Association of Daily Wear of Eyeglasses With Susceptibility to Coronavirus Disease 2019 Infection | Infectious Diseases | JAMA Ophthalmology | JAMA Network
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Table.  Clinical Characteristics of the Study Patients
Clinical Characteristics of the Study Patients
1.
Wu  Z, McGoogan  JM.  Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention.   JAMA. 2020. doi:10.1001/jama.2020.2648 PubMedGoogle Scholar
2.
Pongpirul  WA, Pongpirul  K, Ratnarathon  AC, Prasithsirikul  W.  Journey of a Thai taxi driver and novel coronavirus.   N Engl J Med. 2020;382(11):1067-1068. doi:10.1056/NEJMc2001621 PubMedGoogle ScholarCrossref
3.
Chen  M, Wu  A, Zhang  L,  et al.  The increasing prevalence of myopia and high myopia among high school students in Fenghua City, eastern China: a 15-year population-based survey.   BMC Ophthalmol. 2018;18(1):159. doi:10.1186/s12886-018-0829-8 PubMedGoogle ScholarCrossref
4.
General Office of National Health Commission. Diagnosis and treatment protocols for novel coronavirus pneumonia (trial version 5, revised) [in Chinese]. Published February 4, 2020. Accessed March 15, 2020. http://www.gov.cn/zhengce/zhengceku/2020-02/09/content_5476407.htm
5.
Chinese Student Physique and Health Research Group.  Research on Chinese Students' Physique and Health [in Chinese]. People's Education Press; 1987.
6.
van Doremalen  N, Bushmaker  T, Morris  DH,  et al.  Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1.   N Engl J Med. 2020;382(16):1564-1567. doi:10.1056/NEJMc2004973 PubMedGoogle ScholarCrossref
7.
Kwok  YL, Gralton  J, McLaws  ML.  Face touching: a frequent habit that has implications for hand hygiene.   Am J Infect Control. 2015;43(2):112-114. doi:10.1016/j.ajic.2014.10.015 PubMedGoogle ScholarCrossref
8.
Holappa  M, Vapaatalo  H, Vaajanen  A.  Many faces of renin-angiotensin system—focus on eye.   Open Ophthalmol J. 2017;11:122-142. doi:10.2174/1874364101711010122 PubMedGoogle ScholarCrossref
9.
Xiao  X, Chakraborti  S, Dimitrov  AS, Gramatikoff  K, Dimitrov  DS.  The SARS-CoV S glycoprotein: expression and functional characterization.   Biochem Biophys Res Commun. 2003;312(4):1159-1164. doi:10.1016/j.bbrc.2003.11.054 PubMedGoogle ScholarCrossref
10.
Guan  WJ, Ni  ZY, Hu  Y,  et al; China Medical Treatment Expert Group for Covid-19.  Clinical characteristics of coronavirus disease 2019 in China.   N Engl J Med. 2020;382(18):1708-1720. doi:10.1056/NEJMoa2002032 PubMedGoogle ScholarCrossref
11.
Wu  P, Duan  F, Luo  C,  et al.  Characteristics of ocular findings of patients with coronavirus disease 2019 (COVID-19) in Hubei Province, China.   JAMA Ophthalmol. 2020;138(5):575-578. doi:10.1001/jamaophthalmol.2020.1291 PubMedGoogle ScholarCrossref
12.
Seah  IYJ, Anderson  DE, Kang  AEZ,  et al.  Assessing viral shedding and infectivity of tears in coronavirus disease 2019 (COVID-19) patients.   Ophthalmology. 2020;127(7):977-979. doi:10.1016/j.ophtha.2020.03.026 PubMedGoogle ScholarCrossref
13.
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 PubMedGoogle Scholar
14.
World Health Organization. Coronavirus disease (COVID-19) advice for the public. Updated June 4, 2020. Accessed April 1, 2020. https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public
15.
Machida  M, Nakamura  I, Saito  R,  et al.  Adoption of personal protective measures by ordinary citizens during the COVID-19 outbreak in Japan.   Int J Infect Dis. 2020;94:139-144. doi:10.1016/j.ijid.2020.04.014 PubMedGoogle ScholarCrossref
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    3 Comments for this article
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    Transmission Method
    Paul Jankel, Economics | Not Medical
    Thank you for your work.

    Do the authors consider that hand-to-eye transmission (mentioned in the study) is a sufficient explanation for these results?

    Or should these results be seen as evidence of airborne (air-to-eye) transmission?
    CONFLICT OF INTEREST: None Reported
    Reporting Question
    Alex Szojka | University of Alberta
    Thank you for your work.

