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CLINICAL RELEVANCE This study identifies key signs and symptoms of acute conjunctivitis, that when combined with a point-of-care test, can improve clinician accuracy of diagnosing adenoviral conjunctivitis. BACKGROUND Adenoviral conjunctivitis is a common ocular infection with the potential for high economic impact due to widespread outbreaks and subsequent furloughs from work and school. In this report, we describe clinical signs and participant-reported symptoms that most accurately identify polymerase chain reaction (PCR)-confirmed adenoviral conjunctivitis. METHODS Adults with 'red eye' symptoms of four days or less were enrolled. Participants rated 10 ocular symptoms from 0 (not bothersome) to 10 (very bothersome), and indicated the presence or absence of systemic flu-like symptoms. Clinicians determined the presence or absence of swollen lymph nodes and rated the severity of eight ocular signs using a 5-point scale. An immunoassay targeting adenovirus antigen was utilised for the point-of-care test, and conjunctival swab samples were obtained for subsequent adenovirus detection by PCR analyses. Univariate and multivariate logistic regression models were used to identify symptoms and signs associated with PCR-confirmed adenoviral conjunctivitis. The diagnostic accuracy of these clinical findings, and the potential benefit of incorporating point-of-care test results, was assessed by calculating areas under the receiver operating characteristic curves (AUC). RESULTS Clinician-rated bulbar conjunctival redness, participant-rated eyelid swelling and overall ocular discomfort had the best predictive value in the multivariate logistic regression model with an AUC of 0.83. The addition of the point-of-care test results to these three clinical sign/symptom scores improved diagnostic accuracy, increasing the AUC to 0.94. CONCLUSIONS Conjunctival redness severity and participant-reported eyelid swelling and overall discomfort, along with adenoviral point-of-care test results, were highly predictive in identifying individuals with PCR-confirmed adenoviral conjunctivitis. Improved diagnostic accuracy by clinicians at the initial presenting visit could prevent unnecessary work furloughs and facilitate earlier treatment decisions.

Purpose Epidemic keratoconjunctivitis (EKC) is one of the most severe ocular viral infections. The aim of this interruptive time series study was to quantitatively evaluate the effectiveness of a hygienic EKC outbreak management concept developed in our ophthalmological department. Methods All patients with suspected EKC in the period from August to November 2018 were included in the study. Data were retrospectively collected from the patient’s medical documents and records. The disease was diagnosed clinically and confirmed by virus detection through polymerase chain reaction (PCR) from conjunctival swabs. With the beginning of the epidemic, an outbreak management plan was implemented to reduce the nosocomial spread. Results The outbreak lasted 77 days (20th August 2018 to 4th November 2018) and affected a total of 120 patients. This corresponds to a mean of 1.5 patients per outbreak day. The median age was 58 [1–92] years. Of all patients, 61 (50.8%) were female. Conjunctival swabs were collected in 100/120 (83.3%) cases, the adenovirus being detected in all positive smears (63/63, 100%). The implementation of our outbreak management plan reduced significantly the number of EKC cases per outbreak day and resulted in a reduction of the basic reproduction number by a factor of 2.2. Conclusion The detection of EKC together with the immediate implementation of hygienic outbreak measures can significantly reduce the spread of infection. The implementation of a strict outbreak management concept can significantly reduce the number of EKC cases, thus avoiding possible complications and therefore unnecessary health-related costs.

Purpose: To evaluate the presence of SARS-CoV-2 in conjunctival secretions of COVID-19 patients.Material and Methods: In this retrospective study, the records were examined of patients who were treated in the hospital with the diagnosis of COVID-19 between March-May 2020 and were referred to the eye clinic due to ocular symptoms. Conjunctival swabs from both confirmed and suspected COVID-19 cases during hospitalization were analyzed.Results: A total of 35 patients (22 suspected, 13 laboratory-confirmed COVID-19) were referred to the eye clinic. Conjunctival swab samples from 3 patients yielded positive PCR results. These three patients were being treated in the intensive care unit, and all were suspected COVID-19 patients.Conclusion: SARS-CoV-2 may be detected in patients with suspected COVID-19. Even with conjunctivitis findings, SARS-CoV-2 may not be detected in most conjunctiva swab samples of COVID-19 patients.

Significance The effectiveness of masking is rarely evaluated or reported in single- or double-masked clinical trials. Knowledge of treatment assignment by participants and clinicians can bias the assessment of treatment efficacy. Purpose This study aimed to evaluate the effectiveness of masking in a double-masked trial of 5% povidone-iodine for the treatment of adenoviral conjunctivitis. Methods The Reducing Adenoviral Patient Infected Days study is a double-masked, randomized trial comparing a one-time, in-office administration of 5% povidone-iodine with artificial tears for the treatment of adenoviral conjunctivitis. Masking was assessed by asking participants and masked clinicians at designated time points if they believed the treatment administered was povidone-iodine or artificial tears, or if they were unsure. Adequacy of masking was quantified using a modified Bang Blinding Index. Results Immediately after treatment, 34% of participants who received povidone-iodine and 69% of those who received artificial tears guessed incorrectly or were unsure of their treatment (modified Bang Indices of 0.31 and -0.38, respectively). On day 4, 38% of the povidone-iodine participants and 52% of the artificial tear participants guessed incorrectly or were unsure of their treatment (modified Bang Indices of 0.24 and -0.05, respectively), indicating adequate and ideal masking. On days 1, 4, 7, 14, and 21, masked clinicians guessed incorrectly or were unsure of treatment in 53%, 50%, 40%, 39%, and 42% among povidone-iodine participants compared with 44%, 35%, 38%, 35%, and 39% among artificial tears participants, respectively. The modified Bang Indices for clinician masking in the povidone-iodine group ranged from -0.05 to 0.25 and from 0.13 to 0.29 in the artificial tears group. Conclusions Masking of participants and clinicians was adequate. Successful masking increases confidence that subjective measurements are not biased. We recommend quantitative assessment and reporting the effectiveness of masking in ophthalmic clinical trials.

The coronavirus disease 2019 global pandemic is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Several ophthalmic manifestations have been reported to be associated with SARS-CoV-2 infection, including conjunctivitis, acute sixth nerve palsy, and multiple cranial neuropathies. We present a unique case of unilateral phlyctenular keratoconjunctivitis in a 5-year-old boy in the setting of SARS-CoV-2 infection.

AimsTo describe the clinical profile of epidemic keratoconjunctivitis (EKC) in patients presenting to a multitier ophthalmology hospital network in India.MethodsThis retrospective hospital-based study included 2 408 819 patients presenting between August 2010 and February 2020. Patients with a clinical diagnosis of EKC in at least one eye with a recent onset (≤1 week) were included as cases. The data were collected using the eyeSmart electronic medical record system.ResultsOverall, 21 196 (0.9%) new patients were diagnosed with EKC, of which 19 203 (90.6%) patients reported a recent onset (≤1 week) and were included for analysis. The median age was 32 (IQR: 22–45) years and adults (84.5%) were commonly affected. Most of the patients were male (62.1%) and unilateral (53.4%) affliction was commoner. The most common presenting symptom was redness (63.7%), followed by watering (42.1%). Preauricular lymphadenopathy or tenderness was documented in 1406 (7.3%) cases at presentation. A minority of the eyes had visual impairment worse than 20/200 (7.8%) due to associated ocular comorbidities. The involvement of the cornea was seen in 7338 (38.2%) patients and corneal signs included subepithelial infiltrates (26.3%), epithelial defect (1.4%), corneal oedema (0.9%) and filaments (0.4%). Of the patients who had corneal involvement, 496 (2.6%) patients had a chronic course beyond 1 month of which 105 (0.5%) had a course beyond 1 year.ConclusionEKC is a self-limiting condition that is commonly unilateral and predominantly affects males. About one-third of the patients have corneal involvement which rarely has a chronic course.

