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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 34  |  Issue : 1  |  Page : 42-46

A study on ocular symptomatology and clinical profile of coronavirus disease-19 positive patients admitted at a tertiary care institute in South India


Department of Ophthalmology, KVG Medical College and Hospital, Sullia, Karnataka, India

Date of Submission20-Apr-2021
Date of Decision02-Jun-2021
Date of Acceptance07-Jul-2021
Date of Web Publication21-Apr-2022

Correspondence Address:
Dr. Mahesh Babu
Quarter No B-26, KVG Doctors' Apartment, Kurunjibhag, Sullia - 574 327, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/kjo.kjo_93_21

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  Abstract 


Purpose: To study the ocular symptomatology and clinical profile of coronavirus disease-19 (COVID-19) positive patients admitted at a tertiary care institute. Methods: This cross-sectional, observational, and descriptive study was conducted on 200 reverse transcriptase-polymerase chain reaction positive confirmed COVID-19 patients in a tertiary care institute from September 2020 to October 2020. Ocular and systemic history was collected from the patients, clinical findings and investigation values were noted and analyzed. Results: Out of 200 COVID-19 positive patients in our study, 54% of the patients were graded as mild COVID-19 cases, 34% of the patients were graded as moderate, and 12% of the patients were graded as severe COVID-19 cases. The prevalence of ocular symptoms was 10.5%. Burning sensation of the eyes was the most common ocular symptom. A higher occurrence of ocular symptoms was observed in febrile patients and it was found to be statistically significant. The ocular symptoms worsened with a rise in temperature. Conclusion: Our study reveals that in COVID-19 positive patients, the most common systemic symptom was fever and the most common ocular symptom was burning sensation. In most of the cases, ocular symptoms appeared before or with the appearance of systemic symptoms. Most ocular symptoms were either mild or moderate grade. Ocular symptoms were higher in febrile patients with the severity increasing during febrile period in most patients. With this, we need to consider all patients coming to the outpatient department with complaints of burning sensation of eyes, eye pain and red eye as possible COVID-19 cases, and do due diligent workup.

Keywords: Burning sensation, coronavirus disease 19, eye pain, fever, ocular symptoms, redness in the eye


How to cite this article:
Bidari S, Robert R, Abhilash B, Babu M, Mashitha M S. A study on ocular symptomatology and clinical profile of coronavirus disease-19 positive patients admitted at a tertiary care institute in South India. Kerala J Ophthalmol 2022;34:42-6

How to cite this URL:
Bidari S, Robert R, Abhilash B, Babu M, Mashitha M S. A study on ocular symptomatology and clinical profile of coronavirus disease-19 positive patients admitted at a tertiary care institute in South India. Kerala J Ophthalmol [serial online] 2022 [cited 2022 May 16];34:42-6. Available from: http://www.kjophthal.com/text.asp?2022/34/1/42/343678




  Introduction Top


The outbreak of the novel coronavirus disease (COVID-19) had been declared by the WHO as a global public health emergency.[1] COVID-19 was first reported in Wuhan, China in December 2019, followed by an outbreak across other parts of China, and all over the world.[2],[3]

COVID-19 has a variable spectrum of symptoms.[4] As per some studies, more than 80% of COVID-19 illnesses are asymptomatic or can be symptomatic with mild symptoms, the most common and frequently reported symptoms of COVID-19 being fever, cough, and dyspnea whereas less common symptoms are myalgia, malaise, arthralgia, chest pain, nasal congestion, runny nose, headache, sore throat, and diarrhea.[4],[5],[6] COVID-19 has been described to potentially have ocular involvement.[7] However, scant information is available regarding Severe Acute Respiratory Syndrome-Coronavirus-2 (SARS-CoV-2) and ocular structures tropism.[8],[9],[10]

Patients infected with SARS-CoV-2 can present with a multitude of ocular manifestations such as conjunctivitis, red eye, ocular irritation, foreign body sensation, tearing, chemosis, blurring of vision, and posterior pole changes.[11] Ocular symptoms can also rarely present as an initial manifestation of the COVID-19, although they can present along with other systemic symptoms of COVID-19.[12],[13],[14],[15] Following the outbreak, various studies have been conducted in India where the general clinical profiles of SARS-CoV-2 affected patients have been assessed. However, owing to the lack of sufficient data and observations in India with respect to ocular symptomatology, and its relationship with systemic symptoms, clinical findings, and investigation values, our study aims to fulfill these lacunae of previous studies.[16]


