Alert: Important Coronavirus Updates for Ophthalmologists
The American Academy of Ophthalmology is sharing important ophthalmology-specific information related to the novel coronavirus, referred to as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which was previously known by the provisional name 2019-nCoV. The highly contagious virus can cause a severe respiratory disease known as COVID-19.
The Academy’s web resources related to this ongoing initiative are principally authored by James Chodosh, MD, MPH. Dr. Chodosh is the David G. Cogan Professor of Ophthalmology at Harvard Medical School’s Department of Ophthalmology, a member of Harvard’s PhD program in virology and a world-recognized cornea and external disease expert. The Academy thanks Dr. Chodosh for making his scientific and clinical expertise available to his colleagues.
What you need to know:
- Several reports suggest the virus can cause conjunctivitis and possibly be transmitted by aerosol contact with conjunctiva.
- Patients who present to ophthalmologists for conjunctivitis who also have fever and respiratory symptoms including cough and shortness of breath, and who have recently traveled internationally, particularly to areas with known outbreaks (China, Iran, Italy, Japan, and South Korea), or with family members recently back from one of these countries, could represent cases of COVID-19.
- The Academy and federal officials recommend protection for the mouth, nose and eyes when caring for patients potentially infected with SARS-CoV-2.
- The virus that causes COVID-19 is very likely susceptible to the same alcohol- and bleach-based disinfectants that ophthalmologists commonly use to disinfect ophthalmic instruments and office furniture. To prevent SARS-CoV-2 transmission, the same disinfection practices already used to prevent office-based spread of other viral pathogens are recommended before and after every patient encounter.
- Global cases: 118,326 (updated March 11, 2020; source: WHO)
- Total deaths: 4,292
- Countries reporting cases: 113
- U.S. cases: 938 confirmed and presumptive positive cases (updated March 11, 2020; source: CDC)
- Total deaths: 29
- States reporting cases: 39
On March 11, COVID-19 was officially declared a pandemic by the World Health Organization. Countries with documented ongoing widespread or sustained community transmission include China, Iran, Italy, Japan, and South Korea. The 2 countries with the highest number of cases, China and South Korea, have shown consecutive multi-day declines in new cases.
Currently, U.S. COVID-19 cases include imported cases in travelers, cases among close contacts of a known case and community-acquired cases where the source of the infection is unknown. Based on the Johns Hopkins University COVID-19 interactive map, the states with the highest number of confirmed cases are Washington (281), New York (212), California (175) and Massachusetts (92)
The SARS-CoV-2 is an enveloped, single-stranded RNA virus that causes COVID-19. Although the virus appears not quite as likely to cause fatalities as the SARS coronavirus or MERS coronavirus, a significant number of global fatalities have already occurred. There have been numerous worldwide reports of infections, including in the United States.
Patients typically present with respiratory illness, including fever, cough and shortness of breath; conjunctivitis has also been reported. Severe complications include pneumonia. Symptoms can appear as soon as 2 days or as long as 14 days after exposure. At this time, there is no vaccine to prevent infection, and no medication known to be effective in treatment. Testing for SARS-CoV-2 infection is not yet widely available in the United States, but should be soon.
Current understanding about how COVID-19 spreads is based largely on what is known about other similar coronaviruses. The virus is believed to spread primarily via person-to-person through respiratory droplets produced when an infected person coughs or sneezes. It also could be spread if people touch an object or surface with virus present from an infected person, and then touch their mouth, nose or eyes. Viral RNA has also been found in stool samples from infected patients, raising the possibility of transmission through the fecal/oral route.
Currently, federal officials are trying to determine if there is asymptomatic transmission. A Feb. 21 report in JAMA details a case of an asymptomatic carrier who possibly infected 5 family members despite having normal chest computed tomography (CT) findings. In addition, Li Wenliang, MD, the whistleblower ophthalmologist who sounded the initial alarms on the coronavirus, said he was infected by an asymptomatic glaucoma patient. These reports, however, are preliminary.
Two recent reports suggest the virus can cause conjunctivitis. Thus, it is possible that SARS-CoV-2 is transmitted by aerosol contact with the conjunctiva.
- In a Journal of Medical Virology study of 30 patients hospitalized for COVID-19 in China, 1 had conjunctivitis. That patient—and not the other 29—had SARS-CoV-2 in their ocular secretions. This suggests that SARS-CoV-2 can infect the conjunctiva and cause conjunctivitis, and virus particles are present in ocular secretions.
- In this larger study published in the New England Journal of Medicine, researchers documented "conjunctival congestion" in 9 of 1,099 patients (0.8%) with laboratory-confirmed COVID-19 from 30 hospitals across China.
While it appears conjunctivitis is an uncommon event as it relates to COVID-19, other forms of conjunctivitis are common. Affected patients frequently present to eye clinics or emergency departments. That increases the likelihood ophthalmologists may be the first providers to evaluate patients possibly infected with COVID-19.
Therefore, protecting your mouth, nose (e.g., an N-95 mask) and eyes (e.g., goggles or shield) is recommended when caring for patients potentially infected with COVID-19. In addition, slit-lamp breath shields are helpful for protecting both health care workers and patients from respiratory illness.
Questions you should ask to identify patients with possible exposure to SARS-CoV-2
- Does your patient have respiratory symptoms?
- Has your patient recently traveled internationally?
- Does your patient’s international travel include a recent trip to Iran, Italy, Japan and South Korea, or do they have family members recently back from one of these countries?
- The CDC is urging health care providers who encounter patients meeting these criteria to immediately notify both infection control personnel at your health care facility and your local or state health department for further investigation of COVID-19.
Recommended protocols when scheduling or seeing patients
- When phoning about visit reminders, ask to reschedule appointments for patients with non-urgent ophthalmic problems who have respiratory illness, fever or returned from a high-risk area within the past 2 weeks.
- Patients who come to an appointment should be asked prior to entering the waiting room about respiratory illness and if they or a family member have traveled to a high-risk area in the past 14 days. If they answer yes to either question, they should be sent home and told to speak to their primary care physician.
- Keep the waiting room as empty as possible, and reduce the visits of the most vulnerable patients.
- Sick patients who possibly have COVID-19 with an urgent eye condition can be seen, but personal protective equipment should be worn by all who come in contact with the patient. The CDC's recommendations for personal protective equipment include gloves, gowns, respiratory protection and eye protection. Place a facemask on the patient and isolate them in an examination room with the door closed; use airborne infection isolation rooms (AIIR) if available.
- Rooms and instruments should be thoroughly disinfected afterward based on current CDC recommendations specific to COVID-19. Slit lamps, including controls and accompanying breath shields, should be disinfected after every patient, particularly wherever they put their hands and face.