Incidence and clinical characteristic of ocular surface manifestation: an evaluation of conjunctival swab results in Corona Virus 2019 (COVID-19) patients in Jakarta, Indonesia.

OBJECTIVES: This study aimed to investigate the spectrum of ocular characteristics and viral presence in the conjunctival swab of patients with COVID-19. METHODS: In this cross-sectional study, fifty-three patients were recruited from two COVID-19 referral hospitals in Jakarta (Cipto Mangunkusumo Hospital and Persahabatan Hospital) from July 2020 to March 2021. The inclusion criteria were patients who were suspected of or confirmed cases of COVID-19 with or without ocular symptoms. Demographic data, history of COVID-19 exposure, underlying medical condition, systemic symptoms, ocular symptoms, supporting laboratory results, reverse-transcriptase polymerase chain reaction (RT-PCR) of naso-oropharyngeal (NOP) swab and conjunctival swab were collected. RESULTS: Fifty-three patients who were suspected, probable or confirmed cases of Covid-19 were included. Forty-six out of 53 patients (86.79%) tested positive for either Covid-19 antibody rapid test or naso-oropharyngeal (NOP) swab. Forty-two patients tested positive for NOP swab. Fourteen out of 42 patients (33.33%) experienced symptoms of ocular infection including red eye, epiphora, itchy eyes, and eye discharge. None of these patients were tested positive for conjunctival swab. Two out of 42 patients (4.76%), who were tested positive for conjunctival swab, did not experience any ocular symptoms. CONCLUSIONS: Establishing the relationship between Covid-19 infection, ocular symptoms, and presence of SARS-CoV-2 virus on the ocular surface proves to be challenging. In Covid-19 patients, ocular symptoms did not warrant a positive conjunctival swab result. On the contrary, a patient without ocular symptoms can also have detectable presence of SARS-CoV-2 virus on the ocular surface.

Detection of coronavirus in tear samples of hospitalized patients with COVID-19.

PURPOSE: To assess the presence of viral RNA in conjunctival secretions and tears of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-infected patients in terms of a possible ocular transmission route and also to examine whether a difference between the patients with and without ocular surface positivity existed. METHODS: A prospective cross-sectional study of 70 consecutive patients who were hospitalized in Haseki Training and Research Hospital with SARS-CoV-2 from February 1 to April 1, 2021, was performed. Tears and conjunctival secretions were collected within 24 h of nasopharyngeal sample collection and examined for SARS-CoV-2 using reverse transcription real-time polymerase chain reaction (qPCR). The clinical data, results of blood tests and nasopharyngeal and conjunctival swabs, and CT findings were evaluated for all patients. RESULTS: Seventy patients (37 males, 33 females) were included in this study. Tear-conjunctival samples from eight patients (11.42%) yielded positive PCR results although these eight patients had no eye symptoms or conjunctivitis. In patients with positive conjunctival PCR results, cycle threshold values for conjunctival samples were higher than those for nasopharyngeal samples. All findings (except gender) were similar between patients with either positive or negative conjunctival swab samples. All patients with positive conjunctival swab samples were male; however, the male ratio in patients with negative conjunctival swab samples was only 46.77%. CONCLUSION: In our study, the rate of conjunctival swab PCR positivity was 11.42%. It appears that even in the absence of ocular symptoms, SARS-CoV-2 virus may be present on the ocular surface; therefore, the ocular surface may be a significant viral transmission route.

Conjunctival swab assessment among hospitalized patients with confirmed coronavirus disease 2019 at Zagazig University Hospitals, Egypt

Purpose The aim of this study was to assess the role of PCR in conjunctival swab in the diagnosis of coronavirus disease 2019 (COVID-19) disease. Patients and methods This is a prospective cross-sectional study that included 50 patients with confirmed COVID-19 infection with and without conjunctivitis. Reverse transcriptase PCR was done for all conjunctival swabs to detect the presence or absence of coronavirus RNA. Results The mean age of the patients was 51.9±0.8 years, with 19 (38%) patients having conjunctivitis and 31 (62%) patients without conjunctivitis. The mean days since the onset of COVID symptoms was 9.5±0.7 days. Fever was present in 48 (96%) patients and respiratory symptoms were present in 49 (98%) patients. Positive, weak positive, and negative reverse transcriptase PCR of conjunctival swabs were detected in nine (18%), seven (14%), and 34 (68%) patients, respectively. Conclusion There were low viral RNA loads in the conjunctival swab. So, its analysis cannot offer an opportunity to confirm the diagnosis of COVID-19 infection. © 2022 Delta Journal of Ophthalmology.