  Methods Top


The current study was a cross-sectional, observational, and descriptive study conducted on 200 reverse transcriptase-polymerase chain reaction (RT-PCR) positive confirmed COVID-19 patients in a teaching hospital in Dakshina Kannada, South India. The period of study was between September 2020 and October 2020. All patients were in a normal psychological and physical state and reported systemic symptoms and ocular symptoms accurately. Inclusion criteria include RT-PCR confirmed COVID-19 positive stable patients, with no history of chronic ocular diseases, admitted to our institute between the duration of September 2020 to October 2020. Patients with a history of ocular diseases or any chronic use of ocular medications in the past 1 year were excluded from this study. Patients with a history of previous ocular surgery (except cataract surgery) or ocular trauma were also excluded from this study. A semi-structured questionnaire was formulated, and pilot tested before obtaining information from the patients. There were a total of 10 questions comprising both closed-ended and semi-open questions, which were used to collect information on systemic and ocular symptoms. Sample size was calculated using the formula, 4pq/L2, with p = 27.7712, q = 72.3, and allowable error d = 6.4. The minimum sample size was calculated to be 196 which was approximated to 200.[14] Informed consent was obtained from all participants recruited into the study. The study was approved by the Institutional Ethics Committee and performed in accordance with the tenets of the declaration of Helsinki.

Patients admitted in the COVID ward were communicated by us with the assistance of two-way audiovisual devices (camera, mic, and display screen) set up at COVID ward in our institute. Demographic data of the patients were noted from the patient case sheet. Ocular and systemic history was taken from the patients as per the questionnaire in local language by using audio-visual communications devices. The clinical findings (pulse rate, respiratory rate, temperature, and oxygen saturation) and the investigation values (Laboratory parameters such as Hemoglobin, total count, differential count, erythrocyte sedimentation rate, D-dimer, serum ferritin, and C-reactive protein (CRP) levels) were noted from the patient's case sheet which were recorded by treating physician after examining the patients following COVID appropriate behavior and wearing personal protection equipment. The general clinical profile of all patients was tabulated and graded as mild, moderate, and severe COVID-19 cases as per the guidelines from the directorate general of health services, ministry of health and family welfare, Government of India[17] [Table 1]. Patients grouped under the “severe” category with acute respiratory distress syndrome, sepsis and septic shock were excluded from our study. All ocular symptoms were subjectively graded as mild, moderate, and severe on the scale of 1–10 based on the patient's response as 0-absent, 1–3-mild, 4–6-moderate, and ≥ -severe based on the visual analog scale. The data were entered in Microsoft Office Excel 2007 and the same was analyzed using the SPSS version 21 (SPSS (version 21.0, IBM Corp., Armonk, NY, USA)). The data were expressed in frequencies and percentages. Appropriate parametric (t-test) and nonparametric tests (Chi-square test) were employed for analysis and P < 0.05 was taken as the level of statistical significance in our current study.
Table 1: Grading Of COVID-19 severity as per directorate general of health services, ministry of health and family welfare, Government of India

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  Results Top


In the current study, a total of 200 COVID-19 positive patients, 132 (66%) were male, and 68 (34%) were female. The age of the participating patients ranged from as young as 8 years to 77 years. Mean age of the population under study was 43.28 ± 14.28. The age distribution of COVID-19 patients in our study is depicted in [Figure 1].
Figure 1: Demographic characteristics of the population under study

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Among the RTPCR confirmed cases of COVID-19, 54% of the patients were graded as mild cases, 34% of the patients were graded as moderate cases, and 12% of the patients were graded as severe cases. The systemic symptoms reported across mild, moderate, and severe grades were varied. [Table 2] shows the frequency and severity of systemic symptoms in COVID-19 positive patients in this study.
Table 2: Frequency of systemic symptoms in categories of coronavirus disease-2019 positive patients

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On analysis of the study population, the prevalence of ocular symptoms was observed to be 10.5%. The distribution of ocular symptoms varied among the different age groups [Figure 2] with 28.5% of COVID-19 patients having ocular symptoms falling in the age group of 51–60 years, and no ocular symptoms having been observed in patients aging zero to 10 years.
Figure 2: Distribution of patients with ocular symptoms among various age groups

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[Table 3] shows grading of individual ocular symptoms into mild, moderate, and severe, as analyzed by the visual analog scale and the frequency of occurrence of ocular symptoms. On further analysis, in 40% of the patients, the ocular symptoms appeared before the onset of systemic symptoms, while 20% of the patients developed ocular symptoms after the onset of systemic symptoms. Eighteen out of 21 patients that reported ocular symptoms were febrile. Ocular symptoms reported were higher among patients with fever compared to the afebrile patients and it was found to be statistically significant (P = 0.0050). A trend toward increase in the severity of ocular symptoms was noticed with 70% of the patients having reported an increase in the severity of ocular symptoms during the febrile period whereas in 30% of them, the severity remained unchanged. In mild COVID-19 patients, 14.81% had ocular symptoms, in moderate COVID-19 patients 3.1% had ocular symptoms, and in severe COVID-19 patients 8.4% had ocular symptoms.
Table 3: Severity and frequency of ocular symptoms based on visual analog scale in coronavirus disease-2019 patients

