonin, C-reactive protein, and lactate dehydrogenase than patients without ocular symptoms. In addition, 11 of 12 patients with ocular abnormalities (91.7%; 95% CI, 61.5-99.8) had positive results for SARS-CoV-2 on RT-PCR from nasopharyngeal swabs. Of these, 2 (16.7%) had positive results for SARS-CoV-2 on RT-PCR from both conjunctival and nasopharyngeal swabs.

Conclusions and Relevance In this study, one-third of patients with COVID-19 had ocular abnormalities, which frequently occurred in patients with more severe COVID-19. Although there is a low prevalence of SARS-CoV-2 in tears, it is possible to transmit via the eyes.

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Article Information

Accepted for Publication: March 17, 2020.

Published Online: March 31, 2020. doi:10.1001/jamaophthalmol.2020.1291

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Wu P et al. JAMA Ophthalmology.

Corresponding Author: Liang Liang, MD, Department of Ophthalmology, The First College of Clinical Medical Science, Yichang Central People’s Hospital, China Three Gorges University, 183 Yiling St, Yichang 443003, China (liangliang419519@163.com); Kaili Wu, MD, Zhongshan Ophthalmic Center, State Key Laboratory of Ophthalmology, Sun Yat-sen University, 54 S Xianlie Rd, Guangzhou 510060, China (wukaili@maill.sysu.edu.cn).

Author Contributions: Drs Liang and K. Wu had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Drs P. Wu and Duan contributed equally to this study. Drs Luo, Liu, and Qu contributed equally as senior authors.

Study concept and design: Liang, K. Wu.

Acquisition, analysis, or interpretation of data: P. Wu, Duan, Luo, Liu, Qu, Liang.

Drafting of the manuscript: P. Wu, Duan, Liang.

Critical revision of the manuscript for important intellectual content: P. Wu, Luo, Liu, Qu, Liang, K. Wu.

Statistical analysis: P. Wu.

Obtained funding: Liang, K. Wu.

Administrative, technical, or material support: Duan, Luo, Liu, Qu, Liang.

Study supervision: Liu, Liang, K. Wu.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was supported by grants 81770896 (Dr K. Wu) and 81770920 (Dr Liang) from the National Natural Science Foundation of China.

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: We thank Haijiang Zhang, MD, Minxing Wu, MD, and Min Liu, MD (Yichang Central People’s Hospital, Yichang, China), for collecting the data and preparing the Table. None of these individuals received compensation for their contributions.

References

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AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 CME points in the American Board of Surgery’s (ABS) Continuing Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.