COVID-19 and SARS-CoV-2 Detection in the Conjunctiva: Meta Analysis

Purpose : 10% of COVID patients have eye symptoms1 . Conjunctivitis is the most reported ocular symptom, being reported in 88.8% of all pts with eye symptoms1 . Literature search for SARS-CoV-2 presence in the conjunctiva of COVID patients with conjunctivitis. Methods : Review of articles dated 2020-2021 for conjunctival swabs in COVID-19 positive conjunctivitis patients using search terms: “COVID conjunctival swabs,” “COVID conjunctivitis,” and “COVID and eyes”. Search was done on Google Scholar and PubMed. Cases were excluded if patients did not have conjunctivitis or if a positive conjunctival swab was found in a patient with no clinical or lab-confirmed COVID diagnosis. Results : 27 articles published February 2020-December 2021 were found with 223 conjunctivitis patients. We found that conjunctival swabs tested for SARS-CoV-2 using RT-PCR returned positive 54.4% of the time in COVID-19 patients with conjunctivitis. We also found that 18 patients with no conjunctivitis tested positive on conjunctival swabs. Conclusions : Further research is needed to study the pathophysiology of SARS-CoV-2 in the eyes and its presence on the ocular surface. As we begin our third year of the pandemic, we expect more case reports and clinical studies on COVID conjunctivitis.

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.

CORONAVIRUS TRANSMISSION TROUGH OCULAR SECRETION: A REVIEW OF CORONAVIRUS ANDOCULAR MANIFESTATIONS

COVID-19 (Corona Virus Diseases-2019) is the newest global pandemic caused by SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus-2). This article aims to study the relationship between COVID-19 and the conjunctival swab test systemically. This article is based on several scientific reports related to conjunctival swab performed in COVID-19 patients from the PUBMED database, Google Scholar, Springer Link, Elsevier, medRxiv, bioRxiv, and Wiley Online Library. Keywords used are conjunctivitis, ocular, ophthalmic, COVID-19, SARS-CoV-2, 2019-nCoV, Coronavirus, Coronavirus-19, Coronavirus19, pathophysiology, mechanisms, tear, conjunctival swab, RT-PCR, and conjunctiva. Eight reports were reviewed in this article. Respiratory symptoms and ocular manifestation such as conjunctivitis with hyperemic eyes, conjunctival chemosis, epiphora, and other rare ocular manifestations were observed in COVID-19 patients. Ocular manifestation may present as a sole symptom, prodromal symptom, simultaneously appear with the systemic symptom, or as residual floaters. Various therapy was given according to the complaints. RT-PCR results from the conjunctival swab test may be positive and negative in COVID-19 patients with conjunctivitis. From this article, we hope to highlight the importance to take optimal prevention measures for medical staff despite the presence or absence of ocular clinical manifestation.

