Ocular manifestations and SARS-CoV-2 analysis in tears in patients with COVID-19

Purpose : There are only few reports on ocular symptoms and manifestations in association of COVID-19 disease. The objective of this study is to describe ocular manifestation in the anterior and posterior segment of the eye and additionally analyze viral prevalence in tears of patients with COVID-19 disease. Methods : Hospitalized patients with COVID-19 treated from April 16 to December 15 2020 at the university hospital in Kiel, Germany, were prospectively screened for ocular manifestations or any abnormalities in anterior and posterior segment. Reverse transcriptase-polymerase chain reactions (RT-PCR) from conjunctival swabs (Schirmer strip method) were analyzed for SARS-CoV-2 in all patients. Results : 37 (25 male, 12 female) patients were enrolled in this study. 1 out of 37 patients demonstrated conjunctivitis;6 patients demonstrated chemosis of conjunctiva, all 7 of them were ventilated. One patient who was hospitalized with atypical branch retinal vein occlusion was tested positive for systemic COVID-19 in routine nasopharyngeal screening although completely asymptomatic. He was therefore recruited for the study. His conjunctival swabs were positive in both eyes. Interestingly, this patients showed general symptoms of COVID-19 pneumonia 5 days later and was hospitalized. All other patients were negative for SARS-CoV-2 in the conjunctival swabs. In 11 out of 37 patients vascular alterations and potentially disease specific manifestations of fundus were found: retinal hemorrhages in one or both eyes in 5 patients, cotton-wool spots in 5 patients, tortuosity in 5 patients. One patient demonstrated branch artery occlusion, one with branch retinal vein occlusion (the patient mentioned above). In this patient, it is noteworthy that atypically many cotton-wool spots were present, leading to a pizza-like fundus appearance (image 1). Conclusions : This study suggests that the risk of viral transmission via tears is low. However, the findings might suggest that tears are infectious at an early, preclinical disease stage. Various vascular fundus abnormalities were found in the study including hemorrhages, cotton-wool spots, tortuous vessels and vascular occlusion. Due to the study design, it is unclear whether these were correlated to systemic comorbidities, or whether they were caused or exacerbated by COVID-19. However, given the numerous vascular side-effects of COVID-19 disease, some correlation is thinkable.