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Ocular Manifestations and Clinical Characteristics of Children With Laboratory-Confirmed COVID-19 in Wuhan, China

Educational Objective
To understand the ocular manifestations and clinical characteristics of children with COVID-19
1 Credit CME
Key Points

Question  What are the ocular manifestations and outcomes in children with confirmed coronavirus disease 2019 (COVID-19) and what factors contributed to ocular symptoms during the course of disease in children?

Findings  In this cross-sectional study of 216 children hospitalized with COVID-19 in Wuhan, China, 49 (22.7%) had ocular manifestations, including conjunctival discharge, eye rubbing, and conjunctival congestion. Children with systemic symptoms or cough were more likely to develop ocular symptoms, which were mild, and recovered or improved with minimal eye drops or self-healing.

Meaning  These data could help guide prevention and management of ocular disorders in children with COVID-19.

Abstract

Importance  Ocular manifestations and outcomes in children with confirmed coronavirus disease 2019 (COVID-19), relevant affecting factors, and differences in ocular disease between children and adults have yet to be fully understood.

Objective  To investigate ocular manifestations and clinical characteristics of children with laboratory-confirmed COVID-19.

Design, Setting, and Participants  This cross-sectional study was conducted at Wuhan Children’s Hospital in Wuhan, China. Children with COVID-19 confirmed by severe acute respiratory syndrome coronavirus disease 2 nucleic acid tests of upper respiratory tract specimens between January 26 and March 18, 2020, were included.

Main Outcomes and Measures  Onset clinical symptoms and duration, ocular symptoms, and needs for medication.

Results  A total of 216 pediatric patients were included, among whom 134 (62%) were boys, with a median (interquartile range) age of 7.25 (2.6-11.6) years. Based on the exposure history, 193 children (89.4%) had a confirmed (173 [80.1%]) or suspected (20 [9.3%]) family member with COVID-19 infection. The most common symptoms among symptomatic children were fever (81 [37.5%]) and cough (79 [36.6%]). Of 216 children, 93 (43.1%) had no systemic or respiratory symptoms. All children with mild (101 [46.8%]) or moderate (115 [53.2%]) symptoms recovered without reported death. Forty-nine children (22.7%) showed various ocular manifestations, of which 9 had ocular complaints being the initial manifestations of COVID-19. The common ocular manifestations were conjunctival discharge (27 [55.1%]), eye rubbing (19 [38.8%]), and conjunctival congestion (5 [10.2%]). Children with systemic symptoms (29.3% vs 14.0%; difference, 15.3%; 95% CI, 9.8%-20.7%; P = .008) or with cough (31.6% vs 17.5%; difference, 14.1%; 95% CI, 8.0%-20.3%; P = .02) were more likely to develop ocular symptoms. Ocular symptoms were typically mild, and children recovered or improved.

Conclusions and Relevance  In this cross-sectional study, children hospitalized with COVID-19 in Wuhan, China, presented with a series of onset symptoms including fever, cough, and ocular manifestations, such as conjunctival discharge, eye rubbing, and conjunctival congestion. Patients’ systemic clinical symptoms or cough were associated with ocular symptoms. Ocular symptoms recovered or improved eventually.

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Article Information

Corresponding Author: Shilian Li, MD, Tongji Medical College, Wuhan Children’s Hospital (Wuhan Maternal and Child Healthcare Hospital), Huazhong University of Science & Technology, 100 Hongkong Rd, Wuhan 430016, China (lianshili163@163.com); Fagang Jiang, MD, PhD, Tongji Medical College, Union Hospital, Huazhong University of Science & Technology, 1277 Liberation Ave, Wuhan 430022, China (13554100999@163.com).

Accepted for Publication: August 10, 2020.

Published Online: August 26, 2020. doi:10.1001/jamaophthalmol.2020.3690

Author Contributions: Drs Jiang and S. Li 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 Ma, P. Li, Wang, and Yu contributed equally to the manuscript as joint first authors.