Purpose: To describe the incidence, duration, and complication rate of patients with a clinical diagnosis of pseudomembranous viral conjunctivitis. Methods: A retrospective observational study is performed compiling the data of patients diagnosed as pseudomembranous conjunctivitis at the hospital’s emergency department from June 2016 to May 2018. Demographic variables, duration of symptoms, and follow-up until resolution of the pseudomembranes and associated complications are collected. Results: The incidence rate of pseudomembranous conjunctivitis is 3.47/10,000 people-year and 0.123% of emergency department consultations. The incidence of pseudomembranous conjunctivitis is approximately 20% of the total adenoviral conjunctivitis, with similar peak incidence rates and annual distribution. The presence of pseudomembranes shows a mean duration of 7.86 days. In this series of pseudomembranous patients, 38.4% had at least one of the following complications: 16.7% subepithelial infiltrates (IC 13.0%–21.1%), 20.81% corneal erosions (SE 0.0218, IC 16.7%–25.5%), 3.5% filamentary keratitis (SE 0.010, IC 1.8%–6.0%), and 6.1% subtarsal fibrosis (SE 0.128, IC 3.8%–9.1%). Conclusion: To the best of our knowledge, this is the first study to investigate the incidence and rate of complications of pseudomembranous conjunctivitis. Complications occurred in almost 4 out of 10 patients. The mean duration of the follow-up in the ED was higher in patients with any complication compared with non-complicated patients. The high complication rate makes a closely follow-up advisable, until pseudomembrane resolution, to assess possible complications and symptomatic treatment.

COVID-19 is caused by the coronavirus SARS-CoV-2. Ocular manifestations have been reported including conjunctivitis and retinal changes. Therefore, it is of the utmost importance to clarify eye involvement in COVID-19 in order to help with its diagnosis and to further prevent its transmission. The purpose of this review is to describe the structure and transmission of SARS-CoV-2, reported ocular findings and protection strategies for ophthalmologists.Literature search on PubMed for relevant articles using the keywords 'COVID-19', 'coronavirus', and 'SARS-CoV-2' in conjunction with 'ophthalmology' and 'eye'. Moreover, official recommendations of ophthalmological societies were reviewed.Although the conjunctiva is directly exposed to extraocular pathogens, and the mucosa of the ocular surface and upper respiratory tract are connected by the nasolacrimal duct, the eye is rarely involved in human SARS-CoV-2 infection and the SARS-CoV-2 RNA positive rate by RT-PCR test in tears and conjunctival secretions from patients with COVID-19 is also extremely low.The eye can be affected by SARS-CoV-2, which is supported by some reports of conjunctivitis and retinal changes, but its role in the spread of the disease is still unknown.Given the current scarce evidence, more research is needed to clarify the relationship between SARS-CoV-2 and the eye.Introdução: COVID-19 é o nome atribuído à doença causada pelo novo coronavírus - SARS-CoV-2. Esta infeção rapidamente atingiu uma disseminação mundial, face ao aumento da globalização e adaptação do vírus a ambientes distintos. Foram descritas manifestações oftalmológicas em doentes com COVID-19, nomeadamente, conjuntivite e alterações retinianas. Assim, é fundamental esclarecer o envolvimento ocular na COVID-19, contribuindo para o seu diagnóstico precoce e limitando a sua transmissão. O objetivo desta revisão é descrever a estrutura e o modo de transmissão do SARS-CoV-2, assim como manifestações oculares reportadas e estratégias de proteção para oftalmologistas. Material e Métodos: Revisão dos artigos relevantes publicados na PubMed usando as palavras-chave ‘COVID-19’, ‘coronavirus’ e ‘SARS-CoV-2’ em associação com as palavras ‘ophthalmology’ e ‘eye’. Além disso, foi feita uma revisão das recomendações oficiais de várias sociedades oftalmológicas a nível mundial. Resultados: Apesar da conjuntiva estar diretamente exposta a patógenos exógenos, e da mucosa da superfície ocular e do trato respiratório superior estarem conectados pelo canal nasolacrimal, o olho raramente parece ser afetado pelo SARS-CoV-2. A infeção por SARS-CoV-2 e a taxa de positividade para a pesquisa do RNA do SARS-CoV-2 pelo teste de RT-PCR em lágrimas e secreções conjuntivais de pacientes com COVID-19 também são extremamente baixas. Discussão: O olho pode ser afetado pelo SARS-CoV-2, dada a descrição de casos de conjuntivite e alterações retinianas, mas o seu papel na disseminação da doença ainda é desconhecido. Conclusão: Dada a escassa evidência atual, são necessários mais estudos para esclarecer a relação entre o SARS-CoV-2 e o globo ocular.

The main purpose of this study is to evaluate the presence of viral RNA of severe acute respiratory syndrome coronavirus‐2 (SARS‐CoV‐2) in conjunctival swab specimen of coronavirus disease 2019 (COVID‐19) patients with and without conjunctivitis to establish the diagnostic value of reverse transcription‐polymerase chain reaction (RT‐PCR) in each case and to describe its clinical characteristics. A cross‐sectional study was conducted at the Hospital Clinico San Carlos of Madrid, Spain. Thirty‐six subjects from the COVID admission unit with laboratory‐confirmed SARS‐CoV‐2 infection were included. Conjunctival swabs were collected from 18 patients with conjunctivitis and 18 patients without conjunctivitis and RT‐PCR was performed. Conjunctival swab was collected from both eyes of 36 patients (72 eyes), detecting SARS‐CoV‐2 RNA in conjunctival swab of two patients (5.5%). Among the 18 patients with conjunctivitis, only one of them (5.5%) showed positive results. Likewise, SARS‐CoV‐2 RNA was detected in one patient without conjunctivitis (5.5%). The mean age of the 36 patients was 67.9 years (range, 28‐92 years) and the male‐to‐female ratio was 0.44 (16:20). The mean days since the onset of COVID‐19 symptoms until conjunctivitis manifestation was 8 (range, 1‐24 days). The mean duration of the conjunctivitis was 3 days (range, 1‐7 days). SARS‐CoV‐2 RNA may be detected in conjunctival swabs of both patients with and without conjunctivitis. This study revealed the same rate of positive results amongst the group with and without conjunctivitis, suggesting that detecting SARS‐CoV‐2 in ocular fluids is not conditioned on the presence of conjunctivitis. The presence of SARS‐CoV‐2 RNA in ocular samples highlights the role of the eye as a possible route of transmission of the disease., Highlights SARS‐CoV‐2 RNA can be detected in conjunctival secretions of both patients with and without conjunctivitis. However, PCR essay of tears and conjunctival secretions appear to have a fairly low potential of detecting the virus.

Purpose: To present a patient with bilateral conjunctivitis, testing positive for viral RNA of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in both nasopharyngeal and conjunctival samples. Methods: A 40-year-old man with bilateral acute conjunctivitis and suspicious signs of coronavirus disease 2019 (COVID-19) presented to the hospital. A detailed ophthalmic examination was performed. Samples obtained from conjunctival and nasopharyngeal swabs were tested by reverse transcription PCR (RT-PCR) for the detection of SARS-CoV-2 virus. Ocular findings and duration of the presence of viral RNA in the conjunctival specimens were evaluated at follow-up visits. Results: Slit-lamp biomicroscopy revealed bilateral acute follicular conjunctivitis. The RT-PCR assay demonstrated the presence of viral RNA in the nasopharyngeal and conjunctival specimens at the initial visit and at the 4-day follow-up. Conjunctivitis findings were decreased after 4 days and recovered completely without any sequelae within10 days. The PCR results of both nasopharyngeal and conjunctiva specimens were negative for the viral RNA at 10 days. Conclusions: Bilateral conjunctivitis is rare in patients infected with COVID-19. Although it is difficult to detect viral RNA from conjunctival swabs, conjunctival secretions may be a source of contamination, and protective measures must be taken.

