The recent epidemic caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) represents an unforeseen public health threat and is challenging health care systems worldwide.1 In this regard, the high infectivity of the novel coronavirus disease 2019 (COVID-19) forced many governments to impose severe regulations such as quarantine to limit its spread.2 To date, after China, Italy has been one of the countries most affected by the COVID-19 outbreak.3 Population density has been shown to be directly associated with COVD-19 spread rate.4 Because the Italian population density is higher than that in China (205.45/km2 vs 2.804/km2), the Italian government placed the whole country, whose population accounts for almost 60 million inhabitants, under quarantine.5
The typical presentation of COVID-19 disease is characterized by fever, dry cough, dyspnea, leucopenia, and bilateral ground-glass opacities on chest computed tomography scans.6 SARS-CoV-2 infection may cause severe systemic complications, including cardiac damage, acute respiratory distress syndrome, respiratory failure, and, ultimately, death.7 As opposed to adults, children with COVID-19 have been reported to have a milder course of the disease with a better prognosis8; moreover, COVID-19 infection in newborns is considered a rare event and vertical transmission has not been documented yet.9 Most of the evidence suggests that person-to-person transmission is primarily due to direct contacts or via droplets spread by coughing or sneezing from an infected individual.10 In the pediatric population, there is a huge concern about the real number of asymptomatic or oligo-symptomatic children, who can be potentially infectious SARS-CoV-2 carriers due to the presence of viral particles in their nasopharyngeal secretions and therefore possibly contribute to early transmission to close contacts.11 Given the relatively high transmissibility of SARS-Cov-2 virus among the population, health care professionals are also at high risk to be infected.12 In Italy, to date, of the almost 180,000 people affected, more than 19,665 health care providers have been infected with SARS-CoV-2 and 151 physicians have died.13
Given these incredibly alarming data, it appears crucial for health care workers to adopt appropriate safety measures, including personal protective equipment (PPE). Up to now, no information about the incidence of SARS-CoV-2 infection in the ophthalmology field has been provided; however, ophthalmologists represent a high-risk category for the following reasons. SARS-CoV-2 was proven to be possibly transmitted by aerosol contact with the conjunctiva in individuals not wearing adequate PPE.14 In addition, given the close proximity to the patient during the slit-lamp and indirect ophthalmoscopy examinations and the potential contact with tears and ocular discharge, ophthalmologists are potentially exposed to a higher risk of infection.15 For these reasons, the American Academy of Ophthalmology recently published an alert recommending ophthalmologists wear masks and eye protection, especially when visiting patients with conjunctivitis in combination with respiratory symptoms and/or a medical history of suspected contacts with individuals infected with SARS-CoV-2.16
We share our experience in treating pediatric ophthalmology patients during the pandemic and report the guidelines applied at the University Eye Clinic, IRCCS Policlinic San Martino Hospital, Genoa, Italy.
We adopted the following flow chart for the management of pediatric patients with ophthalmic symptoms during the current COVID-19 outbreak (Figure 1). First, patients were screened by telephone with the aim of distinguishing urgent ophthalmic cases from non-urgent ones. The criteria to define an “ophthalmic urgency” were subjected to the physician's judgment and always considered the individual patient's medical and social circumstances. In non-urgent or routine ophthalmic issues, parents or caregivers of the patients were reassured and the appointments were rescheduled on clearance from the public health authorities. Our pediatric ophthalmologists remained available via telephone consultations for any further clarification or in case of worsening of the symptoms. Medication prescriptions were refilled if needed.
Flow chart adopted for the management of pediatric ophthalmic patients during the novel coronavirus 2019 (COVID-19) outbreak at the University Eye Clinic, IRCCS Policlinic San Martino Hospital.
In unclear cases, patients were asked to send digital pictures (possibly macro pictures) or videos showing the cause of concern to a dedicated email address. The aim of telemedicine was to provide further assistance to the pediatric patient and better characterize the clinical severity of the ophthalmic problem. Through telemedicine, it was possible to more thoroughly triage the patient and define whether the case was urgent or not urgent according to the flow chart.
Patients considered ophthalmic urgencies were subsequently screened for possible SARS-CoV-2 infection. Patients were defined as “suspected COVID-19 patients” when at least one of those respiratory illness symptoms (including fever, cough, or dyspnea) was present in combination with a positive medical history for close contact with SARSCoV-2 in the past 14 days.
For those patients not fulfilling the abovementioned criteria, an urgent pediatric ophthalmological visit was scheduled at our University Eye Clinic. Before the eye examination, the patient's body temperature was measured by a contactless/infrared thermometer. Visits were scheduled with time between them to avoid patients gathering in the waiting room of the clinic. Patients were allowed to be accompanied by only one parent or caregiver. They were immediately placed in an examination room with the door closed and wearing a surgical mask was mandatory for both the companion (parent or caregiver) and all patients older than 2 years. All ophthalmologists were appropriately trained and equipped with PPE, including visors or protective eye goggles, gloves, and surgical masks. All slit lamps were shielded with breath protectors using plastic sheets. Importantly, all health care workers were trained to repeatedly perform hand hygiene with alcohol-based hand sanitizer. The examination room equipment was properly disinfected before and after the pediatric ophthalmological examination.