Concept and design: Ma, P. Li, Wang, S. Li, Jiang.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Ma, P. Li, Wang.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Ma, P. Li, Wang, Yu.

Obtained funding: Wang.

Administrative, technical, or material support: Tan, Chen, S. Li.

Supervision: Jiang.

Conflict of Interest Disclosures: None reported.

Funding/Support: This work was supported by the National Natural Science Foundation of China (81900912).

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 Yun Xiang, PhD (Department of Laboratory Medicine, Wuhan Children’s Hospital, Wuhan, China), for providing COVID-19 testing data in the manuscript. We also thank Chuanyi M. Lu, MD, PhD (University of California, San Francisco), for the valuable English language editing. Neither individuals received compensation for their work.

References
1.
World Health Organization. Coronavirus Disease 2019 (COVID-19) Situation Report: 50. Published March 10, 2020. Accessed July 9, 2020. https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200310-sitrep-50-covid-19.pdf?sfvrsn=55e904fb_2
2.
Zhu  N , Zhang  D , Wang  W ,  et al; China Novel Coronavirus Investigating and Research Team.  A novel coronavirus from patients with pneumonia in China, 2019.   N Engl J Med. 2020;382(8):727-733. doi:10.1056/NEJMoa2001017PubMedGoogle ScholarCrossref
3.
Chan  JFW , Kok  KH , Zhu  Z ,  et al.  Genomic characterization of the 2019 novel human-pathogenic coronavirus isolated from a patient with atypical pneumonia after visiting Wuhan.   Emerg Microbes Infect. 2020;9(1):221-236. doi:10.1080/22221751.2020.1719902PubMedGoogle ScholarCrossref
4.
van Doremalen  N , Bushmaker  T , Morris  DH ,  et al.  Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1.   N Engl J Med. 2020;382(16):1564-1567. doi:10.1056/NEJMc2004973PubMedGoogle ScholarCrossref
5.
Ulhaq  ZSSG , Soraya  GV .  The prevalence of ophthalmic manifestations in COVID-19 and the diagnostic value of ocular tissue/fluid.   Graefes Arch Clin Exp Ophthalmol. 2020;258(6):1351-1352. doi:10.1007/s00417-020-04695-8PubMedGoogle ScholarCrossref
6.
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;2020-Mar-31. doi:10.1001/jamaophthalmol.2020.1291PubMedGoogle Scholar
7.
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(3):391-395. doi:10.1080/09273948.2020.1738501PubMedGoogle ScholarCrossref
8.
Seah  IYJ , Anderson  DE , Kang  AEZ ,  et al.  Assessing viral shedding and infectivity of tears in coronavirus disease 2019 (COVID-19) patients.   Ophthalmology. 2020;127(7):977–979. doi:10.1016/j.ophtha.2020.03.026Google ScholarCrossref
9.
Guan  WJ , Ni  ZY , Hu  Y ,  et al; China Medical Treatment Expert Group for Covid-19.  Clinical characteristics of coronavirus disease 2019 in China.   N Engl J Med. 2020;382(18):1708-1720. doi:10.1056/NEJMoa2002032PubMedGoogle ScholarCrossref
10.
Lu  CW , Liu  XF , Jia  ZF .  2019-nCoV transmission through the ocular surface must not be ignored.   Lancet. 2020;395(10224):e39. doi:10.1016/S0140-6736(20)30313-5PubMedGoogle Scholar
11.
Chen  L , Liu  M , Zhang  Z ,  et al.  Ocular manifestations of a hospitalised patient with confirmed 2019 novel coronavirus disease.   Br J Ophthalmol. 2020;104(6):748-751. doi:10.1136/bjophthalmol-2020-316304PubMedGoogle ScholarCrossref