Serum Calprotectin Levels in Dogs with Diarrhea

Background: Diarrhea induced by infectious factors may lead to significant health problems in dogs. Canine parvovirus (CPV), canine coronavirus (CCV), canine distemper virus (CDV), Giardia spp., Escherichia coli (E. coli), and Salmonella spp. are the important infectious agents that may induce diarrhea in dogs. The present study aimed to investigate the effect of CPV, CCV, CDV, Giardia spp., E. coli, and Salmonella spp. infections on the change in serum calprotectin (Calp) concentration. Materials, Methods & Results: A total of 30 dogs were enrolled in the study. The study dogs were divided into 3 groups. Healthy animals as confirmed by clinical examination and animals negative for the specified pathogens were placed in Group 1. Animals infected by one or more agents, including CPV, CCV, CDV, and Giardia spp., but negative for E. coli or Salmonella spp. were placed in Group 2. Finally, animals positive for E. coli or Salmonella spp. and infected or not infected by one or more agents, including CPV, CCV, CDV, and Giardia spp., were placed in Group 3. Stool samples and rectal and conjunctival swab samples were collected to investigate the etiologic agents that induced diarrhea. Blood samples were collected through vena cephalica antebrachii for hematological and biochemical examinations. The samples were obtained via routine clinical examinations at the Prof. Dr. Servet Sekin outpatient clinic at Dicle University Veterinary Faculty. CPV, CCV, CDV, and Giardia spp. diagnoses were made based on immunochromatographic test kits. The bacteriological analysis of stool samples was used to diagnose E. coli and Salmonella spp. infection. Serum Calp concentrations were measured by Enzyme-Linked Immunosorbent Assay (ELISA). The analysis of swab and stool samples by immunochromatographic rapid diagnosis kits and microbiological methods showed that 5 animals were infected with CPV, 10 with CCV, 6 with CDV, 3 with Giardia spp., 12 with E. coli, and 2 with none of the specified agents. Total leukocyte count (WBC), lymphocyte (Lym - %), and granulocyte (Gra - %) values were higher in the diarrheal dogs when compared with the control group. In the biochemical examination of serum samples, total bilirubin (TBIL) and phosphorus (P) levels were higher and sodium (Na) levels were lower in Group 3 when compared to the control group (P = 0.025, 0.024, and 0.018, respectively). Total protein (TP) and albumin (Alb) values were lower in Group 2 compared to Groups 1 and 3 [P = 0.001 and 0.019 for TP, P = 0.000 and 0.01 for Alb, respectively]. There was a statistically significant difference in creatine kinase (CK) levels between Group 1 and Group 2 (P = 0.013). Serum Calp level was higher in the E. coli infected group (Group 3) compared to the other groups, no significant differences were noted between the groups (P > 0.05). Discussion: In conclusion, to the best of authors knowledge, this study is the first to evaluate serum Calp levels in dogs with diarrhea induced by viral, bacterial, and protozoan infections. The Calp level was higher in the sick dogs that were infected by at least one agent, including CPV, CCV, CDV, and Giardia spp., and were at the same time E. coli positive when compared with the control group and the group without E. coli infections. It was concluded that new studies could be useful to reveal the diagnostic importance of serum Calp concentration in dogs with diarrhea and that these results may contribute to future studies in this area.

Assessing viral shedding of SARS-CoV-2 in tears in Moderate to Severe coronavirus disease 2019 (COVID-19) patients

Background:SARS CoV-2 is a novel coronavirus, the causative agent of COVID-19. Airborne respiratory droplet transmis- sion is well recognized;however, transmission by methods, such as ocular secretions, is yet to be proven. The objective of the study was to investigate the presence of SARS-CoV-2 RNA in tears of patients with moderate to severe coronavirus disease 2019. Methods:Tears were collected within 48 hours of laboratory confirmation using 3 methods: conjunctival swab plus Schirmer’s test strips (group 1), conjunctival swab (group 2), and Schirmer’s test strips (group 3). Samples from both the eyes of each patient were transported in a single viral transport media for real-time RT- PCR. Demographic profiles, sys- temic symptoms, comorbidities, and ocular manifestations were noted. Viral load of a sample was determined using cycle threshold (Ct) value of E gene. Results:Out of 75 patients 48% (36) had moderate disease, while 52% (39) had severe disease. RT -PCR analysis of tears showed positive results in 18 patients (24%). Positive results were found in 11 (14.7%), 11 (14.7%), and 7 (9.3%) patients in groups 1, 2, and 3, respectively (P=0.3105). Mean Ct values in groups 1, 2, and 3 were 28.36+6.15, 29.00 +5.58, and 27.86+6.46 (P= 0.92), respectively. Five patients showed positive RT-PCR results by all 3 methods (mean Ct value, 25.24+6.33), and 12 patients showed positive results by any of the 3 methods (mean Ct value, 32.16+1.94), the differ- ence in Ct values being statistically significant (P=0.029). The median value of symptomatology in patients with positive RT-PCR results from tears was 5 days (range, 4-9 days). Conclusions:SARS-CoV-2 RNA was detected in tears of 24% of patients with laboratory-proven moderate to severe COVID-19. Conjunctival swab remains the gold standard of tear collection for RT-PCR assay. A significantly higher possi- bility of viral transmission exists through tears in patients with moderate to severe COVID-19.

Ocular Surface Infection by SARS-CoV-2 in COVID-19 Pneumonia Patients Admitted to Sub-Intensive Unit: Preliminary Results.

