Omega-3 fatty acids supplements for dry eye - Are they effective or ineffective?

Purpose: To evaluate effectiveness of omega-3 fatty acid supplements in relieving dry eye symptoms and signs in symptomatic visual display terminal users (VDT). Methods: A randomized controlled study was done; eyes of 470 VDT users were randomized to receive four capsules twice daily for 6 months (O3FAgroup), each containing 180 mg of eicosapentaenoic acid and 120 mg docosahexaenoic acid. The O3FA group was compared with another group (n = 480) who received four capsules of a placebo (olive oil) twice daily. Patients were evaluated at baseline, 1, 3, and 6 months, respectively. The primary outcome was improvement in omega-3 index (a measure of EPA and DHA ratio in RBC membrane). Secondary outcomes were improvement dry eye symptoms, Nelson grade on conjunctival impression cytology, Schirmer test values, tear film breakup time (TBUT), and tear film osmolarity. Means of groups (pre-treatment, 1, 3, and 6-months) were compared with repeated measure analysis of variance. Results: At baseline, 81% patients had low omega-3 index. In the O3FA group, a significant increase in omega-3 index, improvement in symptoms, reduction in tear film osmolarity, and increase in Schirmer, TBUT, and goblet cell density was observed. These changes were not significant in the placebo group. Improvement in test parameters was significantly (P < 0.001) better in patients with low omega3 index (<4%) subgroup. Conclusion: Dietary omega-3 fatty acids are effective for dry eye in VDT users; omega-3 index appears to be the predictor to identify potential dry eye patients who are likely to benefit from oral omega-3 dietary intervention.

Effect of facemasks on the tear film during the COVID-19 pandemic.

PURPOSE: To evaluate the effect of wearing facemasks on dry eye symptoms and on the tear film while comparing surgical face masks to N95 particulate respirators. METHODS: A prospective observational study was conducted at Ain Shams University Hospitals in the period from September 2020 to January 2021. Two hundred volunteers were recruited, and the daily number of hours spent by each participant wearing a facemask was recorded. Recruits were divided into two groups: 100 volunteers were allocated to Group A to use the surgical mask, and 100 participants to Group B to use the N95 particulate respirator. The tear film parameters were assessed at baseline by answering the Ocular Surface Disease Index (OSDI) questionnaire and performing tear break-up time (TBUT), corneal fluorescein staining, and Schirmer-I test Subjects then wore a facemask for 60 min and then the tear film parameters were reassessed by repeating TBUT, corneal staining and Schirmer-I test. RESULTS: Facemask use for 60 min significantly worsened all tear film parameters in both groups (P-value <0.0001). The deterioration was significantly larger in Group A subjects (P < 0.0001). The daily number of hours spent wearing a facemask correlated strongly with the OSDI and corneal staining. There was a strong negative correlation between the daily number of hours spent wearing a facemask and Schirmer test, and a weak negative correlation with TBUT. CONCLUSIONS: Wearing facemasks during the COVID-19 pandemic is a risk factor for worsening tear film parameters. This deterioration is significantly greater with surgical masks than with N95 particulate respirators and increases with the duration of facemask use.

Evaluation of the Effect of Infection and Immunity on the Tear Film by Scheimpflug-Placido Disc Topography- A Case Control Study.

PURPOSE: We aimed to compare the tear film stability of individuals who had recovered from coronavirus disease (COVID-19), that of individuals vaccinated against COVID-19 and that of healthy individuals in a control group. METHODS: This study included 61 eyes of 61 post-COVID-19 patients, 63 eyes of 63 participants who had received at least two doses of the SARS-CoV-2 mRNA BNT162b2 (Pfizer-BioNTech) vaccine, and 57 eyes of healthy individuals in a control group. We compared the groups' tear film stability. RESULTS: The mean non-invasive first tear break-up time (NIF-BUT) value was 4.1±2.7 seconds in the post-COVID-19 group, 4.7±2.9 seconds in the vaccinated group, and 5.8±2.8 seconds in the control group. This value was statistically significantly lower in the post-COVID-19 and vaccinated groups than in the control group (p= 0.007). The rate of superotemporal (ST) quadrant breakup, statistically significantly higher in the vaccinated group than in the other two groups (p=0.001). According to a qualitative examination of the results, at least one breakup occurred in 47 (77%) of the post-COVID-19 participants' eyes, 50 (79.4%) of the vaccinated group's eyes, and 33 (57.9%) of the control group's eyes. In terms of this qualitative value, the post-COVID-19 and vaccinated groups had significantly higher breakup rates than the control group (p=0.018). CONCLUSIONS: Destabilization in the tear film was more common in both the post covid group and the vaccinated group. In addition to individuals who have post-Covid, we think that post-vaccination individuals should be followed closely in terms of ocular surface diseases.

