Study Highlights COVID-19 Ocular Manifestations in Children

Children hospitalized with coronavirus disease 2019 (COVID-19) in Wuhan, China presented with a series of ocular manifestations including conjunctival discharge, eye rubbing, and conjunctival congestion, according to a new study published in JAMA Ophthalmology.

Although common symptoms of COVID-19 include fever or chills, cough, and shortness of breath, preliminary data released out of Wuhan at the pandemic’s outset found some patients exhibited epiphora, conjunctival congestion, or chemosis. These symptoms commonly occurred in patients with severe systemic manifestations of COVID-19 and are consistent with conjunctivitis, or pink eye.

“There have been reports of COVID-19 infections among medical staff, including ophthalmologists, presumably acquired during close contact with infected patients,” researchers wrote. “Better understanding of the ocular manifestations of COVID-19 can help develop more effective prevention and mitigation strategies.”

Few data have been published regarding the presence of ocular manifestations in children, as most reported cases were in adults. “Compared with adults, COVID-19 in children could be very different in terms of exposure history, clinical characteristics, and ocular manifestations,” authors wrote.

In a retrospective cross-sectional study of 216 children, the largest sample size to date on this population, researchers aimed to better understand the presence of these symptoms among those hospitalized for COVID-19.

All children included in the study had a laboratory-confirmed case of COVID-19 and were admitted to Wuhan Children’s Hospital between January 26 and March 18, 2020.

Researchers gathered demographic information and clinical manifestations via medical record reviews. Data were collected on name, sex, age, exposure history, past medical history, onset of symptoms, admission time, hospital stay, and laboratory testing and imaging results. Electronic questionnaires were also used to glean information on ocular involvements, such as onset and duration of symptoms and any use of topical medication.

Median patient age was 7.25 years (interquartile range [IR]: 2.6-11.6 years), while that of patients presenting with ocular symptoms was 4.1 (1.1-10.2 years). The majority of patients included were boys (62%).

Analyses revealed:

• 49 participants (22.7%) reported ocular symptoms; 83.7% (n = 41) had contact with confirmed family exposure, and 12.2% (n = 6) had contact with suspected family exposure
• Initial symptoms among all children were predominantly fever (81 [37.5%]) and cough (79 [36.6%])
• 93 of 216 children (43.1%) were asymptomatic (no fever and/or cough), of whom 13 children (14.0%) had ocular symptoms and 80 children (86.0%) did not
• Among those with ocular symptoms, 27 (55.1%) presented with increased conjunctival discharge, including white mucoid (9 [18.4%]), thin watery (7 [14.3%]) and yellow-green purulent (11 [22.4%]) discharge, and with conjunctival congestion (5 [10.2%])
• Addition ocular manifestations included eye rubbing (19 [38.8%]), ocular pain (4 [ 8.2%]), tearing (2 [4.1%]), and eyelid swelling (4 [8.2%])
• Treatment for the 49 patients with ocular symptoms included observation without treatment (self-healing in 23 participants [46.9]), antibacterial eye drops, antiviral eye drops, and antiallergic eye drops
• Eye rubbing and conjunctival discharge were present across all age groups, whereas tearing was only recorded in children aged 1 to 5 years and eyelid swelling only occurred in children aged 10 to 16 years
• Children with systemic symptoms (fever, cough) appeared more likely to have ocular symptoms

In contrast to adults, “all the infected children had mild or moderate symptoms, and some investigators explained the difference by the distribution of angiotensin-converting enzyme 2 receptors and activated innate immune system,” researchers said.

Despite results of this study and preceding investigations, authors caution the correlation between ocular symptoms and COVID-19 remains controversial. Whether viral conjunctivitis was directly caused by SARS-CoV-2, the virus that causes COVID-19, remains unknown, and more studies are needed.

Researchers also point out “the higher incidence of conjunctival congestion in pediatric patients than in adult patients might be attributed to the likely frequent hand-eye contact in children.”

Because the ocular disorders observed were typically very mild, children recovered rather quickly, and these disorders were not associated with any long-term complications, researchers recommend only close observation for COVID-19 related ocular manifestations in children.

However, authors could not acquire the pathogenic evidence of ocular disorders in children, marking a limitation to the study. Descriptions of ocular symptoms can also be subjective, especially in young children.

Reference

Ma N, Li P, Wang X, et al. Ocular manifestations and clinical characteristics of children with laboratory-confirmed COVID-19 in Wuhan, China. JAMA Ophthalmol. Published online August 26, 2020. doi:10.1001/jamaophthalmol.2020.3690