    Is it possible that the rate of glasses-wearing was underreported/underdetected (e.g. patients & treating physicians, being overwhelmed, didn't think it was relevant information and so they did not record it)? Since 16 patients were identified as regular glasses-wearers (and 14 with presbyopia), does that mean the rest (246) were specified explicitly to not wear glasses regularly? Or was it assumed that if glasses-wearing wasn't specified, that the patients did not wear glasses?
    CONFLICT OF INTEREST: None Reported
    Eye Protection as an Essential Part of PPE.
    Gary Ordog, MD, DABEM, DABMT | County of Los Angeles, Department of Health Services, (retired)
    Thank you for the informative study. First, in response to a previous question, the methodology is stated to include direct questioning about eyeglasses, also in my experience, the direct questioning of patients upon hospital admission includes the use of eyeglasses, dentures, prostheses, pacemakers, etc. which would make this information readily available on admission documents. So this set of data seems plausible. The validity of matching of the experimental with the control group is more questionable. Nevertheless, the results show a very strong association in the protective action of eyeglasses against SARS-CoV-2, and in conclusion would support the use of eye protection in PPE use. The preferred PPE should have eye protection that prevents "touching" and direct air flow to the eyes. Also, there may be other confounding variables that are causing this strong association, for example: 'further investigation could show that eyeglass users frequently clean the glasses with sterilizing wipe, thus presenting a chemical shield to the virus.' Again, thank you for your work, and as usual, further study is required. Stay safe with eye protection.
    CONFLICT OF INTEREST: None Reported
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    Brief Report
    September 16, 2020

    Association of Daily Wear of Eyeglasses With Susceptibility to Coronavirus Disease 2019 Infection

    Author Affiliations
    • 1Department of Thoracic Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, China
    • 2Department of Critical Care Medicine, Suizhou Zengdu Hospital, Suizhou, China
    • 3Department of Radiotherapy, Jiangxi Cancer Hospital, Nanchang, China
    • 4Department of Computed Tomography and Magnetic Resonance Imaging, The First Affiliated Hospital of Gannan Medical University, Ganzhou, China
    JAMA Ophthalmol. Published online September 16, 2020. doi:10.1001/jamaophthalmol.2020.3906
    Key Points

    Question  What is the association between the daily wear of eyeglasses and susceptibility to coronavirus disease 2019 (COVID-19)?

    Findings  In this cohort of 276 patients hospitalized with COVID-19 in Suizhou, China, the proportion of daily wearers of eyeglasses was lower than that of the local population (5.8% vs 31.5%).

    Meaning  These findings suggest that daily wearers of eyeglasses may be less likely to be infected with COVID-19.

    Abstract

    Importance  The proportion of daily wearers of eyeglasses among patients with coronavirus disease 2019 (COVID-19) is small, and the association between daily wear of eyeglasses and COVID-19 susceptibility has not been reported.

    Objective  To study the association between the daily wearing of eyeglasses and the susceptibility to COVID-19.

    Design, Setting, and Participants  This cohort study enrolled all inpatients with COVID-19 in Suizhou Zengdu Hospital, Suizhou, China, a designated hospital for COVID-19 treatment in the area, from January 27 to March 13, 2020. COVID-19 was diagnosed according to the fifth edition of Chinese COVID-19 diagnostic guidelines. The proportion of persons with myopia who wore eyeglasses in Hubei province was based on data from a previous study.

    Exposures  Daily wearing of eyeglasses for more than 8 hours.

    Main Outcomes and Measures  The main outcomes were the proportions of daily wearers of eyeglasses among patients admitted to the hospital with COVID-19 and among the local population. Data on exposure history, clinical symptoms, underlying diseases, duration of wearing glasses, and myopia status and the proportion of people with myopia who wore eyeglasses in Hubei province were collected. People who wore glasses for more than 8 hours a day were defined as long-term wearers.

    Results  A total of 276 patients with COVID-19 were enrolled. Of these, 155 (56.2%) were male, and the median age was 51 (interquartile range, 41-58) years. All those who wore glasses for more than 8 hours a day had myopia and included 16 of 276 patients (5.8%; 95% CI, 3.04%-8.55%). The proportion of people with myopia in Hubei province, based on a previous study, was 31.5%, which was much higher than the proportion of patients with COVID-19 who had myopia in this sample.

    Conclusions and Relevance  In this cohort study of patients hospitalized with COVID-19 in Suizhou, China, the proportion of inpatients with COVID-19 who wore glasses for extended daily periods (>8 h/d) was smaller than that in the general population, suggesting that daily wearers of eyeglasses may be less susceptible to COVID-19.