To evaluate ocular findings in patients with Coronavirus Disease 2019 (COVID-19) in the Northeast of Iran.In a cross-sectional, observational study all consecutive patients with confirmed COVID-19 diagnosis at the central referral center of these patients in northeast of Iran were included. Ocular examinations (external and slit) were randomly performed for the patients who were admitted to the Intensive Care Unit (ICU) and six COVID wards of the hospital. Moreover, Chart records and serum chemistry results were collected.A total of 142 patients with the mean age of 62.6 ± 15 years (range: 23-96 years) and almost equal gender distribution (male: N = 77, 54.2%) were included in the study. During the initial external examination by the ophthalmologist, 44 (31%) patients were found to have conjunctival hyperemia and 22 (15.5%) patients had chemosis. Consecutive slit examination showed 41 (28.9%) conjunctival hyperemia, 22 (15.5%) chemosis, 11 (7.7%) cataract, and 9 (6.3%) diabetic retinopathy. The patients with at least one ocular manifestation had significantly higher blood urea levels at the time of admission compared to those with no obvious ocular involvement (median: 41.5, IQR: 28-66.3 vs. median: 33, IQR: 23.8-51.8,Ocular manifestation was observed in more than half of our COVID-19 patients. Hence, it seems important to involve ophthalmologist in the diagnosis and management of these patients.

Purpose Coronavirus disease 2019 (COVID-19) is an ongoing global public health problem, and most of the COVID-19 research is focused mainly on the respiratory system because of life-threatening results. However, manifestations in other organs should not be ignored since they can also be a mode of transmission. We sought to describe the ocular manifestations of COVID-19 and investigate the association between ocular involvement and clinical presentation and laboratory outcomes. Methods This cross-sectional study was conducted between March 1, 2020, and April 30, 2020. Ninety-three sequentially hospitalized and clinically confirmed COVID-19 patients were included in the study. The systemic and ocular symptoms, clinical findings, and laboratory outcomes were recorded. Results Of the 93 COVID-19 patients, 54 (58.1%) were male, and 39 (41.9%) were female. Mean age of the patients was 39.4 ± 21.9 (min 7, max 88) years. Twenty patients (n 21.5%) had at least one ocular abnormality. Most common findings included hyperemia (n = 20), epiphora (n = 9), increased secretion (n = 6), chemosis (n = 3), follicular conjunctivitis (n = 2), and episcleritis (n = 2). The most common symptom was photophobia (n 15). Patients with ocular involvement were more likely to have higher neutrophil counts (p = 0.001), and increased CRP (p < 0.001), PCT (p = 0.001), and ESR levels (p < 0.001). Mean lymphocyte count was statistically lower in patients with ocular manifestations (p = 0.001). Mean age and number of patients with fever over 37.3 °C in the ocular involvement group was found to be higher (p < 0.001, p = 0.006, respectively). Conclusion Older age, high fever, increased neutrophil/lymphocyte ratio, and high levels of acute phase reactants seemed to be risk factors for ocular involvement.

Coronavirus disease 19 (COVID-19) has been described to potentially be complicated by ocular involvement. However, scant information is available regarding severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) and ocular structures tropism. We conducted a systematic review of articles referenced in PubMed, Cochrane Library, Web of Science and Chinese Clinical Trial Register (ChiCTR) from December 20, 2019 to April 6, 2020, providing information on the presence of SARS-CoV-2 in cornea, conjunctiva, lacrimal sac, and tears. We excluded ongoing clinical studies as for unobtainable conclusive results. Of 2422 articles, 11 met the inclusion criteria for analysis and were included in the study. None of the studies were multinational. Among the 11 selected papers there were three original articles, one review, four letters, two editorials, and one correspondence letter. Globally, 252 SARS-CoV-2 infected patients were included in our review. The prevalence of ocular conjunctivitis complicating the course of COVID-19 was demonstrated to be as high as 32% in one study only. Globally, three patients had conjunctivitis with a positive tear-PCR, 8 patients had positive tear-PCR in the absence of conjunctivitis, and 14 had conjunctivitis with negative tear-PCR. The majority of the available data regarding SARS-CoV-2 colonization of ocular and periocular tissues and secretions have to be considered controversial. However, it cannot be excluded that SARS-CoV-2 could both infect the eye and the surrounding structures. SARS-CoV-2 may use ocular structure as an additional transmission route, as demonstrated by the COVID-19 patients' conjunctival secretion and tears positivity to reverse transcriptase-PCR SARS-CoV-2-RNA assay.摘要: 据报道, 冠状病毒疾病-19 (Coronavirus disease 19, COVID-19) 可能因潜在的眼部并发症而变得复杂。然而, 关于重症急性呼吸综合征冠状病毒2型 (Severe Acute Respiratory Syndrome-Coronavirus-2, SARS-CoV-2) 和眼部结构嗜性的信息却很少。我们对2019年12月20日至2020年4月6日在PubMed、Cochrane数据库、科学网和中国临床试验注册中心 (Chinese Clinical Trial Register, ChiCTR)所收录的文章进行了系统回顾, 以提供SARS-CoV-2在角膜、结膜、泪囊和泪液中存在的信息。由于无法获得确定的结果, 我们排除了正在进行的临床试验。在2422篇文章中, 11篇符合纳入标准。这些研究均不是跨国性的。在11篇入选论文中, 有3篇原创文章、1篇综述、4篇快报、2篇社论和1篇通信信函。本文纳入全球范围内252名感染SARS-CoV-2患者。仅一项研究阐述了COVID-19病程中并发眼结膜炎的患病率高达32%。在全部样本中, 有3例结膜炎患者泪液PCR反应呈阳性, 8例无结膜炎患者泪液PCR反应呈阳性, 14例结膜炎患者泪液PCR反应呈阴性。关于SARS-CoV-2在眼部、眼周组织及分泌物中定植的大多数数据目前尚有争议。然而, 不能排除SARS-CoV-2可能感染眼部及其周围结构, 眼部可作为SARS-CoV-2额外的传播途径, 因为COVID-19患者的结膜分泌物和泪液中SARS-CoV-2-RNA逆转录PCR检测呈阳性.

Background The current outbreak of COVID‐19 has spread rapidly all over the world. Respiratory droplets and contaction with infected patients are the two major transmission routes. However, the value of tear virus nucleic acid is still not clear. We dynamic detected the SARS‐CoV‐2 in eye sample of one COVID‐19 patient with obstruction of common lacrimal ducts. Methods Besides the routine examination, nasopharyngeal and eye swab were continuously measured by polymerase chain reaction assay and next‐generation sequencing (NGS). Gene detection was performed for drug use guidance, and flow cytometry was performed to analyse the lymphocyte subsets. Results Nasopharyngeal swabs were positive for 22 days, but eye swabs were still continuously positive for 2 weeks after nasopharyngeal swabs turned negative. The low level of lymphocyte and the high level IL‐6 lasted for almost 4 weeks, then became near normal. Next‐generation sequencing (NGS) confirmed the existing of SARS‐CoV‐2, HSV1 and HHV6B virus nucleic acid. The gene detection for drug use guidance showed the genetic locus ABCB1 (3435T>C) rs1045642 belonged to type CC and it mean the efficiency of lopinavir–ritonavir would be significantly decreased. The flow cytometry of lymphocyte subsets showed PD‐1+ CD95+ cells was accounting for 94.8% in CD3+ CD8+ T subset and for 94.8% in CD3+ TCRγδ+ T subset. Conclusions As obstruction of common lacrimal duct, positively detection in one eye for 2 weeks more after nasopharyngeal swab became negative. More eye swabs should be collected from COVID‐19 patients, especially from those immunocompromised, those with eye symptoms and those had a history of ocular diseases.

