Author’s Note: COVID-19 From the Frontlines

Until the United States took the lead on March 26, 2020, Italy—where I live—had the highest rate of confirmed cases. At the time of this writing (April 1), we are on the 25th day of lockdown, staying home.

Our country seems to be moving through the seven stages of grief. After the denial phase, which unfortunately lasted too long, costing thousands of human lives, we are now through the pain and guilt phase. We have looked for the guilty party to blame for this disaster of human lives, personal finances and the world economy. We have even passed through the bargaining phase—that period of singing and dancing on the balconies to ward off the virus, or at least its psychological implications.

We are currently working on the second half of that phase, anger and perhaps are moving into depression. At this moment, unfortunately, some people have run out of money and no longer have enough to eat, so they either attack the supermarkets or shop and sneak out without paying. These violent and impulsive behaviors ignore social distancing and could potentially worsen the spread of the virus. Our healthcare system is already at risk of collapse.

Fortunately, the depression phase is still limited to a few desperate people, but the rumors of an extended lockdown, do not promise positive psychological reactions and impact.

From a professional point of view, optometrists are considered an essential service, and we remain open. Some practices are open during a narrow time slot (only two to three hours in the morning), while others are available only for emergencies.

As in other countries, we find ourselves inundated with misinformation and fake news. Here, I am personally trying to provide credible and evidence-based information and sources from which professionals and patients may benefit.

A popular Italian saying goes, “there's no two without three," which, in the US, translates to "bad things come in threes." After the severe acute respiratory syndrome coronavirus (SARS-CoV) and the Middle East respiratory syndrome coronavirus (MERS-CoV), the third novel iteration, SARS-CoV-2, could not miss. The fatal consequences of the first two viruses should have, but didn’t, serve to alarm the global population about the risks of the coronavirus.

SARS-CoV-2, commonly known as COVID-19, is a significant global health emergency with substantial psychosocial and business implications. As of April 1, 2020, there are 879,062 confirmed cases globally and 43,893 deaths.1 Generally, patients infected with COVID-19 have the first symptom of fever and then may develop a respiratory disorder, cough and fatigue that can quickly progress into pneumonia.2 Other signs such as conjunctivitis have been observed on occasion.3

Researchers have identified several different potential transmission routes, including respiratory droplets and close contact, and have hypothesized others, such as contact with the ocular surface.4 Several studies have investigated the possibility of viral transmission through the ocular mucus membranes, tears and conjunctiva.5-10 Even with all of this recent research, controversies exist surrounding the transmission route of COVID-19 through the contact lens (CL). Myriad editorials and articles have addressed this topic, ranging from reputable information to speculative and even incredible reporting.

Photo: Pixabay
Photo: Pixabay. Click image to enlarge.

These four scenarios refute the concept that CLs should be avoided during the COVID-19 pandemic:

1. Let’s assume that the virus reaches the eyes by adhering to the surface of the CL and then migrating to the ocular mucous membrane, infecting the individual. Perhaps the virus even penetrates the contact lens material, not just adhering to the surface. This adherence can happen either with airborne contact or from contaminated fingers during insertion or removal.

Even if this proves to be true with further study, patients are not necessarily at an increased risk of exposure due to CL wear. If the virus reaches the contact lens, adhering to the anterior surface, it also reaches the exposed parts of the eye, providing direct contact with the ocular mucous membrane, still infecting the individual. The virus infects the patient in both cases, whether they are wearing CLs or not. Even if the virus is embedded within the lens material, the infected droplets in contact with the exposed mucous membrane will penetrate the organism faster compared with those absorbed by the lens material, as the latter must first be released by the CL material before infecting the organism.

Various studies investigating the potential transmission route of human coronaviruses through the eye found the virus in the conjunctival sac of infected patients, yet they did not note viral transmission via the conjunctival route.5,7,8,10 However, more studies are needed to better understand if the eye may be an alternative transmission route of COVID-19 specifically. Still, even if the virus is transmitted through eyes, the virus will infect the subjects through the ocular mucous membrane, whether they wear CLs or not.

2. Some think spectacles provide some sort of protection from viruses. In this case, clinicians should consider the international experts and the World Health Organization irresponsible for not recommending spectacle wear, whether eyeglasses or sunglasses. In this scenario, manufacturers of spectacles should recommend them to the entire world population. In addition, clinicians should recommend CL wearers wear sunglasses to protect themselves for viral spread.

However, spectacles do not represent adequate protection.11,12 In fact, they may represent a potential source of contagion, probably more than CLs. Spectacles may be made of metal and plastic, while contact lenses are hydrogel or a mixture of hydrogel and silicone. Research shows that SARS-COV can survive on metal and plastic surfaces for up to nine days, but only up to five days on silicone rubber.13 Additionally, patients apply CLs in the morning with washed hands (in the morning the hands have a lower risk of passing infection), while people wearing spectacles tend to touch their spectacles frequently during the day—especially presbyopes—with unwashed hands, transferring the virus from fingers to face. 