12.
Zhang  X , Chen  X , Chen  L , Deng  C .  The evidence of SARS-CoV-2 infection on ocular surface.   Ocul Surf. 2020;18(3):360–362. doi:10.1016/j.jtos.2020.03.010Google ScholarCrossref
13.
Ma  H , Hu  J , Tian  J ,  et al.  A single-center, retrospective study of COVID-19 features in children: a descriptive investigation.   BMC Med. 2020;18(1):123. doi:10.1186/s12916-020-01596-9PubMedGoogle ScholarCrossref
14.
Lu  X , Xiang  Y , Du  H , Wing-Kin Wong  G .  SARS-CoV-2 infection in children: understanding the immune responses and controlling the pandemic.   Pediatr Allergy Immunol. Published April 24, 2020. doi:10.1111/pai.13267PubMedGoogle Scholar
15.
Sun  D , Chen  X , Li  H ,  et al.  SARS-CoV-2 infection in infants under 1 year of age in Wuhan City, China.   World J Pediatr. 2020;16(3):260-266. doi:10.1007/s12519-020-00368-yPubMedGoogle ScholarCrossref
16.
Li  H , Chen  K , Liu  M , Xu  H , Xu  Q .  The profile of peripheral blood lymphocyte subsets and serum cytokines in children with 2019 novel coronavirus pneumonia.   J Infect. Published online April 20, 2020. doi:10.1016/j.jinf.2020.04.001Google Scholar
17.
Qiu  H , Wu  J , Hong  L , Luo  Y , Song  Q , Chen  D .  Clinical and epidemiological features of 36 children with coronavirus disease 2019 (COVID-19) in Zhejiang, China: an observational cohort study.   Lancet Infect Dis. 2020;20(6):689-696. doi:10.1016/S1473-3099(20)30198-5PubMedGoogle ScholarCrossref
18.
Su  L , Ma  X , Yu  H ,  et al.  The different clinical characteristics of corona virus disease cases between children and their families in China: the character of children with COVID-19.   Emerg Microbes Infect. 2020;9(1):707-713. doi:10.1080/22221751.2020.1744483PubMedGoogle ScholarCrossref
19.
China. NHCotpsro. Pneumonia diagnosis and treatment of novel coronavirus infection (Pilot version 7). Published March 30, 2020. Accessed April 2, 2020. http://www.nhc.gov.cn/yzygj/s7653p/202003/46c9294a7dfe4cef80dc7f5912eb1989.shtml.
20.
Lu  X , Zhang  L , Du  H ,  et al.  SARS-CoV-2 infection in children.   N Engl J Med. 2020;382(17):1663-1665. doi:10.1056/NEJMc2005073Google ScholarCrossref
21.
Zeng  L , Xia  S , Yuan  W ,  et al.  Neonatal Early-Onset Infection With SARS-CoV-2 in 33 Neonates Born to Mothers With COVID-19 in Wuhan, China.   JAMA Pediatr. 2020;174(7):722-725. doi:10.1001/jamapediatrics.2020.0878Google ScholarCrossref
22.
Dong  Y , Mo  X , Hu  Y ,  et al.  Epidemiology of COVID-19 among children in China.   Pediatrics. 2020;145(6):e20200702. doi:10.1542/peds.2020-0702Google Scholar
23.
Nishiura  H , Kobayashi  T , Suzuki  A ,  et al.  Estimation of the asymptomatic ratio of novel coronavirus infections (COVID-19).   Int J Infect Dis. 2020;94:154-155. doi:10.1016/j.ijid.2020.03.020Google ScholarCrossref
24.
Mizumoto  K , Kagaya  K , Zarebski  A , Chowell  G .  Estimating the asymptomatic proportion of coronavirus disease 2019 (COVID-19) cases on board the Diamond Princess cruise ship, Yokohama, Japan, 2020.   Euro Surveill. 2020;25(10):2-6. doi:10.2807/1560-7917.ES.2020.25.10.2000180PubMedGoogle ScholarCrossref
25.