Purpose: To evaluate and establishe the number of patients with ocular manifestations in the early phase of systemic COVID-19 infection.Methods: A cross-sectional study was performed in a COVID-19 referral center regarding ocular findings in patients with COVID-19 in the first few days of the disease. The patients were submitted to a clinical examination, an ophthalmic exam and a RT-PCR for SARS-COV-2.Results: Out of 1740 patients, we reported 108 patients with ocular manifestations. Forty-nine with markedly conjunctivitis had conjunctival swab positive for SARS-COV-2, four of them developed keratitis. There were mostly no evidence of retinopathy nor decrease in visual acuity. They had no marked clinical symptoms, which can contribute and demonstrate that the virus may cause ocular disease as an only finding or in the very early stage of the infection.Conclusion: Patients were in the first days of COVID-19 infection, presented ocular manifestations suggested to be related to the virus and need to be aware of the pathways of transmissions.

The novel pandemic coronavirus disease 2019 (COVID-19) leading to health and economic problems worldwide is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Although COVID-19 mainly occurs as a lower respiratory tract infection, there is multiorgan involvement in infected patients. The disease is transmitted from person to person through air droplets or contact with contaminated surfaces. SARS-CoV-2 leads to this systemic involvement by attaching to angiotensin-converting enzyme 2 (ACE2) receptors located on several human cells. Since SARS-CoV-2 RNA has been found in tears of infected patients, ocular surface may allow the virus to transmit to nasopharynx via the nasolacrimal duct. This narrative review aims to sum up all segmental ocular complications, ocular adverse effects of COVID-19 treatment, and preventive measures suggested to minimize the SARS-CoV-2 transmission between patients and ophthalmologists by reviewing currently available literature.

Highlights • Mucocutaneous manifestations of MIS-C: conjunctivitis, oral mucosal changes, rash. • The rash of MIS-C is typically diffuse and non-specific. • Mucocutaneous manifestations of MIS-C are more common in younger children. • KD and MIS-C differ in mean age of onset, race predilection, and associated symptoms., As of May 2020, an emerging immune-mediated syndrome primarily affecting children has been detected primarily in Europe and the United States. The incidence of this syndrome appears to mirror the initial infectious assault with a delay of several weeks. This syndrome has been termed multisystem inflammatory syndrome in children (MIS-C), and is observed in association with the coronavirus disease 2019 (COVID-19). The phenotypes of presentation include several characteristic features, including prolonged fever, skin eruptions, neck stiffness, and gastrointestinal manifestations with pronounced abdominal pain. Shock and organ dysfunction on presentation are frequent but inconsistent, while respiratory distress is typically, and notably, absent. We have reviewed the recent published data aiming to better understanding MIS-C, with a focus on its mucocutaneous manifestations.

Purpose To evaluate the ocular surface properties in epidemic keratoconjunctivitis (EKC) patients during healing process, and to detect the damage on conjunctival goblet cells. Methods Bilateral EKC patients confirmed with polymerase chain reaction (PCR) testing were included. Firstly (Group 1) and secondly (Group 2) affected eyes were compared. Ocular surface parameters were performed at the first visit and first month. Results The study included 34 eyes of 17 patients. The mean age was 44.54 +/- 16.80 (21-70) years (FM/M 20/14). The ocular findings in Groups 1 and 2 were not significant. For Groups 1 and 2, OSDI was 53.53 +/- 23.01 and 35.90 +/- 22.19 (p 0.03), tear osmolarity was 309.12 +/- 19.38 and 297.47 +/- 8.27 mOsm/mu L (p 0.029), OSSS was 1.00 +/- 0.79 and 0.18 +/- 0.39 (p 0.001), T-BUT was 3.59 +/- 2.29 and 6.00 +/- 1.83 s (p 0.002), and Schirmer's 1 test was 10.94 +/- 8.42 and 16.76 +/- 9.05 mm (p 0.061), respectively. In Groups 1 and 2, the IC was Grade (G) 0 in 23.5% and 17.6%, G1 in 35.3% and 41.2%, and G2 in 41.2% and 41.2%, respectively. The ocular surface properties were worse in Group 1 than Group 2, and the difference was significant except for Schirmer's 1 test and IC. Conclusions Dry eye disorder is a complication of EKC and may cause a significant decrease in quality of life.

As the understanding of COVID-19 infection becomes better, it is being recognized as a complex multisystem pathology rather than just affecting the lungs. Several ocular findings have been documented by researchers in individuals infected with COVID-19, and ocular symptoms may even be the first presenting feature of COVID-19 infection in 2.26% individuals. Several countries have started vaccination with inactivated or live vaccines to combat this pandemic, and varied side effects have been reported after vaccination. Few cases of herpes zoster have previously been reported in elderly patients with comorbidities after receiving COVID-19 vaccines. In this article, the authors described 2 interesting cases of herpes zoster ophthalmicus (HZO) after receiving a live COVID-19 vaccine. The first case was a 35-year-old immunocompetent man who developed HZO 3 days postvaccine. The second case was a 40-year-old immunocompetent man who developed HZO 28 days postvaccine. To the best of our knowledge, no literature to date has described HZO after live vaccine.

Purpose: Although acute conjunctivitis has been listed from the beginning as a possible sign of COVID-19, the likelihood of this association remains unclear. The aim of this study was to investigate the relationship between COVID-19 and conjunctivitis. Methods: In this retrospective, observational study, we recruited all patients with signs and symptoms of acute conjunctivitis seen at the Eye Emergency Department (ED), Turin Eye Hospital, between 01/01/2020 and 12/05/2020 and cross-checked our data with the Piedmont Region online COVID-19 registry in the same period. Results: Among 10,065 patients seen at our ED during the timespan considered, 88 underwent a nasopharyngeal swab (NS) for SARS-CoV-2 detection within 4 weeks before/after our examination. On average, NS was performed −0.72 ± 1.8 weeks before/after eye examination. Of the 77 patients with a negative NS, 26 (33.8%) had a diagnosis of acute conjunctivitis, whereas the remaining 51 (66.2%) had other eye disorders. Among the 11 patients with COVID-19, 7 (63,6%) had a diagnosis of acute conjunctivitis. We found a non-statistically significant increase in NS positivity rate (21.2%) among cases examined at our ED for acute conjunctivitis, compared to the NS positivity rate (7.3%) in patients examined for all other eye conditions ( p = 0.092). The Odds Ratio of having a positive NS in patients with acute conjunctivitis was 3.43 (95% I.C. = 0.9–12.8, p = 0.06). Considering online-registry data of Turin population during the same time-span, among 2441 positive NS cases only 27 (1.1%) presented with acute conjunctivitis. Conclusion: Our results do not reveal a statistically significant correlation between COVID-19 and acute conjunctivitis. Synopsis The present study analyzes retrospectively data from a tertiary eye referral center to investigate the relationship between COVID-19 infection and conjunctivitis.

To determine the characteristics of conjunctivitis associated with human adenovirus E4 (AdV E4).Samples and outcomes from 500 patients with conjunctivitis were obtained from the NVC-422 randomized controlled clinical trial comparing auriclosene to placebo. Molecular typing identified 36 cases associated with AdV E4. Signs and symptoms at presentation and at the day 18 endpoint were compared with the larger cohort of 262 subjects with conjunctivitis caused by due to AdV D8. Full viral genomes of 22 AdV E4 isolates were reconstructed.AdV E4 was the most frequently identified adenoviral type in conjunctivitis cases from the United States. Signs and symptoms at presentation were comparable to those associated with AdV D8. Viral load at presentation was comparable between groups but resolution was more rapid in the AdV E4 group. Clinical signs were fully resolved by day 18 in 26 of 36 (72%) patients with AdV E4. Subepithelial infiltrates developed in 12 of 36 (33%) patients with AdV E4 compared with 98 of 215 (45%) patients with AdV D8 (P = .0001). One hundred twenty-four polymorphisms were observed among 22 whole viral genome sequences, which clustered into 3 clades. Patients in each clade developed subepithelial infiltrates. Neither single nucleotide polymorphism analysis nor machine learning approaches identified specific sequence features predictive of presenting signs or outcome.AdV E4 conjunctivitis may be indistinguishable at presentation from AdV D8-associated disease. Resolution of viral load for AdV E4 appears more rapid than for AdV D8, and the risk for subepithelial infiltrates appears lower. Multiple substrains of AdV E4 are in circulation but all appeared equivalently pathogenic for conjunctivitis. NOTE: Publication of this article is sponsored by the American Ophthalmological Society.