Prevalence of Dry Eye Symptoms and Associated Risk Factors among University Students in Poland.

Aim: The aim of the study was to demonstrate the prevalence and risk factors of dry eye symptoms (DES) among university students in Poland. Material and methods: A cross-sectional study survey was conducted among 312 Polish university students. The questionnaire consisted of the Ocular Surface Disease Index (OSDI), the 5-Item Dry Eye Questionnaire (DEQ-5) and questions regarding medical history and risk factors. Results: According to the OSDI, more than half of respondents (57.1%) have symptoms of ocular surface disease. Time spent using electronic devices is correlated with scores gathered in both OSDI and DEQ-5 (p < 0.001). There is a statistically significant dependence between psychotropics (p = 0.002), glucocorticosteroids usage (p = 0.026), the presence of depression (p < 0.001), diabetes (p = 0.01) or allergy (p = 0.008) and dry eye symptoms proved in both questionnaires. Respondents with refractive errors and those living in metropolitan areas have a statistically higher symptom intensity(p < 0.022). Stress felt by students is associated with higher DES risk. No correlation between DES and smoking habits was observed. The history of SARS-CoV-2 infection was associated with the severity of DES (p = 0.036). Conclusion: Pathogenesis of DES is multifactorial and its severity depends on several factors, both genetic and environmental. Its prevalence among the young population is underestimated. Determining risk factors will enable the implementation of appropriate prophylaxis and early diagnosis.

Face mask use and effects on the ocular surface health: A comprehensive review.

In the COVID-19 period, face masks increased exponentially. Several studies suggest that the rise in ocular discomfort symptoms during the pandemic is mostly part of dry eye disease and that these are due to the effect of face masks, resulting in the newly described term MADE, for "mask-associated dry eye". The most commonly proposed mechanism states that wearing a face mask creates an unnatural upward airflow towards the ocular surface during expiration, although the increased temperature, humidity and levels of carbon dioxide of the exhaled air, stress, increased use of video display terminals, as well as changes in the ocular microbiota may contribute. Evidence supports that the use of face masks causes an increase in dry eye disease symptoms, a decreased tear break-up time, corneal epithelial trauma, periocular temperature changes and inflammatory markers secretion. Given that the use of masks may be frequent in some settings in the near future, it is important to establish its effects and consequences on the ocular surface.

The Ocular Surface Symptoms and Tear Film Parameters during and after COVID-19 Infection.

PURPOSE: This study aimed to evaluate the ocular surface parameters of post-COVID-19 patients when compared to healthy controls. METHODS: Patients after symptomatic SARS-CoV-2 infection, as confirmed by a PCR test of their nasopharyngeal swab sample, were enrolled. Complete ophthalmic examination, including visual acuity test, intraocular pressure measurement (IOP), slit-lamp examination, tear osmolarity test, central corneal thickness, endothelial cell number measurements, non-invasive keratograph break-up time (NIKBUT), meniscus height, and the Schirmer's test were performed and compared with the controls. RESULTS: It must be noted that there were 36 COVID-19 patients and 25 control subjects included in the study. Eye itching and burning (19%) were the most common symptoms of COVID-19 infection, followed by a subjective decrease in vision (17%), conjunctivitis and eye pain were present in 11%, and 6% of the patients had episcleritis. The mean time from initial infection was 6.5 ± 3.9 (range 1-24 weeks). Meniscus height was not significantly changed between the COVID-19 (0.34 ± 0.13 mm) group and the control (0.33 ± 0.12 mm, p = 0.88) group. In addition, the NIKBUT-1 (p = 0.88; 7.22 ± 4.60 s and 6.91 ± 4.45 s) and NIKBUT average (p = 0.91, 12.30 ± 5.86 s and 11.77 ± 4.97 s) test results showed no significant change either. Neither was a significant result found in the IOP (p = 0.17, 14.56 ± 2.10 mmHg and 14.11 ± 1.96 mmHg); the Schirmer test (p = 0.18, 20.22 ± 7.92 mm and 20.02 ± 7.17 mm); Tosm (p = 0.16, 294.42 ± 54.51 mOsm/dL and 299.33 ± 5.65 mOsm/dL); CCT (p = 0.06, 549.15 ± 28.98 vs. 539.21 vs. 29.08 µm); nor the endothelial cell density (p = 0.07, 2516.64 ± 287.61 vs. 2454.21 ± 498.60 cells/mm2). CONCLUSIONS: Through this study it was not revealed that there were any significant differences between the post-COVID group and control group in the objective measurements of ocular surface conditions, when performed after the acute phase of COVID-19. The exact incidence and mechanism of ocular findings, especially dry eye disease, in correlation with SARS-CoV-2 requires further research.