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Among the COVID-19 patients with ocular symptoms, burning sensation appeared first in most patients followed by eye pain [Figure 3]. There was no statistical significance in the D-Dimer values CRP values in relation to ocular symptoms among COVID-19 patients.
Figure 3: First ocular symptoms in COVID-19 patients

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  Discussion Top


Of the 200 patients in our study, 21 of them reported ocular symptoms. In a study by Wu et al., conducted among COVID-19 patients in China, out of a total of 38 patients, 12 had ocular manifestations consistent with symptoms suggestive of conjunctivitis i.e., a prevalence of 31.6%.[11] A study by Sindhuja et al. in a hospital in North India, found 8.66% prevalence of ocular symptoms.[16] However, in our study, we observed a 10.5% prevalence of ocular symptoms among COVID-19 patients. The variable results could be due to the small sample size in the study by Wu et al.

In our study, the most common systemic symptom was fever (55%), followed by cough (37%), myalgia (29%), headache (27%), sore throat (19%), and cold/running nose (15%). Fever was the most common systemic symptom in the mild, moderate, and severe groups of COVID-19 patients. The observations of our study were similar to findings seen in Liwen Chen et al. study in which the most common clinical symptoms reported were fever, cough, and fatigue.[18] In a similar study by Wang et al., on 138 hospitalized patients, the most common symptoms were found to be fever, fatigue, and dry cough.[4]

In our study, we observed that the distribution of ocular symptoms varied with age, with 28.57% of COVID-19 patients with ocular symptoms falling in the age group of 51–60 years. There were no ocular symptoms reported in patients aging zero to 10 years. However, since the sample size in this age group was inadequate, comprising only four patients, further studies with a higher sample size must be conducted in age-matched study population, to arrive at a general consensus.

Patients with ocular symptoms reported mild or moderate grade symptoms and none of the patients presented with severe ocular symptoms. In our study, the most common ocular symptom reported was burning sensation of the eyes (6%) followed by redness (5%), eye pain (4%), watering (3%), foreign-body sensation (3%), increased sensitivity to light (3%), lid swelling (3%), and itching sensation (3%). No patients presented with ocular discharge. In a study by Akçay et al., a similar trend was observed, with burning sensation being the most commonly reported ocular symptom among COVID-19 patients.[19] The time scale of the appearance of ocular symptoms varied in relation to the systemic symptoms in different patients. In our study, we observed that, in most cases, ocular symptoms appeared before or with the appearance of systemic symptoms. Initially, burning sensation was the earliest noticed ocular symptom among most patients in our study.

The prevalence of ocular symptoms was higher in patients with fever compared to the afebrile patients and it was found to be statistically significant. Another notable observation was that among the febrile patients, the severity of ocular symptoms worsened during their febrile periods compared to the afebrile periods. However, further studies are needed to arrive at a consensus.

Strengths of the study

Our study explores the idea of the spectrum of COVID-19 symptomatology and could further aid in the case identification of unsuspected cases of SARS-CoV-2 presenting with ocular symptoms only. It also explores the relationship between ocular symptoms and systemic symptoms, and the time scale of their appearance.

Limitations of the study

Sample size is comparatively small, and it is a single-center study.


  Conclusion Top


Our study reveals that in COVID-19 positive patients, the most common systemic symptom was fever and the most common ocular symptom was burning sensation. In most of the cases, ocular symptoms appeared before or with the appearance of systemic symptoms. Most ocular symptoms were either mild or moderate grade. There was a statistically significant positive relationship between fever and the presence of ocular symptoms. Ocular symptoms were higher in febrile patients with the severity increasing during febrile period in most patients. A higher incidence of ocular symptoms in febrile patients goes to show that it may have a direct correlation with the inflammatory process at work in COVID patients, although further studies about targeted ocular microbiology and ocular inflammation in infectious diseases may yield more accurate results. We did not find any statistical significance in the D-dimer values and CRP values in relation to ocular symptoms among COVID-19 patients. With this, we need to consider all patients coming to the outpatient department (OPD) with complaints of burning sensation of eyes, eye pain and red eye in the current climate as possible COVID-19 cases, and do due diligent workup such as RT-PCR for confirming or refuting the diagnosis. This would be useful in the early detection of COVID-19 cases while they present to the Ophthalmology OPD with the above-mentioned ocular symptoms.