Purpose This study was designed to detect CoV-RNA in the tears of polymerase chain reaction (PCR)-confirmed SARS-CoV-2 positive patients. Methods We performed a prospective case series study of hospitalized patients who have been confirmed SARS-CoV-2 positive by oropharyngeal swab within the previous 5 days. Tear samples obtained with a laboratory capillary and oropharyngeal swabs were analyzed by real-time PCR using the Altona SARS-CoV-2 Assay or the Roche SARS-CoV-2 LightMix PCR, depending on the availability. Patient history was documented, and ophthalmoscopy was used to assess for ocular surface disease. Results Of all 18 patients recruited in April 2020, 5 suffered from respiratory failure and were submitted to an intensive care unit. None of our patients had signs of viral conjunctivitis although all patients in intensive care showed chemosis and conjunctival hyperemia because of third-spacing or fluid overload. The presence of coronavirus RNA was confirmed by PCR in 5 of 18 patients (28%) in tears and 72% for oropharyngeal swabs. Conclusions Using a tear fluid sampling technique similar to oropharyngeal lavage presents a higher percentage of SARS-CoV-2 positive tears in contrast to earlier reports that used a conjunctival swab. This does not automatically indicate viral shedding in ocular tissue or contagiousness of tear fluid.

PURPOSE: To assess the effect of severe acute respiratory syndrome coronavirus-2 infection on the conjunctiva and tear film. METHODS: Thirty-eight patients with confirmed COVID-19 and 31 healthy controls were included in this prospective and observational study. Individuals with COVID-19 formed the patient group, and healthy individuals formed the control group. Conjunctival impression cytology (CIC), TBUT, Schirmer II test, and ocular surface disease index were evaluated in all participants. RESULTS: No significant difference was observed regarding the mean age and gender between the groups (P=0.786 and P=0.122, respectively). The mean TBUT and Schirmer II test results did not differ between the two groups (P=0.496 and P=0.447, respectively). The CIC results revealed decreased density and cell size of goblet cells and moderate to high enlargement, squamous changes, and increased nucleocytoplasmic ratio in nongoblet epithelial cells in the COVID-19 group compared with the control group. Based on the Nelson classification in CIC samples, 60.6% of the COVID-19 group and 19.4% of the control group had changes consistent with grade 2 or above. The presence of neutrophils in CIC was significantly higher in the COVID-19 group (P

PURPOSE: To report bilateral follicular conjunctivitis in two confirmed Coronavirus (COVID-19) patients with the presence of Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2) in conjunctival swab specimens. PARTICIPANTS AND METHODS: Two unrelated patients with confirmed SARS-CoV-2 infection and bilateral acute conjunctivitis were examined. Conjunctival swabs were assessed for the presence of SARS-CoV-2 by quantitative real-time polymerase chain reaction (RT-PCR) and viral culture. RESULTS: Both patients developed eye redness 3 days after the onset of COVID-19 symptoms. Slit lamp examination showed bilateral acute follicular conjunctivitis, which was resolved within 6 days. RT-PCR demonstrated the presence of viral RNA in conjunctival specimens from both eyes, which was unrelated to viral RNA from throat swabs. CONCLUSION: SARS-CoV-2 may cause ocular manifestations such as viral conjunctivitis. Conjunctival sampling may be useful for infected patients with conjunctivitis and fever. Precautionary measures are recommended when examining infected patients throughout the clinical course of the infection.

PURPOSE: The aim of this study was to investigate the ocular findings observed in patients with coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 and to present the relationship between ocular involvement, systemic findings, and laboratory results. MATERIAL AND METHODS: This cross-sectional study was carried out between 1 May and 30 June 2020. The study included 359 patients diagnosed with COVID-19 and assessed by clinical evaluation, nasopharyngeal polymerase chain reaction, and lung computed tomography. RESULTS: One hundred ninety-seven (54.9%) of the patients were male and 162 (45.1%) were female. The mean age of the patients was 58.5 years (20-91). Two hundred ninety-four (81.9%) patients were treated in the inpatient clinic and 65 (18.1%) patients were treated in the intensive care unit. Various ocular diseases were observed in 16 (4.5%) of the patients. Although the rate of ocular disease was 12 out of 294 (4.1%) in patients followed up in the inpatient clinic, this rate was 4 out of 65 (6.2%) in intensive care patients. There was no systemic problem in one patient, in whom conjunctival hyperemia was the first and only reason for admission to the hospital. Four patients followed up in the inpatient clinic had conjunctivitis at the time of admission, and conjunctivitis occurred in three patients during hospitalization. Subconjunctival hemorrhage occurred in five patients and vitreous hemorrhage in one patient. CONCLUSION: Ocular diseases are uncommon in COVID-19 patients but may occur during the first period of the disease or during follow-up. Ocular diseases may be the initial or only sign of COVID-19 infection.

The proximity required of a thorough biomicroscopic slit-lamp examination may put ophthalmologists at increased risk for respiratory-borne infection with SARS-CoV-2. Conjunctivitis has been described in a few patients with COVID-19 and other coronavirus syndromes. Although SARS-CoV-2 has been detected in the conjunctival secretions or tears of patients with COVID-19 and conjunctivitis, transmission of infection through respiratory droplets to ophthalmologists without eye protection or masks may be the bigger concern.

Background Since the outbreak of Coronavirus Disease 2019 (COVID-19) in December 2019, many studies have reported the presence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the conjunctival sac of patients infected with this virus, with several patients displaying symptoms of viral conjunctivitis. However, to our best knowledge, there is no in-depth report on the course of patients with COVID-19 complicated by relapsing viral conjunctivitis or keratoconjunctivitis. Case presentation A 53-year-old man confirmed with COVID-19 developed symptoms of viral conjunctivitis in the left eye approximately 10 days after the onset of COVID-19. The results of a nucleic acid test were positive for SARS-CoV-2 in the conjunctival sac of the left eye. The symptoms were relieved 6 days after treatment. However, the patient was subsequently diagnosed with viral keratoconjunctivitis in both eyes 5 days after the symptoms in the left eye were satisfactorily relieved. The disease progressed rapidly, with spot staining observed at the periphery of the corneal epithelium. Although SARS-CoV-2 could not be detected in conjunctival secretions, the levels of inflammatory factors, such as interleukin-6, were increased in both eyes. Both eyes were treated with glucocorticoids, and symptoms were controlled within 5 days. There was no recurrence. Conclusions In this case report, the pathogenesis, clinical manifestations, treatment, and outcome of a case with COVID-19 complicated by relapsing viral keratoconjunctivitis is described, and the involvement of topical cytokine surge in the pathogenesis of COVID-19 as it relates to viral keratoconjunctivitis is reported.