In contrast, suspected patients fulfilling the above-mentioned criteria for COVID-19 infection were sent to the local, age-appropriate emergency department, which was properly equipped for COVID-19 infection evaluation and management. In the “COVID-19 track,” suspected pediatric patients with urgent ophthalmic issues were visited by a pediatric ophthalmologist in an isolated room located in the emergency department. All ophthalmologists were appropriately trained to perform all disinfecting, antiseptic procedures and equipped with full PPE, including visors or protective eye goggles, gloves, disposable gowns, single-use head covers, and N95 masks. All disposable PPE were removed and immediately disposed of after the examination. All of the slit lamps were shielded with breath protectors using plastic sheets and the examining room equipment was properly disinfected before and after examination. If SARSCoV-2 infection was confirmed, the guidelines for the management of COVID-19 patients were followed to facilitate infection control and better assist the patient.
Recently, a novel rare syndrome known as the pediatric multi-system inflammatory syndrome has been described and it is thought to be possibly related to COVID-19. This syndrome shares common features with other pediatric inflammatory diseases, including Kawasaki disease, staphylococcal and streptococcal toxic shock syndromes, and bacterial sepsis. In fact, its clinical presentation consists of persistent fever, inflammation (neutrophilia, elevated C-reactive protein, and lymphopenia), and evidence of single or multi-organ dysfunction. In some cases, children may present conjunctival vascular injection as in Kawasaki disease.17 To date, no cases have been reported in our University Eye Clinic; however, in case of suspected symptoms of pediatric multi-system inflammatory syndrome, children should be considered as urgent cases.
During the COVID-19 outbreak, it is crucial to stratify patients according to the severity of the presented symptoms. Moreover, multidisciplinary collaboration with local infection control experts is important for risk assessment and to modulate the infection control measures in the clinical setting. Nonetheless, the adoption of appropriate safety measures against the infection should always be considered a priority. Further clinical studies should better define the clinical presentation of COVID-19 in children, not neglecting the presence of severe syndromes such as the novel pediatric multi-system inflammatory syndrome.
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- Rocklov J, Sjodin H. High population densities catalyze the spread of COVID-19. J Travel Med. 2020;27(3):taaa038. doi:10.1093/jtm/taaa038 [CrossRef]
- Sjödin H, Wilder-Smith A, Osman S, Farooq Z, Rocklöv J. Only strict quarantine measures can curb the coronavirus disease (COVID-19) outbreak in Italy, 2020. Euro Surveill. 2020;25(13). doi:10.2807/1560-7917.ES.2020.25.13.2000280 [CrossRef]
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- Porcheddu R, Serra C, Kelvin D, Kelvin N, Rubino S. Similarity in case fatality rates (CFR) of COVID-19/SARS-COV-2 in Italy and China. J Infect Dev Ctries. 2020;14(2):125–128. doi:10.3855/jidc.12600 [CrossRef]
- Ludvigsson JF. Systematic review of COVID-19 in children shows milder cases and a better prognosis than adults. Acta Paediatr. 2020;109(6):1088–1095. doi:10.1111/apa.15270 [CrossRef]
- Lu Q, Shi Y. Coronavirus disease (COVID-19) and neonates: what neonatologists need to know. J Med Virol. 2020;92(6):564–567. doi:10.1002/jmv.25740 [CrossRef]
- Wu P, Hao X, Lau EHY, et al. Real-time tentative assessment of the epidemiological characteristics of novel coronavirus infections in Wuhan, China, as at 22 January 2020. Euro Surveill. 2020;25(3). doi:10.2807/1560-7917.ES.2020.25.3.2000044 [CrossRef]
- Wölfel R, Corman VM, Guggemos W, et al. Virological assessment of hospitalized patients with COVID-2019. Preprint. Published online April 1, 2020. Nature. doi:10.1038/s41586-020-2196-x [CrossRef]
- Bartoszko JJ, Farooqi MAM, Alhazzani W, Loeb M. Medical masks vs N95 respirators for preventing COVID-19 in healthcare workers: a systematic review and meta-analysis of randomized trials. Influenza Other Respir Viruses. 2020;irv.12745. doi:10.1111/irv.12745 [CrossRef]
- Italian Ministry of Health Data. Published April 24, 2020. https://www.epicentro.iss.it/coronavirus/bollettino/Bollettinosorveglianza-integrata-COVID-19_23-aprile-2020.pdf
- Lu CW, Liu XF, Jia ZF. 2019-nCoV transmission through the ocular surface must not be ignored. Lancet. 2020;395(10224):e39. doi:10.1016/S0140-6736(20)30313-5 [CrossRef]
- Lai THT, Tang EWH, Chau SKY, Fung KSC, Li KKW. Stepping up infection control measures in ophthalmology during the novel coronavirus outbreak: an experience from Hong Kong. Graefes Arch Clin Exp Ophthalmol. 2020;258(5):1049–1055. doi:10.1007/s00417-020-04641-8 [CrossRef]
- American Academy of OphthalmologyCenters for Disease Control and PreventionWorld Health Organization. Alert: important coronavirus context for ophthalmologists. Published May 11, 2020. https://www.aao.org/headline/alert-important-corona-virus-context?fbclid=IwAR2aIWGFtZ8zmU6zg15hKTz6eoVcsDCizsEDL-_UnN4CQA88BpEKlTO1j3o
- Royal College of Paediatrics and Health. Paediatric multisystem inflammatory syndrome temporally associated with COVID-19. https://www.rcpch.ac.uk/sites/default/files/2020-05/COVID-19-Paediatric-multisystem-%20inflammatory%20syndrome-20200501.pdf