Therapeutic potential of the MDM2 inhibitor Nutlin-3 in counteracting SARS-CoV-2 infection of the eye through p53 activation.

Starting from the beginning of the severe acute respiratory syndrome Coronavirus-2 (SARS-CoV-2) global pandemic, most of the published data has concentrated on the respiratory signs and symptoms of Covid-19 infection, underestimating the presence and importance of ocular manifestations, such as conjunctivitis, usually reported in SARS-CoV-2 infected patients. With the present review we intend to resume the ocular involvement in SARS-CoV-2 infection and the recent discoveries about the different cell types and tissues of the eye that can be directly infected by SARS-CoV-2 and propagate the infection. Moreover, reviewing literature data about p53 expression in normal and diseased eye tissues, we hypothesize that the pleiotropic protein p53 present at high levels in cornea, conjunctiva and tear film might play a protective role against SARS-CoV-2 infection. Since p53 can be easily up-regulated by using small molecule non-genotoxic inhibitors of MDM2, we propose that topical use of Nutlin-3, the prototype member of MDM2 inhibitors, might protect the anterior surface of the eye from SARS-CoV-2 infection, reducing the spreading of the virus.

Eyes: conduit to COVID-19, relevance of eye protection, and face shield in ophthalmology waiting areas

COVID-19 pandemic caused by highly contagious Severe Acute Respiratory Syndrome Coronavirus 2 has affected the health and economy of the population worldwide. A major route of transmission of coronavirus is through respiratory system by aerosols and microdroplets. Virus can also spread by direct or indirect touching of the inmate objects harboring live virus. Virus can gain access through the nasal and oral ororopharyngeal mucosa. Coronavirus has been isolated from the ocular surface and tearfilm. Severe Acute Respiratory Syndrome Coronavirus 2 has been documented to drain from the ocular surface to oropharyngeal mucosa through tears. In the preventive measures, the mask acts as a barrier to touch and aerosol transmission and its use has been advocated all over the world. Transmissions through eyes (ocular surface and tear film) are possible, however, compared to the aerosol transmission the risk may be small. The use of glasses, safety goggles and face shields may provide protection to eyes from contamination and minimizes the risk of transmission from the ocular surface and tear film. In this review, the authors aim to highlight the role of the ocular surface and tear film in the transmission and possible measure to prevent the infection through the eyes. [ FROM AUTHOR] Copyright of Asian Journal of Medical Sciences is the property of Manipal Colleges of Medical Sciences and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

Systemic and Laboratory Risk Factors for Retinopathy and Detection of Tear Film SARS-CoV-2 RNA