Pan  X , Chen  D , Xia  Y ,  et al.  Asymptomatic cases in a family cluster with SARS-CoV-2 infection.   Lancet Infect Dis. 2020;20(4):410-411. doi:10.1016/S1473-3099(20)30114-6Google ScholarCrossref
26.
Qiu  J .  Covert coronavirus infections could be seeding new outbreaks.   Nature. Published online March 20, 2020. doi:10.1038/d41586-020-00822-xPubMedGoogle Scholar
27.
Ludvigsson  JF .  Systematic review of COVID-19 in children shows milder cases and a better prognosis than adults.   Acta Paediatr. 2020;109(6):1088-1095. doi:10.1111/apa.15270Google ScholarCrossref
28.
Chang  T-H , Wu  J-L , Chang  L-Y .  Clinical characteristics and diagnostic challenges of pediatric COVID-19: a systematic review and meta-analysis.   J Formos Med Assoc. 2020;119(5):982-989. doi:10.1016/j.jfma.2020.04.007Google ScholarCrossref
29.
Castagnoli  R , Votto  M , Licari  A ,  et al.  Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in children and adolescents: a systematic review.   JAMA Pediatr. Published online April 22, 2020. doi:10.1001/jamapediatrics.2020.1467Google Scholar
30.
Colavita  F , Lapa  D , Carletti  F ,  et al.  SARS-CoV-2 isolation from ocular secretions of a patient with COVID-19 in Italy with prolonged viral RNA detection.   Ann Intern Med. 2020;173(3):242-243. doi:10.7326/M20-1176PubMedGoogle ScholarCrossref
31.
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(6):589-594. doi:10.1002/jmv.25725PubMedGoogle ScholarCrossref
32.
Holappa  M , Vapaatalo  H , Vaajanen  A .  Many faces of renin-angiotensin system: focus on eye.   Open Ophthalmol J. 2017;11:122-142. doi:10.2174/1874364101711010122PubMedGoogle ScholarCrossref
33.
Wan  Y , Shang  J , Graham  R , Baric  RS , Li  F .  Receptor recognition by the novel coronavirus from Wuhan: an analysis based on decade-long structural studies of SARS coronavirus.   J Virol. 2020;94(7):e00127-20. doi:10.1128/JVI.00127-20PubMedGoogle Scholar
34.
Zhang  BN , Wang  Q , Liu  T ,  et al.  [Expression analysis of 2019-nCoV related ACE2 and TMPRSS2 in eye tissues].   Zhonghua Yan Ke Za Zhi. 2020;56(0):E011. doi:10.3760/cma.j.cn112142-20200310-00170Google Scholar
35.
Liu  L , Sun  Y , Pan  X ,  et al  Expression of SARS coronavirus sprotein functional receptor-angiotensin-converting enzyme 2 in human cornea and conjunctiva.   Ophthalmic Research. 2004;22(6):561-564.Google Scholar
36.
Kahbazi  M , Fahmizad  A , Armin  S ,  et al.  Aetiology of upper respiratory tract infections in children in Arak city: a community based study.   Acta Microbiol Immunol Hung. 2011;58(4):289-296. doi:10.1556/AMicr.58.2011.4.5PubMedGoogle ScholarCrossref
37.
Foong Ng  K , Kee Tan  K , Hong Ng  B , Nair  P , Ying Gan  W .  Epidemiology of adenovirus respiratory infections among hospitalized children in Seremban, Malaysia.   Trans R Soc Trop Med Hyg. 2015;109(7):433-439. doi:10.1093/trstmh/trv042PubMedGoogle ScholarCrossref
38.
Wrotek  A , Kobialka  M , Grochowski  B ,  et al.  Respiratory complications in children hospitalized with respiratory syncytial virus infection.   Adv Exp Med Biol. 2020;1279:113-120. doi:10.1007/5584_2020_530Google ScholarCrossref
39.
Leibowitz  HM .  The red eye.   N Engl J Med. 2000;343(5):345-351. doi:10.1056/NEJM200008033430507PubMedGoogle ScholarCrossref
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