The aim of the present study is to check the relationship between virus detection on the conjunctival swabs by RT-PCR and the systemic and ocular clinical data, treatments, and to the modalities of administration of supplemental oxygen. The SARS-CoV-2 RNA reverse-transcriptase PCR assay of conjunctival brushing samples and the corneal/conjunctival clinical findings were evaluated in 18 eyes of 9 consecutive patients admitted to the COVID-19 Sub-intensive Unit of Salerno Hospital University, Italy. Conjunctival swabs were positive for SARS-CoV-2 in 13 eyes of 7 patients; corneal epithelial defects were detected in 9 eyes. The seven patients with ocular involvement from SARS-CoV-2 had undergone treatment with a full-face mask or oxygen helmet in the last week, while the two subjects with negative conjunctival swabs had been treated with high flow nasal cannula. The positivity to the conjunctival test for SARS-CoV-2 was higher (72%) than that reported in the literature (10-15%) and related in all cases to the use of facial respiratory devices. These results suggest that exposure of unprotected eyes to aerosols containing high concentrations of SARS-CoV-2 could cause a keratoconjunctival viral infection. Further studies are needed to verify the causal link with the use of respiratory facial devices in patients suffering from COVID-19 pneumonia.

Detection of SARS-CoV-2 RNA in a conjunctival swab sample in real-time-polymerase chain reaction positive COVID-19 patients and its association with comorbidity and severity at a designated COVID-19 hospital in Central India.

PURPOSE: To evaluate the presence of SARS-CoV-2 RNA in the conjunctival swab sample of positive confirmed COVID-19 patients and to find out its association with comorbidity and severity of COVID-19 disease. METHODS: We conducted an observational cross-sectional study at a dedicated tertiary COVID-19 hospital in central India for a period of 8 weeks from February 2021to March 2021. We included patients who tested positive for SARS-CoV-2 RNA through nasopharyngeal swab and were above 18 years of age. Swab samples have been collected within 48 h of admission. Conjunctival swab was taken from the lower fornix of both eyes and sent to microbiology laboratory for real-time- polymerase chain reaction (RT-PCR). RESULTS: Out of 150 patients, conjunctival swab RT-PCR was positive in five patients (3.33%). Two patients had conjunctival manifestations in the form of conjunctivitis but conjunctival swab RT-PCR was negative in those patients. Among the RT-PCR positive patients, two (40%) were from mild, one (20%) was from moderate, and two (40%) were from severe category. No association could be established between conjunctival swab RT-PCR positivity and severity of the disease or associated comorbidity. CONCLUSION: Our study provides evidence that SARS-CoV-2 RNA could be detected in conjunctival secretions, and though the risk is relatively low, the eye may act as source of transmission. Extra caution should be taken by healthcare workers, and use of proper precautions like face shields and goggles should be encouraged.

Post-Mortem RT-PCR Assay for SARS-CoV-2 RNA in COVID-19 Patients' Corneal Epithelium, Conjunctival and Nasopharyngeal Swabs.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) disease has been described to possibly be associated with ocular surface disturbances. However, whether the virus could invade ocular tissues still remains elusive. In the present study, we tried to investigate the post-mortem presence of SARS-CoV-2 RNA in corneal epithelium gathered by patients with an ante-mortem confirmed diagnosis of Coronavirus disease-19 (COVID-19). Cadavers with an ante-mortem confirmed diagnosis of moderate to severe COVID-19 were examined. Clinical and demographic features were retrieved from hospital patients' notes. For each cadaver, corneal scrapings, conjunctival swabs (CS) and nasopharyngeal swabs (NPS) were collected to perform real-time reverse transcriptase polymerase chain reaction ((RT)-PCR) for SARS-CoV-2. Fourteen consecutive cadavers with an ante-mortem confirmed diagnosis of moderate to severe COVID-19 were examined. The last NPS performed ante-mortem confirmed SARS-CoV-2 infection in 12/14 (85.7%) patients. The mean death-to-swab time (DtS) was 3.15 ± 0.5 (2.10-5.1) h. The post-mortem NPS and CS found positive for SARS-CoV-2 RNA were 9/14 (64.3%) and 3/28 (10.7%), respectively. None of the corneal epithelium scrapes tested positive to RT-PCR for SARS-CoV-2 RNA. These data promote the SARS-CoV-2 as not able to contaminate the post-mortem corneal epithelium, while it can persist in different other structures of the ocular surface (i.e., the conjunctiva). It is reasonable to assume that such a contamination can occur ante-mortem too.