Purpose : Coronavirus-19 (COVID-19) has been associated with ophthalmic manifestations. The relationship between tear film SARS-CoV-2 RNA, timing of illness and eye disease are unknown. We evaluated hospitalized COVID-19 inpatients for retinopathy and tear film viral RNA. Methods : Hospitalized COVID-19 inpatients were offered enrollment from January-June 2021. Full dilated ophthalmic examination and conjunctival swabs were taken for triplex RT-PCR for SARS-CoV-2 RNA targeting N2, E and RNAse P. Demographic, clinical outcomes and laboratory data were collected. Univariate and multivariate analyses of systemic disease and laboratory risk factors for retinopathy and SARS-CoV-2 RNA detection were assessed. Results : Sixty patients were prospectively enrolled in this cross-sectional, observational study. The mean age was 58.8 years (Standard deviation [SD] 15.2 years) and 29 (48%) were female. Retinopathy associated with COVID-19 in 12 of 60 patients (20%). Univariate analyses revealed that younger age, greater body mass index (BMI) and extracorporeal membrane (ECMO) requirement were associated with increased odds of COVID-19 retinopathy. The mean age (SD) of patients with COVID-19 retinopathy was 49.0. (11.6) compared to 61.2 (15.1) years in individuals without retinopathy (p=0.01). The mean BMI was 38.8 (9.8) in patients with retinopathy compared to 31.8 (9.0) in those without retinal disease findings (p=0.04). ECMO requirement was observed in 33% of patients with retinopathy compared to 8% in those without retinopathy (p=0.04). Multivariate analyses trended towards increased risk of retinopathy with younger age (aOR 0.95 (95% CI 0.90- 1.01, p=0.095) and with increased BMI (aOR. 1.08, 95% CI 1.00-1.18, p=0.056). Fifteen of 60 patients (25%) tested positive in their tear film for SARS-CoV-2 RNA with a trend towards a shorter length of illness and hospitalization in patients who were positive. The N2 gene was particularly sensitive with 18 of 19 eyes (94.7%) showing N2-positivity (with or without E gene detection), including 2 patients in whom the B.117 / B.1.525 alpha or ?United Kingdom? variant was detected. Conclusions : A 20% rate of retinopathy was observed and SARS-CoV-2 RNA within tear film was detected in 25% of hospitalized COVID-19 patients. Continued infection control precautions are required given the risk of viral RNA in tear film, which may also be sensitive for the detection of COVID-19 variants.

Face-Mask Associated Dry Eye (F-MADE) Symptoms and Ocular Surface Alterations

Purpose : Since the onset of the coronavirus disease 19 (COVID-19) pandemic, people's lives have adapted, with the use of face masks becoming a part of our daily routine. Despite being a useful device to prevent disease contagion, a marked increase in dry eye and stye symptoms has been detected. We aimed to perform an observational correlation analysis between face-mask use and to report both objective and subjective ocular surface measurements performed on a multi-purpose advanced corneal topographer and a high-definition camera. Methods : This study included 25 healthy subjects without any ocular diseases, ages ranging from 19 to 68 years. We measured tear meniscus height, Non-Invasive Tear Breakup Time (NIBUT), overall redness score, and tear film lipid layer characterization using Keratograph 5M (Oculus, Wetzlar, Germany), as well as Ocular Surface Disease Index (OSDI) scores for dry eye symptomatic assessments. Patients were asked the number of hours of mask-use at the moment of enrollment, the average hours of mask use daily, and the type of face mask used. We assessed for differences between OSDI scores and gender and type of mask used, as well as correlation coefficients for all subjective and objective measurements. Results : The mean age of the subjects was 42.44±14.49 years. OSDI scores had no significant differences according to gender (p = 0.1664) or type of mask used (p = 0.0791). Correlation between hours of mask use at the time of testing and ocular surface modifications were minimal. Hours of mask-use at the time of the test and OSDI scores were moderately correlated (r= 0.5047, p=0.01). No correlation was found between the average hours of mask use and any ocular surface measurements or OSDI scores. Conclusions : The use of face masks increased subjectively dry eye symptoms. Nevertheless, ocular surface objective measurements remain unchanged by maskwearing.