3. Some believe that even appropriate hand washing does not eliminate all the microbes and viruses from hands, suggesting CL wearers remain at risk even with proper hygiene. If this is true, studies demonstrate that ethanol is excellent in inactivating human coronavirus.13 Clinicians can suggest patients use disposable gloves, ethanol or alcohol wipes to disinfect their fingers before lens handling as an extra precaution.14

4. Realistically, CL wearers won’t stop wearing their lenses. Instead of a drastic ban on contact lens wear, clinicians should use this as an opportunity to educate patients on:

  • Proper hand washing.
  • Adequate disinfection of CLs every evening (ethanol, hydrogen peroxide and sodium hypochlorite all inactivate human coronaviruses).13
  • Compliance with CL case hygiene and care solutions.
  • Proper spectacles disinfection several times during the day (spectacle disinfection, unfortunately, is not recommended as often as it should).
  • Discontinue lens wear if sick. This recommendation is valid for any type of illness, including this one.

We want to protect the eyes, but contact lenses and spectacles are not the issue. Patients should instead use compliant and approved masks, whether or not they wear CLs, remembering to disinfect them often and correctly.

Falsely Accused

The attention paid to CL surfaces and materials is curious, considering few as expressed similar concern for cell phones, which are made of plastic and glass that can harbor the virus far better than CLs. Imagine how many times in a day people touch their smartphone and then, thinking they have clean hands, touch their face, transporting microbes and viruses to the eyes, nose and mouth. Cell phones and computer keyboards are terrible sources of viruses. Should we ask everyone to stop using their mobile phone and computer as well?

Suggesting patients limit their CL wear to emergencies only and to instead wear spectacles makes no sense. Various CL experts have added to the conversation, providing evidence-based statements on CL wear safety.15-19

Another essential and sensible factor to consider during this pandemic is the psychological impact. COVID-19 has significant psychosocial implications, and CLs have shown to improve patients' quality of life compared with spectacles correction, not only by correcting refractive errors but also by providing better appearance and fewer physical limitations.20,21 This last factor should not be underestimated during the pandemic.

Ongoing research on this topic is needed to truly understand the role of CLs with COVID-19. While the literature is emerging, clinicians should be practical in their recommendations with conservative precautions that patients can adopt at this time. Practitioners must keep up-to-date on the evidence-based recommendations in this fast-changing pandemic situation and refer to credible sources such as academic institutions and global organizations' regulatory and government sources.

Hopefully, by the time this editorial makes it to print Italy will have made the upward turn toward reconstruction, acceptance and hope. Together, we can all work through this pandemic to keep our families and patients as safe as possible.

Dr. Fadel is an optometrist specializing in contact lenses for irregular cornea, scleral lenses and orthokeratology. She has a contact lens private practice in Italy, where she designs special customized contact lenses.

1. World Health Organization. Coronavirus disease (COVID-2019) situation reports. Accessed March 27, 2020.
2. Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;395:497-506.
3. Rothe C, Schunk M, Sothmann P, et al. Transmission of 2019-nCoV Infection from an 205 Asymptomatic Contact in Germany. N Engl J Med. 2020;382(10):970-971.
4. Brankston G, Gitterman L, Hirji Z, et al. Transmission of influenza A in human beings. Lancet Infect Dis. 2007;7:257e265.
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6. Lu CW, Liu XF, Jia ZF. 2019‐nCoV transmission through the ocular surface must not be ignored. Lancet. 2020;395:e39.
7. Zhou YY, Zeng YY, Tong YQ, et al. Ophthalmologic evidence against the interpersonal transmission of 2019 novel coronavirus through conjunctiva. 2020. unpublished.
8. Seah I, Agrawal R. Can the coronavirus disease 2019 (COVID-19) affect the eyes? a review of coronaviruses and ocular implications in humans and animals. Ocul Immunol Inflamm. 2020;16:1-5.
9. Dai X. Peking University Hospital Wang Guangfa disclosed treatment status on Weibo and suspected infection without wearing goggles. Beijing News. January 22, 2020.
10.  Jun ISY, Anderson DE, Kang AEZ, et al. Assessing viral shedding and infectivity of tears in coronavirus disease 2019 (COVID-19) patients. Ophthalmology. March 24, 2020. [Epub ahead of print].
11. Centers for Disease Control and Prevention. Interim infection prevention and control recommendations for patients with suspected or con-firmed coronavirus disease 2019 (COVID-19) in healthcare settings. Accessed March 30, 2020.
12. World Health Organization. Coronavirus disease (COVID-19) advice for the public. Accessed March 30, 2020.
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14. Fonn D, Jones L. Hand hygiene is linked to microbial keratitis and corneal inflammatory events. Contact Lens Anterior Eye. 2019;42:132-35.
15. Walsh K. COVID-19 and contact lens wear: what do eye care practitioners and patients need to know? Contact lens Update. March 16, 2020.
16. Centre for Ocular Research & Education. Top contact lens experts dispel misinformation regarding coronavirus / COVID-19 protections for contact lens wearers. Accessed March 30, 2020.
17. Centre for Ocular Research & Education. Contact lens update special edition: COVID-19 and contact lens wear. Accessed March 30, 2020.
18.  British Contact Lens Association. Contact lens wear and coronavirus (COVID-19) guidance. Accessed March 30, 2020.
19. Fadel D, Walsh K. Covid-19, [when the use of lenses is safe]. Accessed March 30, 2020.
20. Porisch E. Football players’ contrast sensitivity comparison when wearing amber sport‑tinted or clear contact lenses. Optometry. 2007;78:232‑35.
21. Queirós A, Villa-Collar C, Gutiérrez AR, et al. Quality of life of myopic subjects with different methods of visual correction using the NEI RQL-42 questionnaire. Eye Contact Lens. 2012;38(2):116-21.