1. EYES AND COVID-19 

Research on the impact of COVID-19 on the eyes continues to be updated, with increasing information on eye-related conditions, and the role of eyes in infection control. 

Consequence of COVID-19 for the eyes

The prevalence of conjunctivitis associated with COVID-19 has been found to be as high as 32% (1), however the role of the eyes remains controversial and further investigations are required.(2) Other ocular signs associated with COVID-19 have included dry eye (20.97%), blurred vision (12.73%) and foreign body sensation (11.80%).(3) Studies have also recently identified retinal microvascular changes in 1 in 9 COVID-19 patients, in both symptomatic and asymptomatic patients. (4) 

Mucormycosis, sometimes known as black fungus, is a life-threatening opportunistic infection that can affect the rhino-orbital cavities. More recently, mucormycosis has become more prevalent, in particular affecting patients with diabetes and compromised immune systems.(5) Simple tests like vision, pupil, ocular motility and sinus tenderness can be part of routine physical evaluation of a COVID-19 patient. 

Are the eyes a vector for contamination?

SARS-CoV-2 RNA has been isolated in the conjunctivae and tears using reverse transcriptase–polymerase chain reaction. However, expression levels seem relatively low compared to respiratory tissue with viral RNA detected in ocular specimens in between 1.8 and 7.1% of lab-confirmed COVID-19 patients. Although the percentage of patients who tested positive for COVID-19 by conjunctival swabs was relatively low, the risk of transmission cannot be eliminated.(6) The American Academy of Ophthalmology has added new infection prevention strategies because of the close proximity of eye care professionals to their patients’ faces.(1)

SARS-CoV-2 may be present on the eye surface and two key entry proteins, ACE2 and TMPRSS2, have been found in corneal cells.(7) However, health experts believe we're more likely to become infected via our nose and mouth (2) because:

• our nose and mouth provide a direct passageway to the lungs, whereas infectious particles that enter through our eyes have to take a more indirect route,
• our tears contain antibodies that can help detect and attach to unfriendly bacteria and viruses, destroying them,
• a relatively low rate of eye complications — most notably, viral conjunctivitis (or pink eye) develops in people with COVID-19

A microbiologist’s perspective:

 

Professor Willcox is a medical microbiologist who has specialised in the ocular surface for over 25 years. His research areas include analysis of the ocular microbiome, development of new antimicrobials that have applications as antibiotics and disinfectants, and tear film biochemistry. He often studies these in relation to how contact lenses affect the ocular surface and the potential to make antimicrobial contact lenses.

 

Are spectacles adequate eye protection?

Spectacles could provide protection from a ‘direct hit’ of COVID-19 carrying materials e.g. a cough. However, given the high levels of COVID-19 circulating in the air in many environments, they will not protect the eyes from infection in the same way that eye protection can, as droplets are likely to circulate in and around the spectacles.

 

Are the eyes a portal for infection from COVID-19?

The eyes are definitely a potential path for infection from the SARS-COV-2 virus, in particular with receptors on the surface of our eyes, as well as the drainage that occurs through the nasolacrimal duct, however the other known paths of entry are more likely to result in infection.

 

What is the role of spectacles in contamination? The SARS-COV-2 virus has been found to stick to surfaces for extended periods. Because of this, spectacles may be a source of infection, depending on how often people touch their spectacles. When putting on and taking off spectacles, it is important to ensure proper hand hygiene. Compliance with standard hygiene practices remains the most important way to prevent the spread of infection.