Investigation of SARS-CoV-2 in tear and conjunctival secretions of hospitalized patients with clinically-confirmed COVID-19 pneumonia.

BACKGROUND: The aim of this study was to demonstrate the presence of the virus in tear and conjunctival secretions of clinically-confirmed COVID-19 pneumonia patients. METHODS: This prospective study was conducted at Bakirkoy Dr. Sadi Konuk Training and Research Hospital (2020/190). Nasopharyngeal and ocular samples were obtained by swab technique and investigated by RT-PCR. RESULTS: A total of 83 patients were included. The mean age was 61.88 ± 16.04 years. 28.92% of the patients had mild, 65.06% moderate and 6.02% severe pneumonia radiologically. RT-PCR was positive in 31 (37.35%) patients in the first nasopharyngeal swabs and in 19 (22.89%) in the second swabs. 17 of 19 patients had positive both first and second nasopharyngeal swabs; only the second swabs of two patients were positive. The first conjunctival swabs RT-PCR were positive in 5 out of 83 clinically-confirmed patients or 33 laboratory-confirmed patients (rates: 6.02% and 15.15%). There were no positives detected in the second conjunctival swabs. CONCLUSIONS: SARS-CoV-2 can be detected in the conjunctival swabs of patients with COVID-19 pneumonia.

Testing the Sensitivity of Conjunctival Swabs from Confirmed COVID-19 Patients.

OBJECTIVE: To investigate the incidence of COVID-19 viral RNA in the conjunctiva of patients priorly confirmed to have COVID-19, using a conjunctival swab and to determine swab sensitivity. METHODS: This cross-sectional study enrolled patients who tested positive for COVID-19 with PCR via nasopharyngeal swabs. Conjunctival swabs were collected for each patient and subjected to RT-PCR assay. Demographic data and clinical history of patients were investigated and analysed. RESULTS: In this study, 4.9% of the patients tested positive with conjunctival swabs for COVID-19; 29.9%, 28.7%, 20.1%, and 12.2% of the patients had fever, shortness of breath, cough, and red eye, respectively. Among all patients, 18.9% and 73.2% had a history of traveling and contact with positive COVID-19 cases, respectively. There were significant correlations between the conjunctival results and diabetes (P=0.049) and hypertension (P=0.002). Traveling was a risk factor for positive conjunctival swab testing (P=0.016). The sensitivity of the conjunctival swab was 4.8%. CONCLUSION: Among all positive cases of COVID-19, a small percentage had positive results when tested using a conjunctival swab. Conjunctival swabs have very low sensitivity for the detection of COVID-19. However, tears could still be a mode of disease transmission, especially from patients to eye care specialists.

Comparison of the simultaneous conjunctiva and oropharynx-nasopharynx swab results in patients applying to the SARS-CoV-2 outpatient clinic for the first time.

The aim is to comparatively evaluate the results of simultaneous conjunctiva and oropharynx-nasopharynx (ONP) swabs in patients who had presented to the outpatient department with a suspicion of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). An ONP sample was obtained following bilateral conjunctiva swabs in 85 subjects with a contact history or symptoms but unknown SARS-CoV-2 status and with no ocular symptoms or findings. The results were evaluated according to the patient's symptoms and how the swab was taken. The conjunctiva swab was positive in 29 (34.1%) cases and the ONP swab in 20 (23.5%) cases. Both methods produced positive results in 11 (14.1%) cases. The mean cycle threshold (Ct ) value was 30.15 ± 3.41 in symptomatic cases and 33.62 ± 1.76 in asymptomatic cases (p = .008). The mean Ct value was 24.37 ± 3.48 when only the ONP swab was positive and 31.22 ± 1.99 when only the conjunctiva swab was positive. In cases that were positive by both methods, the mean Ct value was 25.21 ± 4.94 for the ONP swab and 30.29 ± 5.05 for the conjunctiva swab. We found higher SARS-CoV-2 detection rates with the conjunctiva swab than the ONP swab in cases with unknown SARS-CoV-2 status in the early period. In addition, the conjunctival viral load seemed to be higher in symptomatic cases than in asymptomatic cases. We, therefore, believe a conjunctiva swab could be an alternative method to detect SARS-CoV-2 at the time of the first presentation to the outpatient department.

