Unfolding COVID-19: Lessons-in-Learning in Ophthalmology
Received 30 April 2020
Accepted for publication 17 August 2020
Published 28 September 2020 Volume 2020:14 Pages 2807—2820
Checked for plagiarism Yes
Review by Single anonymous peer review
Peer reviewer comments 4
Editor who approved publication: Dr Scott Fraser
Ranju Kharel Sitaula,1 Anadi Khatri,2 MK Janani,3 Rajendra Mandage,4 Soumen Sadhu,5 HN Madhavan,6 Madan Prasad Upadhyay,7 Jyotirmay Biswas8
1Department of Ophthalmology, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal; 2Birat Eye Hospital, Biratnagar, Nepal; 3Sankara Nethralaya Referral Laboratory, Medical Research Foundation, Chennai, India; 4Department of Biochemistry, All India Institute of Medical Sciences, New Delhi, India; 5Department of Optometry, The SankaraNethralaya Academy, Unit of Medical Research Foundation, Chennai, India; 6Larson & Turbo Microbiology Research Center, Sankara Nethralaya Referral Laboratory, Chennai, India; 7Children Hospital for Eye, Ear Nose Throat and Rehabilitation Services, Bhaktapur, Nepal; 8Department of Uvea and Ocular Pathology, Medical and Vision Research Foundations, Sankara Nethralaya, Chennai, India
Correspondence: Anadi Khatri Department of Vitreoretina Services
Birat Eye Hospital, Biratnagar, Nepal
Importance: An observant Chinese doctor Li Wenliang became the first physician to alert the world about COVID-19. Being an ophthalmologist himself, he has put the additional onus on us. The fact that the ocular manifestation could be the first presenting feature of novel coronavirus pneumonia should not be ignored and the possibility of spread of SARS-CoV-2 through the ocular secretions cannot be ruled out. However, with breakthroughs still evolving about this disease, the calls are now louder for closer examination on the pathogenesis of conjunctivitis associated with it. Hence, we conducted a scoping review of all available literature till date to fill in the “potential” gaps in currently available knowledge on ocular manifestations of SARS-CoV-2 infection in an attempt to establish continuity in the “chain of information” from December 2019 till April 2020. We also summarize a possible hypothesis on much less understood and highly debated topics on regard to the etiopathogenesis of ocular involvement in SARS-CoV-2 based on either presence or absence of ACE2 receptor in the ocular surface.
Methods: We conducted a scoping review search of published and unpublished SARS-CoV-2-related English language articles from December 2019 till mid of April 2020 from the online databases. The findings were summarized using text, tables, diagrams, and flowcharts.
Results: The commonest ocular manifestation in SARS-CoV-2 infection is follicular conjunctivitis and has been the first manifestation of SARS-CoV-2 infection in 3 reported cases till date. The ocular surface inoculated with the SARS-CoV-2 leads to the facilitation of the virus to the respiratory system via the lacrimal passage. RT-PCR analysis of the ocular secretions has shown the presence of the SARS-CoV-2 nucleotides indicating the possibility of infection of ocular secretions. ACE2 receptors and its expression on the ocular mucosal surface are linked behind the etiopathogenesis of conjunctivitis.
Conclusion: Conjunctivitis can be the presenting manifestation but may go unnoticed due to its mild nature. The ocular surface could serve as the entry gateway for the virus and ocular secretions could play a role in virus shed. The eye care personnel, as well as the general people, need to be more vigilant and adopt protective eye measures.
Keywords: ACE2 receptor, conjunctiva, coronavirus, COVID-19 infection, ocular, ophthalmic, 2019-nCOV, SARS-CoV-2