USING THE TEAR FILM IMAGER FOR COVID19 DETECTION-A PILOT STUDY

Purpose : <div style='direction: ltr;'>A key challenge in limiting the spread of Covid-19 is the absence of a fast non-invasive tool to detect infected individuals in the general population. Using polymerase chain reaction (PCR) testing, it has been demonstrated that SARS-CoV-2 is present in the tear film of patients with ocular symptoms. The presence of virions in or next to the lipid layer of the tear film would theoretically cause a measurable interruption of the normal tear bi-layer structure. The goal of this pilot study is to test the hypothesis that a specialized version of Tear Film Imager (vTFI) could be used for detection of infected individuals, in a quick, non-invasive manner. It is important to note that vTFI findings are not specific to SARS-Cov-2, and similar enveloped virions might cause a comparable disturbance.</div> Methods : <div style='direction: ltr;'>In our pilot study, twenty eyes of ten patients that were hospitalized due to Covid-19 infection in a designated quarantine department were compared to twenty eyes of ten healthy control patients. The study was approved by the Wolfson medical center's Institutional Review Board. All participants had a nasopharyngeal PCR swab confirming infection status up to 72 hours prior to examination by vTFI. Any patients with chronic viral infection (i.e. HIV, HBV etc'), corneal abnormalities, or corneal/refractive surgery were excluded to ensure uniformity of the data and focus on virion detection</div> Results : <div style='direction: ltr;'>Using vTFI 16 out of 20 healthy eyes correctly tested negative. 15 out of 20 Covid-positive eyes were correctly identified positive using TFI. In total 70% of the control group were correctly categorized by TFI algorithm as healthy (positive if one eye positive) and 80% of the Covid-infected individuals were positively identified.</div> Conclusions : <div style='direction: ltr;'>Identification of Covid-19 status from the tear film layer using ultra-fast non-invasive vTFI shows promise and a larger sample blinded study should be performed to assess its implementation in an outpatient setting. Being a nonspecific test, the use of vTFI is not dependent on special primers and may offer a modality for diagnosing individuals suspected of being infected with other emerging pathogens. </div>.

IgA-Based Secretory Response in Tears of COVID-19 Patients: A Potential Biomarker of Pro-Inflammatory State in Course of SARS-CoV-2 Infection.

Mucosal immunity, including secretory IgA (sIgA), plays an important role in the early defence against SARS-CoV-2 infection. However, a comprehensive evaluation of the local immune response in tears in relation to blood antibody reservoirs has not yet been conducted. A total of 179 symptomatic laboratory-confirmed COVID-19 patients were included in this single-centre study. Conjunctival swabs were analysed by a reverse transcription polymerase chain reaction for the detection of SARS-CoV-2 RNA. In parallel, tear samples collected by Schirmer test strips and plasma samples were analysed by ELISA to detect anti-S1 IgA levels. The concentrations of selected inflammatory cytokines in tears were determined by a magnetic bead assay. Anti-SARS-CoV-2 sIgA was present in the tears of 81 (45.25%) confirmed COVID-19 patients, and the tear IgA levels were correlated with the plasma IgA levels (Rs = +0.29, p = 0.0003). SARS-CoV-2 RNA in the conjunctival sac was identified in 18 COVID-19 patients (10%). Positive correlations between the tear IgA level and the concentrations of several cytokines TNF-α (Rs = +0.23, p = 0.002), IL-1ß (Rs = +0.25, p < 0.001), IL-2 (Rs = +0.20, p = 0.007), IL-4 (Rs = +0.16, p = 0.04), IL-5 (Rs = +0.36, p < 0.001), IL-6 (Rs = +0.32, p < 0.001), IL-8 (Rs = +0.31, p < 0.001), VEGF (Rs = +0.25, p < 0.001) and GM-CSF (Rs = +0.27, p < 0.001) were also found. Quantitative tear film-based sIgA could potentially serve as a rapid and easily accessible biomarker of external mucosal immunity to SARS-CoV-2. The concentration of sIgA is directly related to individual host immune responses to SARS-CoV-2 infection.

Evaluating Ocular Symptoms and Tear Film Cytokine Profiles in Symptomatic COVID-19 Patients.

BACKGROUND: This study investigated the presence and duration of ophthalmic symptoms in the early phase of COVID-19 to assess the corresponding local immune response on the ocular surface. METHODS: The study included data from 180 COVID-19 patients and 160 age-matched healthy controls. The main finding was the occurrence of ophthalmological manifestations at the time of admission to the hospital and during the preceding 7 days. Tear film concentrations of TNF-α, IL-1b, IL-2, IL-4, IL-5, IL-6, IL-8, IL-10, IL-12 p70, GM-CSF, and IFN-γ were determined by a magnetic bead assay. RESULTS: Among the COVID-19 patients, 12.64% had at least one ocular symptom at the time of admission, and 24.14% had symptoms within the preceding 7 days (p < 0.001 vs. controls). We found that the COVID-19 patients complained more frequently about eye tearing (p = 0.04) and eye pain (p = 0.01) than controls. A multivariate analysis of the patients and controls adjusted for age and sex revealed that COVID-19 was an independent factor associated with higher VEGF and IL-10 tear film concentrations (ß = +0.13, p = 0.047 and ß = +0.34, p < 0.001, respectively) and lower IL-1ß, IL-8, and GM-CSF levels (ß = -0.25, p < 0.001; ß = -0.18, p = 0.004; and ß = -0.82, p = 0.0 respectively). CONCLUSIONS: SARS-CoV-2 does not attract a strong local response of the conjunctival immune system; therefore, ophthalmic symptoms may not constitute a substantial element in the clinical picture of novel COVID-19 infection.