2. PATIENT NEEDS, CONCERNS, AND BEHAVIOURS

Amongst spectacle wearers’ needs that emerged during this health crisis, issues that have been identified have included:

• Eye fatigue- related to more intensive use of screens
• Fogging of spectacles when wearing a mask
• Glasses disinfection
• Adjusting frames- especially for children as parents adjusted the frames themselves

To help answer these needs, key advice for patients includes:

i) Eye fatigue

Symptoms of digital eye strain, such as dry, irritated eyes, blurred vision, neck and back pain and headaches, are increasingly reducing our quality of life. With up to 73% of those in their 20’s and 60% those over 40 reporting digital eye strain (8) which has been exacerbated during confinements, it is imperative and a good reminder to promote good eye health and hygiene by taking regular rest breaks from near work. A general rule of thumb is to follow the 20/20/20 rule: every 20 minutes, shift your eyes to look at an object at least 20 feet away (six metres), for at least 20 seconds. It is also an important reminder for patients to have regular eye exams to ensure an up-to-date and accurate prescription for spectacle lenses. Having lenses that are optimised for vision requirements ensure visual comfort, protection, and performance (12).

ii) Fogging 

For spectacle wearers the increased use of facemasks which is mandatory in many countries, has led to problems with fogging of spectacles. Prescribed spectacles can be fitted by your optometrist or optician to minimize fogging. Anti-Fog coatings can also be utilized to minimize fogging.

iii) Glasses disinfection

Data relating to COVID-19 infection rates has indicated that the proportion of patients who wore glasses was less than that of the general population.(9) Whilst it may be tempting to assume that everyone should wear glasses to avoid infection, it is difficult to draw this conclusion from one observational study with relatively small numbers.(10) As the patients featured in the study wore their glasses for more than 8 hours per day, it is possible that the glasses may serve as a physical barrier and that people wearing glasses all day are less likely to touch their eyes, and therefore transmit the infection to their eyes. Spectacles may provide some protection, however they don’t provide the same level of protection as PPE (personal protective equipment), because of the large gaps between the eyes and glasses and potential for the eyes to be exposed to the virus.

Wearers need to be informed of the risk of contamination when removing, replacing or adjusting spectacles or eye protection. Self-contamination when putting on (donning) or removing (doffing) protection is well-documented and should be considered, particularly for those who are not familiar with wearing spectacles or eye protection. Spectacle wearers should be advised to follow the simple steps below to help reduce self-contamination:

Step 1: Perform hand hygiene (11).

Step 2: Remove spectacles or eye protection and then face mask (if worn). NB: When removing a mask it is important to untie or unhook from the ears and pull away from the face, without touching the front of the mask.

Step 3: Clean spectacles using isopropyl alcohol 70% (ECP’s) or gentle soap and water at home.

*We also need to continue to remind people to prevent risks by continuing to observe the fundamentals by following the World Health Organization’s rules, with the 3Cs (crowded places, close-contact settings, confined and enclosed spaces) and the barrier gesture, and/or any local health authorities and national professional and governmental organizations.

iv) Adjusting frames: 

An important reminder is the need for periodic adjustment by your eye care professional, as well as the potential for frames to be broken or incorrectly fitted if done by a non-professional. Periodic frame adjustments by an eye care professional ensures the best quality of vision.

3. NEW OPPORTUNITIES FOR ECPS

Patients' visual needs are changing as new manifestations of ocular diseases appear. They are adopting new behaviors in terms of consumption, including their eye health. Habits and behaviors are changing faster than before, and the Phygital (technology bridging the digital and physical world) patient journey is becoming increasingly important. Patients are now more likely to prepare for their appointment by using online tools to conduct eye health history, book  their appointment, and even use tele-ophthalmology and tele-optometry technologies. The technical nature of glasses, expertise of eye care practitioners, and the tailor-made approach that is offered must be able to meet alongside these new requirements and expectations. This new patient journey has highlighted opportunities for education and recommendations with the increased importance of the 'expert advice' of eye care practitioners - an increasingly positive outcome from these trends.

CONCLUSION

This crisis brings patients back to basics and reminds us all that health is a priority. As countries push for herd immunity with vaccination programs, we need to focus on the positive lessons and gains achieved from the COVID-19 crisis and use it as an opportunity to accelerate implementation of these learnings now and in the future. Maintaining improved practices, such as online booking appointments, and continuing to support innovation aligns with patient’s new expectations, and is key to future success. Ultimately, the pandemic stands as a reminder of the value of trusting relationships between the patient and eye and vision care providers, allowing the wearer to see more, do more, and live life to its fullest.