Patients infected with SARS-CoV-2 can present with symptoms of conjunctivitis, including eye redness, ocular irritation, foreign body sensation, tearing, and chemosis. These symptoms have more commonly affected patients with severe systemic symptoms of COVID-19, though they can rarely present as an initial manifestation of the disease.[8]

Examination findings include those consistent with mild follicular conjunctivitis, including unilateral or bilateral bulbar conjunctiva injection, follicular reaction of the palpebral conjunctiva, watery discharge, and mild eyelid edema. Bilateral chemosis alone may represent third-spacing in a critically ill patient rather than a true ocular manifestation of the virus.

There have been no reports of COVID-19 patients experiencing blurred vision, subconjunctival hemorrhage, eyelid ecchymoses, conjunctival scarring, keratitis, or pseudomembrane formation.

A thorough history should be conducted regarding the onset, duration, and characteristics of symptoms. A presumptive diagnosis can be made based on detailed history taking alone, provided that the patient denies more concerning symptoms such as significant eye pain, decreased vision, or light sensitivity. Anterior segment examination at the slit lamp or bedside can confirm findings of conjunctivitis. Measurement of visual acuity, intraocular pressure, and dilated fundus examination may be warranted to rule out more harmful ocular diseases.

SARS-CoV-2 can be detected in RT-PCR by sweeping the lower eyelid fornices to collect tears and conjunctival secretions with a virus sampling swab.[9]

All patients should be questioned about recent fever, respiratory symptoms, exposure, and travel history to assess the need for further evaluation of COVID-19.

As with other viral infections, ocular manifestations of COVID-19 are presumed to be self-limited and can be managed with symptomatic care.

As of March 18, 2020, the American Academy of Ophthalmology has urged all ophthalmologists to provide only urgent or emergent care to reduce the risk of SARS-CoV-2 transmission and to conserve disposable medical supplies. In the absence of significant eye pain, decreased vision, or light sensitivity, many patients can be managed remotely with a trial of frequent preservative-free artificial tears, cold compresses, and lubricating ophthalmic ointment. A short course of topical antibiotics can be added to prevent or treat bacterial superinfection based on the patient's symptoms and risk factors (e.g., contact lens wear).[10] Specific criteria are presented below. 

Although preliminary studies suggest that the risk of viral transmission through ocular secretions is low, large-scale research has not yet been done, and new data is emerging daily. Healthcare providers are, therefore, still urged to wear proper protection of the eyes, nose, and mouth when examining patients (see below). It has been suggested that ocular transmission of the COVID-19 virus may occur.[4]

Eye care providers and technicians may be more susceptible to infection due to the nature and proximity of the ophthalmic examination.[11] Eye care providers are encouraged to use slit lamp breath shields and should counsel patients to speak as little as possible when sitting at the slit lamp to reduce the risk of virus transmission. Disinfection and sterilization practices should be employed for shared clinic equipment such as tonometers, trial frames, pinhole occluders, B-scan probes, and contact lenses for laser procedures.[2][11] Disposable barrier protection of clinic tools should be used where possible.

Stratification of Ophthalmic Patients for Clinic Visits

In the presence of life-threatening infections such as this, ophthalmologists have to achieve a balance between providing ophthalmic care and infection control. Most ophthalmic conditions are not life-threatening. Furthermore, many can be managed with some delay in treatment as they progress relatively slowly (cataracts, glaucoma, ptosis, etc.). However, some conditions like retinal detachments, acute infections (cellulitis, orbital cellulitis), severe inflammation (uveitis), and trauma require more urgent attention. To that end, the following is suggested for the management of ophthalmic patients:

1. All routine ophthalmic patients are delayed until the severity of disease spread reduces as determined by the WHO and the local Chief Medical Officer. These include chronic conditions and routine clinic annual and other follow-ups as well as new patients with chronic conditions like cataracts, ptosis, etc. 

2. New patient referrals are reviewed by the consultant surgeon to determine urgency. If necessary, telephone interviews with the referring doctor and/or the patient are held. 

3. All patients considered for a clinic visit are reviewed for three things: 

• presence of a fever, cough or shortness of breath
• any foreign travel or travel to an area with a high infection rate within the prior 14 days
• any contact with patients who have been diagnosed as having COVID-19

The presence of any of these would be a reason to consider the necessity of seeing and examining the patient more closely. If a patient has two of the three are referred for medical assessment. If a patient with COVID-19 or one with a fever, cough, or shortness of breath needs to be examined, the patient is seen in a separate isolation room. Ideally, only one person (physician, technician, etc.) should be present in the room (as ophthalmic rooms tend to be small) and should wear the full personal protective equipment (PPE): gown, N95 mask, face shield, and gloves. Hands are washed before and after examination for a minimum of 20 seconds with soap and water. Once the ophthalmic examination is completed, the patient is referred for further assessment by the medical team. 

Protection of Medical Workers:

Although the 2003 SARS-CoV crisis did not create quite so severe a spread of infection in the United States, it was noted that health care workers (HCW) accounted for about 20% of all patients with infections.[12] Most recent figures show that HCWs make up 9% of Italy's COVID-19 cases, and more than 100 health care workers have died from COVID-19 infections, including, at the last count, more than 60 doctors (in Italy). Figures in other countries will continue to increase. 