Quantitative Evaluation of Aerosol Generation from Non-contact Tonometry and its Correlation with Tear Film Characteristics.

INTRODUCTION: Ophthalmologists are inevitably exposed to tears and ocular discharge during ophthalmologic examinations and are at high risk for SARS-CoV-2 infection. To understand the role of aerosols in disease transmission, we adopted a prospective cross-sectional study design and investigated the count and size distribution of aerosols generated by a non-contact tonometer and its correlation with individual tear film characteristics. METHODS: This study constituted two parts. The study population included outpatients who underwent an intraocular pressure examination in an intraocular pressure examination room (Part I) and 20 participants who underwent an intraocular pressure examination in a laboratory (Part II). The following main outcomes were measured: aerosol counts at 0, 50, 100, 150, and 200 cm from the non-contact tonometer (Part I); aerosol counts after each participant underwent non-contact tonometry, and lipid layer thickness score and tear film break-up time (Part II). RESULTS: The aerosol count decreased with increasing distance from the tonometer. The aerosol count at 0 cm had the highest value compared to that at other distances. For aerosols of diameters 0.25-0.5 µm and 0.5-1.0 µm, the count decreased at 50 cm and remained stable at further distances. For aerosols of diameters 1.0-2.5 µm and ≥ 2.5 µm, the count dropped progressively at all five distances. The aerosol count from each tonometer correlated positively with the lipid layer thickness score (r = 0.490, P = 0.028), whereas the aerosol count correlated negatively with the tear film break-up time (r = - 0.675, P = 0.001). CONCLUSIONS: Aerosols tended to coagulate during diffusion. A 50-cm distance from the tonometer could confer safety from aerosols with < 1.0-µm diameter. Aerosols generated during non-contact tonometry could contain a lipid layer component. Moreover, tear film stability could affect aerosol generation. Protective eyewear is recommended for reducing infection risk from aerosols. Individual tear film characteristics should be considered during non-contact tonometry.

A Narrative Review of Current Understanding and Classification of Dry Eye Disease with New Insights on the Impact of Dry Eye during the COVID-19 Pandemic.

Dry eye disease (DED) is a complex, progressive and multifactorial condition that is commonly seen in clinical practice and can be challenging to accurately diagnose. Untreated or suboptimally managed dry eye can progress to severe, chronic disease which may become resistant to treatment. Symptoms include ocular irritation and visual impairment. Patients frequently report negative consequences regarding quality of life (QoL), productivity and psychological wellbeing. Certain lifestyle factors (e.g. use of screen-based devices, air conditioning) can induce or exacerbate symptoms of DED, leading to progressive and debilitating complications. Exposures to such triggers are likely to have increased significantly during the ongoing COVID-19 pandemic with people across the globe living with heightened levels of stress/anxiety while being forced to adapt most aspects of their daily lives (from work and education through to social activities) to accommodate social distancing, primarily through the use digital technologies. This review aims to provide a concise and practical overview of current understanding regarding DED, highlighting proposals for refined diagnostic categories and therapeutic terminologies that are designed to improve identification and management of dry eye as well as reduce or slow disease progression. Finally, the findings of a European survey are shared to illustrate the impact of the COVID-19 pandemic on the lives of people with DED. The survey was conducted during the first lockdown period (March-September 2020) and explored issues relating to psychological wellbeing, QoL and engagement with healthcare services. The results demonstrate the ways in which the pandemic amplified the impact of dry eye on daily life and may be valuable in enhancing understanding among clinicians of the challenges faced by people with DED, which extend beyond the signs and symptoms of disease.

The "Quarantine Dry Eye": The Lockdown for Coronavirus Disease 2019 and Its Implications for Ocular Surface Health.

