Ophthalmic Manifestations of Coronavirus Disease 2019 and Ocular Side Effects of Investigational Pharmacologic Agents

Daniel J. Olson; Arko Ghosh; Alice Yang Zhang


Curr Opin Ophthalmol. 2020;31(5):403-415. 

In This Article

Ocular Manifestations of Coronavirus Disease 2019

The incidence of ocular involvement in COVID-19 infections is rare. The presence of ocular signs or symptoms in the literature ranged between 0 and 31.6%.[20,22] Guan et al.[23] reported conjunctival congestion in nine of 1099 (0.8%) COVID-19-positive patients in the largest single study currently published that reported ocular manifestations. A meta-analysis including six studies, yielded a pooled prevalence of ocular involvement in 5.5% of study patients.[18] Other studies with higher reported prevalence of ocular involvement had considerably smaller study populations.

The most common ocular manifestation of COVID-19 infection is conjunctivitis with a combination of conjunctival injection, chemosis, hyperemia, clear ocular secretions, conjunctival follicles, and tender preauricular lymphadenopathy.[17,19,22–25] Patient reported symptoms include eye redness, itching, foreign body sensation, photophobia, and blurry vision.[26] Prior studies show that some coronaviruses can cause anterior uveitis, retinitis, and optic neuritis in murine and feline models,[17] but none of these have yet to have been reported in humans. As in epidemic keratoconjunctivitis (EKC), the severity of COVID-19 ocular presentation can vary considerably. Some patients report only mild eye irritation or redness while signs and symptoms on the opposite end of the spectrum can be quite severe. Cases of significant inflammation of the tarsal conjunctiva and hemorrhagic pseudomembranous conjunctivitis with petechiae and tarsal hemorrhages have been reported.[27,28] Cheema et al.[29] reported a patient with progressive subepithelial infiltrates with overlying epithelial defects and a pseudodendrite on the cornea in addition to eyelid swelling, mucous discharge, and conjunctival injection and follicles. The duration of symptoms is typically between 7 and 14 days, similar to that of EKC.[27,30] Neuro-ophthalmologic findings have also been found in COVID-19 patients, including Miller Fisher syndrome, polyneuritis cranialis, and cranial nerve palsy.[31,32]

While ocular manifestations of COVID-19 infection are uncommon, they should not be taken lightly and great caution should be taken when caring for patients with these symptoms. In a cross-sectional cohort study of 56 patients, 15 (27%) reported ocular symptoms, including sore eyes, itching, foreign body sensation, tearing, redness, dry eyes, eye secretions, and/or floaters. Among these, six individuals reported having these eye symptoms before they developed any fever or respiratory symptoms.[26] While it is not likely that floaters would be connected to COVID-19 infection, the remainder of these reported symptoms are consistent with conjunctivitis. Multiple case reports detail accounts of patients presenting to the ophthalmologist with conjunctivitis and no other symptoms of COVID-19 infection that were later found to be COVID-19 positive on PCR testing, some patients ultimately developing systemic symptoms while others did not.[30,33] This highlights the importance of using extreme caution and employing personal protective equipment when examining patients with conjunctivitis in a clinical setting. Ocular findings may be the only manifestation of a systemic COVID-19 infection and eye care professionals run the risk of not only becoming infected, but also infecting many patients in a high-risk population.

It is unclear what predisposes some patients to have ocular manifestations of their COVID-19 infections while do not. One proposed risk factor is the patient's overall infection severity and clinical picture, which was supported by three studies. Of patients with ocular findings, 60–87.5% were classified as severe or critical COVID-19 infections.[25,26,34] One possible explanation for this is that patients with more severe infections have an overall decreased ability to mount an immune response to the COVID-19 infection, leading to more organ systems being involved. Another possibility could be that patients with more severe respiratory infections aerosolize more virus particles around the eyes, resulting in an increased viral load on the ocular surface. Furthermore, severe infections often require supplemental oxygen or breathing support, which may lead to the redirection of oral secretions/droplets toward the eyes with poorly fitting ventilation masks. Additional research would be necessary to determine if ocular symptoms can be considered a poor prognostic factor or if patients with ocular symptoms tend to go on and develop worse respiratory symptoms.