It is, therefore, vital that front-line medical workers wear proper protection. Secondly, it is important to monitor these health care workers for disease and implement appropriate containment measures. 

As has become increasingly evident, there is a severe shortage of appropriate personal protective equipment for healthcare providers. To that end, it behooves us to choose the level of protective gear based upon the risk of infection. The following is suggested:

• For all patients who have none of the three criteria mentioned above, the medical workers will wear a surgical mask, a face shield, and gloves. Hands are washed before and after every encounter.
• If a patient is positive for any of the three criteria, the full PPE of gown, face shield, gloves, and the N95 mask are worn. 
• It has been noted that droplets from sneezes can travel up to 6 m.[13] To that end, inventive ophthalmic technicians at the Moran Eye Center have developed a slit-lamp shield made by passing two plastic sheets through a laminator without a paper in between and cutting openings for the eye-pieces (Fig 1). Others have used old x-ray films in a similar way since commercially available shields are in short supply. 
• Conversations are kept to a minimum during the consultation. Ophthalmologists are, by nature, a gregarious lot. Such temptations are to be resisted. 
• As a shortage of surgical masks has become a reality, some institutions are storing used masks at the end of each day in a container with a view to re-sterilization if necessary. 
• As many as a quarter of patients being injected under sedation may develop a severe involuntary sneeze.[14][15] This is more common with eyelid injections than with retrobulbar injections. Ophthalmic surgeons should be acutely aware of this to take appropriate precautions during the administration of the local anesthetic. 

Surveillance of Medical Workers:

• In Singapore, health workers report their temperatures twice a day via an online system: this is eminently sensible as the "walk-by" temperature-testing that is currently practiced may not be as accurate or complete with staff arriving early, leaving late, etc.[16]
• All travel outside the state or country should be declared to the medical administration for review. 
• All health workers should self-report any symptoms, so appropriate testing may be performed: isolation and contact-tracing would then be undertaken as deemed necessary. 

Sterilization of Equipment

• The slit-lamp shields are disinfected with 70% ethyl alcohol after each patient. 70% ethyl alcohol has been shown to reduce coronavirus infectivity.[13]
• Slitlamps, B-scan probes, and any other tools are similarly cleaned with 70% ethyl alcohol.
• Goldman tonometers are sterilized with a 10% diluted sodium hypochlorite solution, which inactivates coronaviruses.[17]

Ocular manifestations of COVID-19 have so far been uncommon, with most patients experiencing mild conjunctivitis otherwise indistinguishable from other viral etiologies. Differential diagnosis includes a broad range of common ocular manifestations of eye redness and increased tearing:

• Other viral conjunctivitis (e.g., Adenovirus)
• Bacterial conjunctivitis
• Allergic conjunctivitis
• Herpes simplex virus keratitis
• Anterior uveitis
• Corneal abrasion
• Foreign body
• Dry eye syndrome
• Exposure keratopathy in an intubated patient
• Chemosis in a critically ill patient

Ocular manifestations of COVID-19 are currently thought to be self-limited. There are currently no reports of sight-threatening manifestations of COVID-19.

There have been no complications of ocular manifestations of COVID-19 reported, though larger studies and long-term follow up of these patients have not yet been conducted.

Prevention strategies are vital to limiting the spread of disease. In addition to physical distancing and practicing good hand-washing hygiene, patients should employ behavioral changes that reduce the direct touching of the eyes and face.

• Refraining from wearing contact lenses during the outbreak
• Refraining from applying cosmetics
• Wearing glasses and sunglasses

• Ocular shedding of SARS-CoV-2 via tears is a distinct possibility of which ophthalmologists should be aware.
• Conjunctivitis or tearing can be the first presentation in a patient with the COVID-19 infection.
• Patients may present with chemosis in advanced cases (Fig 2), or follicular conjunctivitis (Fig 3).
• The ocular examination should be performed while wearing gloves and the use of extension instruments (cotton swabs, etc.) to avoid direct contact with secretions.
• As many patients who visit the ophthalmic clinic are elderly, many with comorbidities, it is important to screen the need for the visit ahead of time and only see patients who need urgent care.
• Social distancing, as advocated in many countries, means being 6 ft away from others: this is clearly impossible in the clinical world and certainly in the small confines of ophthalmic examination lanes. One way to practice it is to have only one person in the room with the patient.
• Anecdotally, it has been observed that physicians most at risk of becoming infected include ophthalmologists, otolaryngologists, and anesthesiologists because of the proximity of the examiners to mucosal surfaces.
• When performing surgery under general anesthesia, it has been recommended that surgeons and other staff do not enter the room for 15 minutes after intubation or extubation. In our institution, this is applied to all general anesthesia cases, whether the patient is COVID-19 positive or negative.

Within the outpatient, inpatient, and surgical settings, an interprofessional approach is necessary to manage COVID-19 patients and mitigate the spread of disease successfully.

There should be clear communication between hospital administration, provider teams, and clinic support staff regarding expectations for screening patients, wearing personal protective equipment, and utilizing new technologies for telemedicine consultations. [Level 5 evidence]