The pandemic of coronavirus disease 2019 (COVID-19) has led many countries of the world to impose a series of containment measures such as lockdowns (mass quarantines), curfews or similar restrictions (eg, stay-at-home orders, or shelter-in-place orders). All these restrictions were established in order to limit spread of COVID-19. Thus, approximately 3.9 billion people worldwide were under lockdown by early April 2020. During this time (home confinement), some solutions have been proposed by experts to improve work and school productivity, including smart working and online school lessons. However, many of the restrictive measures are likely to act as predisposing factors for dry eye disease (DED), directly or related to sick building syndrome (SBS). Herein, we discuss the implications of quarantine measures on eye health, in particular on DED associated with SBS, and introduce some potential preventive strategies for lockdown-related ocular surface disorders. Several risk factors are implicated in their pathogenesis, including environmental changes (eg, air quality) and modifications in personal behaviors (eg, the abuse of digital devices, malnutrition, and sleep/psychiatric disorders). Considering a number of predisposing factors for DED, it is possible to state that patients under lockdown are at risk of ocular surface alterations. Accordingly, the COVID-19 pandemic era is expected to determine an increase in dry eye patients all around the world (a new phenomenon that we propose to name the "quarantine dry eye") in the event that the restrictive measures will be recursively extended over time.

SARS-CoV-2 and the Eye: A Relationship for a Possible Prognostic Tool in COVID-19 Patients.

PURPOSE: In December 2019 there was the first report about a new viral infection in Wuhan, China. The new virus was taxonomically designed as Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) causing the coronavirus disease 2019 (COVID-19). SARS-CoV-2 uses the angiotensin-converting enzyme 2 (ACE2) receptor for cell invasion, which is expressed in different tissues including lungs, small intestine, testicles, kidneys, brain, and the eye. The purpose of this article is to review the available information on the relationship of COVID-19 with the eye, as well as evaluating the possible usefulness of ocular diagnostic tests to help in the diagnosis and/or monitoring of patients with this disease. METHODS: We performed a retrospective review of relevant articles from November 2019 to April 2020. RESULTS: Ocular infection by SARS-CoV-2 is still controversial; nevertheless, the possibility of being a viral reservoir has been suggested, increasing the likelihood of infection. Some reports demonstrated the presence of SARS-CoV-2 in tears, and previously published data suggest a pathological increase of cytokine concentrations in COVID-19 patients; the cytokine release syndrome or cytokine storm contributes to lung and central nervous system damage. The usefulness of tears for the measurement of inflammatory cytokines in various diseases is well known, in particular IL-6, which has been correlated to the severity of COVID-19. CONCLUSION: Considering that the IL-6 signaling cascade may be activated in patients with COVID-19, makes it an excellent target for diagnostic and/or monitoring purposes.

SARS-COV-2 and Ocular Surface: From Physiology to Pathology, a Route to Understand Transmission and Disease.

Coronaviruses gained public attention during the severe acute respiratory syndrome (SARS) outbreak in East Asia in 2003 and spread of Middle Eastern respiratory syndrome (MERS) in 2012. Direct human-to-human contact and droplet are the main methods of transmission. Viral stability in aerosols on different surfaces supports evidence on indirect viral acquisition from fomites through the mucous membranes of the mouth, nose, and eyes. Given the pandemic circumstances, the level of evidence in COVID-19 and ophthalmology regarding eye infection, conjunctival transmission, and viral shedding through tears is insufficient. Presently, conjunctival transmission of coronaviruses has not been confirmed and remains controversial. Considering the physiology of the lacrimal system and ocular surface, the eyes are considered an immunoprotective site, with several antiviral molecules and anti-inflammatory proteins. Nevertheless, they represent an interface with the exterior world and face daily putative aggressors. Understanding the host's ocular surface immunological and protective environment is crucial to clarify the potential of the conjunctiva as an entry route for SARS-CoV-2 and as part of this viral infection. We will discuss hypothetical ocular surface transmission mechanisms and related counterarguments addressed to both angiotensin-converting enzyme 2 receptors found on the conjunctival and corneal epithelia and lactoferrin, lysozyme, lipocalin and secretory IgA levels in the tear film. Hopefully, we will promote better understanding of this organ in COVID-19 infection and the potential transmission route that can be helpful in setting recommendations on best practices and protective guidelines to mitigate the disease spread.