Purpose The purpose of this study was to evaluate the frequency and clinical presentation of conjunctivitis in hospitalized patients with COVID-19. Methods A cross-sectional study was conducted at the Hospital Clinico San Carlos of Madrid, Spain. A total of 301 subjects from the COVID admission unit with laboratory-confirmed SARS-CoV-2 infection were included. The presence and clinical characteristics of conjunctivitis were evaluated. Laboratory, radiological, and clinical results in patients with and without conjunctivitis stratified by sex were analyzed. Results Of the 301 subjects included, 180 patients (59.8%) were male and the median age was 72 years (IQ 59–82). Overall, 35 patients (11.6%) were diagnosed with acute conjunctivitis. We found no relationship between the COVID-19 severity score and the presence of conjunctivitis (P = 0.17). However, conjunctivitis was more frequent in males with moderate clinical severity and in women classified as clinically mild. The natural history of the disease seems to be a rapid self-limited conjunctivitis that improves without treatment and does not affect visual acuity nor associate short-term complications. Conclusions Approximately, 1 out of 10 hospitalized non-critical COVID-19 patients presents conjunctivitis during the disease. Compared with other viral conjunctivitis, we found distinctive clinical findings that could guide defining and differentiating conjunctivitis in COVID-19 patients. Trial registration number 20/336_E_COVID

We report here the case of a 27-year-old man who consulted by telemedicine during the Coronavirus disease 2019 (COVID-19) pandemic, due to foreign body sensation and left eye redness. Examination revealed unilateral eyelid edema and moderate conjunctival hyperemia. A few hours later, the patient experienced intense headache and developed fever, cough and severe dyspnea. A nasopharyngeal swab proved positive for SARS-CoV-2. This case demonstrates that conjunctivitis can be the inaugural manifestation of the COVID-19 infection. It illustrates the interest of telemedicine in ophthalmology during the COVID-19 pandemic, since moderate conjunctival hyperemia can be the first sign of a severe respiratory distress.

Purpose To investigate the ocular manifestations and clinical characteristics of COVID‐19 patients caused by SARS‐CoV‐2 in Wuhan, China. Methods A total of 535 COVID‐19 patients were recruited at Mobile Cabin Hospital and Tongji Hospital. Information on demographic characteristics, exposure history, ocular symptoms, eye drop medication, eye protections, chronic eye diseases, systemic concomitant symptoms, radiologic findings and SARS‐CoV‐2 detection in nasopharyngeal swabs by real‐time PCR was collected from questionnaires and electronic medical records. Results Of 535 patients, 27 patients (5.0%) presented with conjunctival congestion and 4 patients had conjunctival congestion as the initial symptom. The average duration of conjunctival congestion was 5.9 ± 4.5 days (mean [SD]). The other ocular symptoms, including increased conjunctival secretion, ocular pain, photophobia, dry eye and tearing, were also found in patients with conjunctival congestion. Notably, hand–eye contact was independently correlated with conjunctival congestion in COVID‐19 patients. We also found that some COVID‐19 patients had chronic eye diseases, including conjunctivitis (33, 6.2%), xerophthalmia (24, 4.5%) and keratitis (14, 2.6%). Similar to the published studies, the most common clinical symptoms were fever, cough and fatigue. A total of 343 patients (64.1%) had positive SARS‐CoV‐2 detection in nasopharyngeal swabs. Conclusions Conjunctival congestion is one of the COVID‐19‐related ocular symptoms, which could occur as the initial symptoms. Frequent hand–eye contact may be the risk factor for conjunctival congestion in COVID‐19 patients. Screening of patients with conjunctival congestion by ophthalmologists is advocated during the outbreak of COVID‐19. It is essential to provide eye‐care equipment and strengthen education on eye protection.

Purpose To compare efficiency and tolerance between topical 0.5% cyclosporine A (CSA) and fluorometholone (FML) for subepithelial infiltrates (SEI) complicating epidemic keratoconjunctivitis. Methods We conducted a prospective double-blind randomized study involving 72 eyes with SEI. Thirty-eight eyes were treated with topical FML (FML group) and 34 eyes with CSA 0.5% eye drops (CSA group). Treatment was considered successful in case of SEI reduction and visual acuity improvement. Tolerance was evaluated by Schirmer test value, burning on eye drops instillation, and conjunctival injection. Results Baseline characteristics of both groups were similar (P > 0.05). After 3 months of the regimen, resolution of SEI was 3 times more observed in the FML group than that in the CSA group (P = 0.026). After 6 months, resolution of SEI was observed in 70% of the FML group and in 47% of the CSA group (P = 0.068). The recurrence of SEI was almost twice higher in the FML group than that in the CSA group (16% vs. 9%). FML was better tolerated during the first 3 months: a higher Schirmer test value (P = 0.0003), less burning on instillation (P = 0.242), and less conjunctival injection (P = 0.003). For the rest of the follow-up period, the 2 groups were comparable in tolerance. No ocular hypertension was noted. Conclusions Epidemic keratoconjunctivitis can evolve favorably under both FML and CSA. The effect of FML is faster and CSA is more durable with fewer recurrences. Both are safe therapeutic options for long-term control of SEI.

Purpose To describe and explain the implications of COVID-19(SARS-CoV-2) for ophthalmologists in light of the rapid developments in our understanding of the virology, transmission and ocular involvement. Design Evidence-based perspective Methods Review and synthesis of pertinent literature Results Retrospective studies highlight that less than 1% of patients display COVID-19 related-conjunctivitis. However, prospective studies suggest the rate is higher, approximately 6%. Viral RNA has been identified in tears and conjunctival secretions in patients with active conjunctivitis as well as asymptomatic cases. Overall, conjunctival swabs are positive in 2.5%. Samples taken earlier in the disease course are more likely to demonstrate positive virus. Viral transmission through ocular tissues has not been substantiated. Ophthalmologists are in the high-risk category for COVID-19 infection for several reasons: high volume clinics, close proximity with patients, equipment intense clinics and direct contact with patients’ conjunctival mucosal surfaces. COVID-19 is predominantly contracted through direct or airborne transmission by inhalation of respiratory droplets. Evidence that aerosol transmission occurs is increasing in particularly prolonged exposure to high concentrations in a relatively closed environment. Based on the current evidence ophthalmologists should consider measures that include social distancing, wearing masks, sterilisation techniques and managing clinic volumes. Conclusions A major challenge to containing COVID-19 is that many infected people are asymptomatic. Droplet spread, contaminated environmental surfaces and shared medical devices are particular areas that require management by ophthalmologists. More studies are required to explore the role of the conjunctiva and ocular tissues in the transmission of disease.

Although current studies suggested that conjunctivitis is not a common presentation of coronavirus disease 2019 (COVID-19), several studies have reported the presence of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) in ocular secretions. Coronavirus had not yet been successfully cultured from tears or conjunctival swabs in humans, neither SARS-CoV-2 nor SARS-CoV. However, live feline coronavirus has been isolated from conjunctival swabs. In addition, infection of COVID-19 through unprotected eye exposure had been suspected in several articles. Reports of ophthalmologists and otolaryngologists died of COVID-19 also raised concern on ocular transmission. As a result, we strongly suggest that personal protective equipment (PPE) should cover the mouth, nose, and eyes of ophthalmologists, especially when conjunctivitis caused by SARS-CoV-2 is clinically indistinguishable from other viral follicular conjunctivitis.

The current coronavirus disease 2019 (COVID-19) pandemic is rapidly spreading around the world. The first doctor to report this new disease was an ophthalmologist: this exemplifies the role of ophthalmologists in an infectious disease pandemic. Here we review how severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) affects the eye and discuss implications for ophthalmologists.