Evidence-based of conjunctival COVID-19 positivity: An Italian experience: Gemelli Against COVID Group.

BACKGROUND: The possible transmission of severe acute respiratory coronavirus 2 (SARS-CoV-2) by tears and conjunctiva is still debated. METHODS: Main outcome was to investigate the agreement between nasopharyngeal swab (NPs) and conjunctival swabs (Cs) in patients with SARS-CoV-2 infection. We divided patients into four groups: (1) NPs and Cs both negative (C-NF-), (2) NPs positive and Cs negative (NFs+Cs-), (3) NPs negative and Cs positive (NFs-Cs+), and (4) NPs and Cs both positive (NFs-Cs+). The secondary outcomes were to correlate Cs results with systemic clinical parameters such as: oxygen saturation (SpO2), dyspnea degree (DP), radiologic pulmonary impairment based on chest radiography (XR) or computed tomography (CT), blood chemistry as D-Dimer (D-Dimer), fibrinogen, ferritin, lactate dehydrogenase (LDH), and C-reactive protein (C-RP). RESULTS: A total of 100 conjunctival swabs in 50 patients with SARS-CoV-2 have been enrolled in this interventional clinical trials. Ocular signs (conjunctivitis) were present in five patients (10%). NPs and Cs highlighted a poor level of agreement (0.025; p = 0.404). Median SpO2 levels are the highest in the NF-C- group (98%) and the lowest (90%) in the group NF+C+ (p = 0.001). Pulmonary impairment was statistically significantly different between NFs and Cs groups (p = 0.019). Pulmonary impairment score increased from NFs-Cs- group (3.8 ± 3.9), to NFs+Cs+ group (6.7 ± 4.1). Intensive care unit patients showed higher COVID-19 Cs positivity in conjunctiva (12.5%) against hospitalized ones (5.8%). CONCLUSIONS: In patients hospitalized for SARS-CoV-2 the virus can be detected in conjunctival swab. Intensive care unit patients may reveal a higher COVID-19 presence in the conjunctiva. The most severe pulmonary impairment can be observed in NFs and Cs positivity. TRIAL REGISTRATION: Clinicaltrials.gov registration. ETHICAL COMMITTEE AUTHORIZATION: ID number: 0013008/20.

Identification of SARS-CoV-2 RNA in the conjunctival swab of an Italian pediatric patient affected with COVID-19: A case report.

INTRODUCTION: To report a case of identification of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) RNA in ocular specimen in a pediatric patient affected with Coronavirus disease 2019 (COVID-19) with no signs of ocular involvement. CASE DESCRIPTION: A 11-year old male patient with confirmed COVID-19 infection was hospitalized at the Pediatric Clinic Clinic of the IRCCS Foundation and Hospital San Matteo, Pavia, Italy. Three days after hospital admission, because of the patient complaining very mild ocular symptoms, an ophthalmological evaluation was performed. No signs related to conjunctivitis or keratitis were found but a conjunctival swab was collected as well, based on patient's medical history. The specific SARS-CoV-2 reverse transcription PCR (RT-PCR) was performed, unearthing the presence of viral RNA from the swab. On day 25 from hospitalization, the conjunctival swab was repeated, giving negative result. CONCLUSIONS: This is the first report of the identification of SARS-CoV-2 RNA in ocular specimen in a pediatric patient without signs of ocular involvement. However, despite the transmission through tears is theoretically possible, it is still unclear whether this could be considered as an important route for the spread of SARS-CoV-2.

Evaluation of SARS-CoV-2 in Tears of Patients with Moderate to Severe COVID-19.