Acknowledgment

We would like to thank Dr. Dinesh Peraje Vasu for the ideas and support during the entire work.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
World Health Organization. WHO Director-General's Opening Remarks at the Media Briefing on COVID-19; 11 March 2020. https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-11-march-2020 [Last accessed on 2020 Sep 18].  Back to cited text no. 1
    
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Hui DS, I Azhar E, Madani TA, Ntoumi F, Kock R, Dar O, et al. The continuing 2019-nCoV epidemic threat of novel coronaviruses to global health – The latest 2019 novel coronavirus outbreak in Wuhan, China. Int J Infect Dis 2020;91:264-6.  Back to cited text no. 2
    
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World Health Organization. COVID-19 weekly operational update on COVID-19, 29 March 2021. https://www.who.int/publications/m/item/weekly-operational-update-on-covid-19---29-march-2021. [Last accessed on 2020 Sep 21].  Back to cited text no. 3
    
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Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. JAMA 2020;323:1061-9.  Back to cited text no. 4
    
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Chen N, Zhou M, Dong X, Qu J, Gong F, Han Y, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: A descriptive study. Lancet 2020;395:507-13.  Back to cited text no. 5
    
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Huang PC, Wang Y, Li PX, Ren PL, Zhao PJ, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020;395:497-506.  Back to cited text no. 6
    
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Hu K, Patel J, Swiston C, Patel BC. Ophthalmic manifestations of coronavirus (COVID-19). StatPearls [Internet]. 2021 Feb 26.  Back to cited text no. 7
    
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Lu C, Liu X, Jia Z. 2019-nCoV transmission through the ocular surface must not be ignored. Lancet 2020;395:e39.  Back to cited text no. 8
    
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Hong N, Yu W, Xia J, Shen Y, Yap M, Han W. Evaluation of ocular symptoms and tropism of SARS-CoV-2 in patients confirmed with COVID-19. Acta ophthalmologica. 2020;98:e649-55.  Back to cited text no. 9
    
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Hassani RT, Sandali O. Le nouveau Coronavirus COVID-19: Quells risques ophtalmiques? J Fr Ophtalmol 2020;43:291-3.  Back to cited text no. 10
    
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Wu P, Duan F, Luo C, Liu Q, Qu X, Liang L, et al. Characteristics of ocular findings of patients with coronavirus disease 2019 (COVID-19) in Hubei Province, China. JAMA Ophthalmol 2020;138:575-8.  Back to cited text no. 11
    
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Güemes-Villahoz N, Burgos-Blasco B, García-Feijoó J, Sáenz-Francés F, Arriola-Villalobos P, Martinez-de-la-Casa JM, et al. Conjunctivitis in COVID-19 patients: Frequency and clinical presentation. Graefes Arch Clin Exp Ophthalmol 2020;258:2501-7.  Back to cited text no. 12
    
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Xia J, Tong J, Liu M, Shen Y, Guo D. Evaluation of coronavirus in tears and conjunctival secretions of patients with SARS-CoV-2 infection. J Med Virol 2020;92:589-94.  Back to cited text no. 13
    
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Ceran BB, Ozates S. Ocular manifestations of coronavirus disease 2019. Graefes Arch Clin Exp Ophthalmol 2020;258:1959-63.  Back to cited text no. 14
    
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Invernizzi A, Pellegrini M, Messenio D, Cereda M, Olivieri P, Brambilla AM, et al. Impending central retinal vein occlusion in a patient with coronavirus disease 2019 (COVID-19). Ocul Immunol Inflamm 2020;28:1290-2.  Back to cited text no. 15
    
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Sindhuja K, Lomi N, Asif MI, Tandon R. Clinical profile and prevalence of conjunctivitis in mild COVID-19 patients in a tertiary care COVID-19 hospital: A retrospective cross-sectional study. Indian J Ophthalmol 2020;68:1546-50.  Back to cited text no. 16
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17.
Clinical Management Protocol: COVID-19 Government of India Ministry of Health and Family Welfare Directorate General of Health Services (EMR Division) Version 4 27.06.20. https://www.mohfw.gov.in/pdf/ClinicalManagement ProtocolforCOVID19 dated27062020.pdf. [Last accessed on 2020 Sep 18].  Back to cited text no. 17
    
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Chen L, Deng C, Chen X, Zhang X, Chen B, Yu H, et al. Ocular manifestations and clinical characteristics of 535 cases of COVID-19 in Wuhan, China: A cross-sectional study. Acta Ophthalmol 2020;98:e951-9.  Back to cited text no. 18
    
19.
Akçay Bİ, Kardeş E, Kıray G, Ayaz B, Karakuş Hacıoğlu G, et al. Evaluation of ocular symptoms in COVID-19 subjects in inpatient and outpatient settings. Int Ophthalmol 2021;41:1541-8.  Back to cited text no. 19
    


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