PurposeTo report the ocular characteristics and the presence of viral RNA of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in conjunctival swab specimens in a patient with confirmed 2019 novel coronavirus disease (COVID-19).Participant and methodsA 30-year-old man with confirmed COVID-19 and bilateral acute conjunctivitis which occurred 13 days after illness onset. Based on detailed ophthalmic examination, reverse transcription PCR (RT-PCR) was performed to detect SARS-CoV-2 virus in conjunctival swabs. The ocular characteristics, presence of viral RNA and viral dynamics of SARS-CoV-2 in the conjunctival specimens were evaluated.ResultsSlit lamp examination showed bilateral acute follicular conjunctivitis. RT-PCR assay demonstrated the presence of viral RNA in conjunctival specimen 13 days after onset (cycle threshold value: 31). The conjunctival swab specimens remained positive for SARS-CoV-2 on 14 and 17 days after onset. On day 19, RT-PCR result was negative for SARS-CoV-2.ConclusionSARS-CoV-2 is capable of causing ocular complications such as viral conjunctivitis in the middle phase of illness. Precautionary measures are recommended when examining infected patients throughout the clinical course of the infection. However, conjunctival sampling might not be useful for early diagnosis because the virus may not appear initially in the conjunctiva.

Purpose To determine whether topical tobramycin 0.3%/dexamethasone 0.1% plus ozonized oil eye drops reduces clinical signs and infectious viral titers of presumed viral conjunctivitis more than tobramycin/dexamethasone eye drops alone. Methods Prospective, single-blind, randomized, parallel-groups trial. Eighty patients with a clinical diagnosis of presumed viral conjunctivitis were randomizedly divided into two treatment groups: a study group and a control group, 40 for each group. Patients in the study group received topical tobramycin 0.3%/dexamethasone 0.1% eye drops, plus ozonized oil eye drops, both four times daily; patients in the control group received only topical tobramycin 0.3%/dexamethasone eye drops four times daily. The treatment was for seven days in both groups. Swabs were taken from the conjunctival fornix for adenovirus PCR analysis on the day of recruitment and at seven days follow-up. Clinical signs were also recorded on the day of recruitment and at follow-up examination: the main outcomes were conjunctival injection and conjunctival chemosis, graded on a 4-point clinical scale, presence or absence of superficial punctate keratitis and subepithelial corneal infiltrates. Results No statistically significant difference was reached in adenoviral infection negativization between the two groups, although the study group showed a higher number of PCR negative results at seven days follow-up. PCR real time detected adenoviral infection in 17 of 24 patients on the day of recruitment and it was positive in 4 patients on the seventh day (viral positivity reduction of 76%). In the control group PCR was positive for adenovirus in 18 of 24 patients on the day of recruitment and in 7 patients at seven days follow-up (reduction of 61%). There was statistically significant difference on conjunctival clinical signs between the study and control groups. Significant difference was also found on superficial punctate keratitis resolution between the study and the control group. In the former superficial punctate keratitis was detected in 14 eyes on the first day and in 5 eyes after seven days while in the latter superficial punctate keratitis was found in 124 eyes on the first day and in 6 eyes on the seventh day. No difference was found in subepithelial corneal infiltrates appearance between the two groups. Conclusions The use of ozonized-oil containing eye drops in combination with topical tobramycin 0.3%/dexamethasone 0.1% eye drops four times daily seems to reduce the signs of conjunctivitis, and the duration of viral infection, although it does not affect the subepithelial corneal infiltrates appearance.

Herpes zoster ophthalmicus (HZO) has the potential to cause significant visual morbidity and functional disability in patients with recalcitrant disease, keratitis, and postherpetic neuralgia. This article will review the current methods of prevention and treatment of anterior segment-related chronic complications of HZO.HZO-related anterior segment ocular complications can range to include conjunctivitis, keratitis, and uveitis that can all be difficult to manage. Furthermore, many clinicians differ in their approach to disease management given the relative lack of large randomized controlled trials to guide therapy. The goal in managing complications of HZO is to reduce visual morbidity and to improve analgesia, and here, we present current recommendations for the management of anterior segment complications of HZO.Recent advances in vaccine technology and the initiation of the Zoster Eye Disease Study improve the possibility of reducing the burden of disease while also further standardizing management of HZO.

Background: Viral conjunctivitis are the most frequent infections in ophthalmology clinics. The diagnosis is usually relying on clinical findings and medical history. However, topical antibiotics are often used unnecessarily addition to symptomatic treatment because of unsure agents. We aimed to detect the Adenovirus, Coxsackievirus and Enterovirus from conjunctiva and pharyngeal samples of patients. Methods: The conjunctiva and pharyngeal samples of the patients with conjunctivitis were taken by Virocult transport media and kept at −80 ̊C up to study day. Adenovirus spp, Enterovirus 70 and Enterovirus 71, Coxsackie A24 and Coxsackie A16 were detected by real-time PCR. Samples from healthy health care workers of ophthalmology clinic were used for control group. Results: A total of 176 samples (conjunctival and pharyngeal samples of 62 patient and 26 healthy subjects) were included. The mean age of 34 (55.7%) male and 27 (44.3%) female patients was 34 ± 17. Twenty five (40.3%) of the patients were receiving antibiotic drops at first visit. The main etiologic agent in conjunctival samples was found to be Adenovirus (46/62, 74.2%) followed by Enterovirus 70 (4/62, 6.4%) and Enterovirus 71 (4/62, 6.4%). Coxsackievirus 16 and 24 were also found in 2 patients (1/62 each, 1.6%). Pharyngeal samples were also positive for Adenovirus (20/62, 32.3%), Enterovirus 70 and 71 (7/62, 11.3% and 5/62, 8.1% respectively), Coxsackievirus 16 and 24 (2/62, 3.2% and 1/61, 1.6%). Conclusions: It is very difficult in viral conjunctivitis to make clinical differentiation caused by different agents because of common clinical signs and symptoms. In routine clinical work, the viral conjunctivitis usually related with Adenovirus. But almost one fourth of the patients’ conjunctivitis were not related to Adenovirus, which shows the importance of the laboratory diagnostics. True diagnosis plays an important role on prevention of contamination and unnecessary use of antibiotics in viral conjunctivitis. Keywords: Adenovirus, Conjunctivitis, Viral, PCR

BackgroundEpidemic keratoconjunctivitis (EKC) is one of the most common eye infections worldwide. The analysis of clinical manifestations in different age groups help better know the disease. This study aims to provide more detailed analysis of 272 cases of EKC in 8 years, describe the differences of the clinical features among different age groups, and establish new clinical grading criteria.Methods272 individuals were reviewed (2011–2019) in Beijing China. All the patients were classified into 3 grades according to the new grading criteria. The typical clinical signs of EKC and the photographs of the multiple subepithelial corneal infiltrates (MSI) were collected and analyzed. The number of 3 grades among and within different age groups were compared. The incidence of the typical signs among and within different age groups were compared. The proportion of each region of the cornea involved by MSI were compared.ResultsNo significant differences were detected among the 4 groups in terms of the number of mild, moderate and severe cases, no matter in all-patients analysis (P = 0.271) nor in acute-phase-patients analysis (P = 0.203). The proportion of the severe cases was the highest among all patients (P = 0.000). Among the incidence of the typical signs, corneal involvement was the most common accounting for 69.8% (PP = 0.015) and peripheral region involvement (P = 0.000).ConclusionsAppropriate attention should be paid on EKC, because of the considerable proportion of severe cases, the high incidence of corneal lesion, and the high incidence of central region involvement of MSI.

Objective Increase in the evidence of global occurrence of Zika viral infection suggests that in Africa the circulation of the virus which causes 80% of asymptomatic infection could be undetected and/or overlooked. We sought to serologically detect Zika virus infection in febrile patients at Greater Accra Regional Hospital, Ghana. Results Of the 160 patient serum samples analyzed, 33 were found to have antibodies against Zika virus infection. Among the sero-positives 30 (91%) of the cases were anti-Zika virus IgM with the 21–30-year age group recording the highest number of 8 (26%) and 2 (7%) cases being the least for the 61 years and above age group. All sero-positive febrile patients developed at least one symptom consistent with Zika virus infection: 33 (100%) fever, 25 (76%) muscle pain, 24 (73%) joint pain, and conjunctivitis 2 (6%). Digestive symptoms recorded include 16 (49%) nausea, 12 (36%) vomiting and diarrhea 18 (55%). In addition, 28 (85%) loss of appetite, 14 (75%) rapid respiration and chest pain 15 (42%) were reported by seropositive febrile patients. Our data indicates exposure to Zika virus which suggests the possible circulation of the virus among febrile patients in Ghana with a sero-prevalence rate of 20.6%.