PURPOSE: To investigate the presence of SARS-CoV-2 RNA in tears of patients with moderate to severe coronavirus disease 2019 (COVID-19). DESIGN: Cross-sectional study. PARTICIPANTS: Patients with laboratory-proven moderate to severe COVID-19. METHODS: Tears were collected within 48 hours of laboratory confirmation using 3 methods: conjunctival swab plus Schirmer's test strips (group 1), conjunctival swab (group 2), and Schirmer's test strips (group 3). Samples from both the eyes of each patient were transported in a single viral transport media for real-time RT-PCR. Detailed demographic profiles, systemic symptoms, comorbidities, and ocular manifestations were noted. MAIN OUTCOME MEASURES: Viral load of a sample was determined using cycle threshold (Ct) value of E gene. A specimen was considered to show positive results if the amplification curve for the E gene crossed the threshold line within 35 cycles and if it showed positive results on an RNA-dependent RNA polymerase or open reading frame 1b gene assay. RESULTS: Of the 78 patients enrolled in the study, samples from 3 patients were found to be inadequate for analysis. Thirty-six patients (48%) had moderate disease, whereas 39 patients (52%) had severe disease, with no ocular involvement in any patient. In the 75 patients, RT-PCR analysis of tears showed positive results in 18 patients (24%), and 29 of 225 samples (12.9%) showed positive results. Positive results were found in 11 (14.7%), 11 (14.7%), and 7 (9.3%) patients in groups 1, 2, and 3, respectively (P = 0.3105). Mean Ct values in groups 1, 2, and 3 were 28.36 ± 6.15, 29.00 ± 5.58, and 27.86 ± 6.46 (P = 0.92), respectively. Five patients showed positive RT-PCR results by all 3 methods (mean Ct value, 25.24 ± 6.33), and 12 patients showed positive results by any of the 3 methods (mean Ct value, 32.16 ± 1.94), the difference in Ct values being statistically significant (P = 0.029). The median value of symptomatology in patients with positive RT-PCR results from tears was 5 days (range, 4-9 days). CONCLUSIONS: SARS-CoV-2 RNA was detected in tears of 24% of patients with laboratory-proven moderate to severe COVID-19. Conjunctival swab remains the gold standard of tear collection for RT-PCR assay. A significantly higher possibility of viral transmission exists through tears in patients with moderate to severe COVID-19.

The implication of ocular manifestation of COVID-19 for medical staff and patients - systematic review.

INTRODUCTION: SARS-CoV-2 (severe acute respiratory syndrome-coronavirus-2) is a coronavirus that causes COVID-19 (coronavirus disease 2019) with mild to severe respiratory illness. It is a highly contagious disease transmitted through direct or indirect contact with infected people or contaminated surfaces, mainly through respiratory droplets, but other routes are being investigated. OBJECTIVE: It is known that coronaviruses (CoVs) can cause a variety of ocular pathologies in animals, including conjunctivitis, anterior uveitis, retinitis, and optic neuritis, many of which are severe. However, there is no evidence of the SARS-CoV-2 presence in the eye tissue of asymptomatic patients, even if the symptomatic incidence is low. This systematic review presents updated literature on this issue. ABBREVIATED DESCRIPTION OF THE STATE OF KNOWLEDGE: COVID-19 has now spread throughout the continents and poses a global threat to public health. The risk of rapidly overloading health care systems and causing substantial mortality worldwide is real. On 11 March 2020, the World Health Organization (WHO) announced coronavirus as a global pandemic. Several studies described a few cases with initial ocular symptoms followed by systemic symptoms of the disease. SUMMARY: Although the frequency of transmission of SARS-CoV-2 infection through the eye is low, ocular symptoms are not uncommon in COVID-19. In some cases, eye symptoms may be the first signs of illness. This implies the need for hygienic recommendations and use of personal protective equipment (PPE) for medical staff and other services to minimize COVID-19 infection of both health-care workers and patients. A triage for ophthalmic outpatient clinic is mandatory.

Evaluation of Conjunctival Swab PCR Results in Patients with SARS-CoV-2 Infection.

PURPOSE: The study objective was to identify severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA in conjunctival swabs from patients with confirmed SARS-CoV-2 infection. METHODS: Forty patients who tested positive by real-time reverse transcription (rRT)-polymerase chain reaction (PCR) of nasopharyngeal and oropharyngeal swabs were enrolled. Conjunctival swabbing was used to collect the tear and conjunctival secretions of patients. RESULTS: Conjunctival swab rRT-PCR was positive for three patients and negative for 37 patients. Ten of the patients (25%) were diagnosed with conjunctivitis during the ophthalmic examination. Of these patients, one was found positive by conjunctival swab rRT-PCR, and nine were found negative. The difference between patients who tested positive or negative using conjunctival swab rRT-PCR was without statistical significance in terms of the presence of conjunctivitis (p = .720). CONCLUSION: The rate of positivity from conjunctival swab rRT-PCR was 7.5% in patients with confirmed SARS-CoV-2 infection.