Importance To update the literature on the current trends of viral conjunctivitis infections in Sydney, Australia. Background To find correlations between viral and patient characteristics on disease outcomes and to assess the rates of antibiotic and steroid use in patients with viral conjunctivitis prior to and after assessment by ophthalmology trainees. Design Retrospective single-centre case series. Participants 368 eyes of 224 patients diagnosed with viral conjunctivitis at the Sydney Eye Hospital from 1 st January - 31 st March 2017. Methods Patients were identified from hospital records or polymerase chain reaction results. Results 368 eyes of 224 patients, median age 35.3 (range 7–82) and 59.8% males, were included. 152 (67.9%) patients presented already on antibiotic treatment. Most patients (83.5%) had no previous ocular history aside from 35 (15.6%) who were regular contact lens wearers. PCR was performed in 170 (75.9%) patients, with 92 (54.1%) positive for adenovirus, and 7 (4.1%) for HSV. The average duration of symptoms prior to presentation was 6.3 days. 177 (78.0%) patients presented within 1 week of symptom onset and these patients were more likely to be adenovirus positive on PCR (OR = 2.37). Patients with symptoms of longer duration were more likely to have photophobia (OR = 2.96) and have had steroid treatment (OR = 3.80). Conclusions and relevance Patients with viral conjunctivitis typically presented within a week of symptom onset, with bilateral disease and on topical antibiotics. Pseudomembranes and a palpable preauricular lymph node were not common. As treatments emerge for viral conjunctivitis patients may need to be encouraged to present earlier.

Importance Adenoviral conjunctivitis is highly contagious, can be associated with systemic infections, and can cause chronic visual impairment. It accounts for a large proportion of acute conjunctivitis. Outbreaks of epidemic keratoconjunctivitis (EKC) are costly in terms of productivity loss from work furloughs and spread to patients and have resulted in clinic and departmental closures. Objective To examine the institutional cost savings of a policy to diagnose adenoviral conjunctivitis and triage and furlough medical center employees with this condition to prevent outbreaks. Design, setting, and participants This quality improvement study assessed Johns Hopkins Medicine employees with red eye from November 1, 2011, through October 31, 2018, who were triaged at the occupational health clinic whose conditions were diagnosed using polymerase chain reaction (PCR) validated for adenoviral conjunctivitis. Interventions Only employees with positive PCR test results were furloughed, with furlough length tailored to subtype (a minimum of 2 weeks for EKC and 1 week otherwise). Main outcomes and measures Total number of furloughs avoided and cost savings associated with reducing unnecessary furloughs. Results Of 2142 employees with red eye, 1520 (71.0%) underwent PCR testing; 130 (8.6%) had positive adenoviral PCR test results, of whom 41 (31.5%) had EKC. Furloughing 130 employees with positive PCR test results vs furloughing all 1520 employees clinically suspected of having adenoviral conjunctivitis represented an estimated annual savings of $442 073, or $3 094 511 during 7 years. The cost of performing PCR on employees suspected of having adenoviral conjunctivitis was 5.0% of the cost associated with furloughing all employees with red eye. No outbreaks occurred. Conclusions and relevance In this quality improvement study, this policy, notable for development and use of PCR for adenoviral conjunctivitis on a large scale, resulted in substantial cost savings from fewer work furloughs compared with the number of employees who would have been furloughed based on clinical diagnosis. These results may provide impetus for policy adoption by other institutions and for development of a rapid, sensitive, and specific diagnostic test for adenoviral conjunctivitis.

Purpose: The aim of this study was to determine the frequency and various types of ophthalmic manifestation of patients with COVID-19. Methods: This is a prospective observational study conducted on patients with SARS-Co-V-2 infection, at a dedicated tertiary COVID-19 hospital in South India from April 1 to July 31, 2020. At the time of their admission to the COVID hospital, demographic data such as name, age, sex was recorded. A thorough history regarding the onset, duration, progression, nature of symptoms and its associated factors, medication history, treatment history were elicited and documented. Ocular examination was performed under torchlight by an ophthalmologist posted for COVID duty. Further investigations including imaging were sought for, depending on clinical indications. Serial follow-up examinations of all patients were carried out every 72 hours or when patients complained of any ocular symptoms whichever earlier, until discharge. All relevant data were compiled and statistically analyzed. Results: A total of 2742 patients were examined. Of them, 1461 (53.28%) were males and 1281 (46.72%) were females. The mean age (±SD) was 39.46 ± 17.63 years. None of the patients in our study had any ocular symptoms or signs as the presenting complaint at the time of their admission. On subsequent follow-up, only 20 (0.72%) developed ocular manifestations, of which 19 (95%) had features suggestive of Bilateral viral conjunctivitis. However, 1 (5%) patient had orbital cellulitis secondary to pansinusitis. Conclusion: Ophthalmic manifestations in the clinical spectrum of COVID-19 infection are uncommon and unlikely to be the presenting clinical impression. However, it has broadened our view to a wider spectrum of COVID-19 presentations enhancing our clinical acumen for staunch detection of COVID-19 suspects in our daily practice, augmenting early diagnosis and management and also break the chain of transmission for the greater good of humanity.

PURPOSE: To investigate the prevalence of ocular manifestations and visual outcomes in patients with herpes zoster ophthalmicus (HZO). METHODS: Consecutive cases diagnosed with HZO who attended 2 hospitals between July 1, 2011, and June 30, 2015, were retrospectively reviewed. Patient demographics, clinical presentations, and management were reviewed. The logistic regression model was used to estimate the odds ratio of visual loss with ocular manifestations. RESULTS: A total of 259 patients were included. Of these, 110 (42.5%) patients were

Purpose To describe 3 cases of herpes simplex virus (HSV) vesicular blepharitis that progressed to infectious epithelial keratitis despite treatment with oral acyclovir, but responded to topical antiviral therapy. Methods Retrospective review of a small case series. Results One adult and 2 children presented with unilateral HSV vesicular blepharitis without evidence of corneal involvement. Each patient was placed on a therapeutic dose of oral acyclovir. While taking oral antiviral therapy, the patients developed HSV infectious epithelial keratitis, which was treated with trifluridine 1% solution 9 times daily in the adult and ganciclovir 0.15% ophthalmic gel 5 times daily in the 2 children. All 3 cases showed resolution of epithelial keratitis within 3 to 10 days after initiation of topical antiviral treatment while oral acyclovir was continued. Conclusions Oral antiviral therapy alone may not adequately prevent progression of infectious ocular HSV blepharoconjunctivitis. Topical antiviral therapy appeared to enable resolution of HSV epithelial keratitis that arose during oral acyclovir treatment.

Purpose: To compare the efficiency and ocular side-effect profile of topical loteprednol applied to one eye and topical dexamethasone applied to the other eye in the early period on the same patient who has subepithelial infiltrates (SEI).Methods: The patients who developed bilateral SEI following epidemic keratoconjunctivitis (EKC) were applied topical loteprednol on one eye (group 2) and topical dexamethasone on the other (group 1).Results: Decrease in the symptoms was faster in the dexamethasone group, but this difference between the groups was not statistically significant (p = 0.073). Both groups were found to have substantial recurrence. However, the difference between the groups was not statistically significant (p = 0.131).Conclusions: The study has found that in the treatment of SEI, which developed after EKC, statistically similar results can be obtained with loteprednol, which is known to have fewer adverse effects.