    Introduction

    Coronavirus disease 2019 (COVID-19), the pathogen of which is severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is a highly infectious disease that broke out in Wuhan, China, in December 2019 and has spread to more than 200 countries.1 COVID-19 has been proven to be transmitted mainly through droplets and contact.2 The eye is also considered an important route of infection.

    According to reports published in recent years, the prevalence of myopia in China is now more than 80% of the population. Wearing of eyeglasses is common among Chinese individuals of all ages.3 However, since the outbreak of COVID-19 in Wuhan in December 2019, we observed that few patients with eyeglasses were admitted in the hospital ward. Therefore, we collected information on the wearing of eyeglasses from all inpatients with COVID-19 as part of their medical history and used the data to examine the association between wearing eyeglasses and COVID-19 infection.

    Methods

    This cohort study was approved by the ethics committee of Suizhou Zengdu Hospital, Suizhou, China, and followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline. Patients signed written informed consent and were not provided with any incentive or compensation to participate in the study. The study enrolled patients admitted to the hospital from January 27 to March 13, 2020, with the admission criteria of a diagnosis of COVID-19. The diagnostics and clinical classification of COVID-19 were based on the fifth edition of Chinese COVID-19 diagnostic guidelines.4 Throat swab samples were obtained from patients at admission and tested using real-time reverse transcriptase–polymerase chain reaction assays to identify COVID-19 infection. Patients were specifically asked about the reason they wore eyeglasses, the length of time that they wore eyeglasses during daily activities, and whether they wore contact lenses or had ever undergone refractive surgery. This information was recorded by the patients’ treating physicians while taking their medical history, starting February 4, 2020. Information on exposure history and clinical symptoms was extracted from the medical records. People who wore eyeglasses for more than 8 hours a day were defined as long-term wearers, and these people were considered to wear eyeglasses when socializing.

    To estimate the population myopia rate, we extracted data from the Research on Chinese Student Physique and Health Study,5 which recorded data from a survey about the physical and health status of Chinese students, organized by state educational institutions and the Ministry of Health of China in 1985. We used descriptive statistics to characterize the study sample.

    Results

    As shown in the Table, a total of 276 patients with COVID-19 were enrolled in the study. The median age was 51 (interquartile range, 41-58) years; 155 patients (56.2%) were male and 121 (43.8%) were female. Most patients with COVID-19 were moderately ill, with 14 (5.1%) severely ill. Common symptoms were fever (227 [82.2%]), cough (218 [79.0%]), and fatigue (141 [51.1%]). Underlying disease was present in 88 patients (31.9%), with hypertension the most common, accounting for 47 (17.0%) of all admitted patients. Thirty patients with COVID-19 wore eyeglasses (10.9%), including 16 cases of myopia and 14 cases of presbyopia. None of the patients in this study wore contact lenses or underwent refractive surgery. All 16 patients with COVID-19 who wore glasses for more than 8 hours per day had myopia, accounting for 5.8% (95% CI, 3.0%-8.6%), and the median age was 33 years. Their symptoms, underlying disease, and COVID-19 severity were not significantly different from those of other patients.

    The results from previous research5 showed that the mean rate of myopia among students aged 7 to 22 years in Hubei province was 31.5%. By 2020, these students were aged 42 to 57 years, which is close to the median age of our patients with COVID-19. The myopia rate of 31.5% is higher than the 5.8% among our patients with COVID-19.

    Discussion

    At the time of writing, this study was the only research, to our knowledge, to assess the association between wearing eyeglasses and COVID-19 infection. Our main finding was that patients with COVID-19 who wear eyeglasses for an extended period (>8 h/d) every day were relatively uncommon, which could be preliminary evidence that daily wearers of eyeglasses are less susceptible to COVID-19. Considering the prevalence of COVID-19, conducting a sample survey among the local population would have been difficult. Instead, we used data from a previous survey for approximate reference and comparison, although the age, region, and educational level of the students in that survey had some differences compared with our study population.

    We hypothesized that eyeglasses prevent or discourage wearers from touching their eyes, thus avoiding transferring the virus from the hands to the eyes.6 Studies have shown that normal people will involuntarily touch their eyes about 10 times per hour.7 Eyes usually lack protection, and an abundance of the SARS-CoV-2 receptor angiotensin-converting enzyme 2 has been found on the ocular surface,8 through which SARS-CoV-2 can enter the human body. SARS-CoV-2 may also be transported to the nasal and nasopharyngeal mucosa through continuous tear irrigation of the lacrimal duct, causing respiratory infection.9 According to available statistics, nearly 1% to 12% of patients with COVID-19 have ocular manifestations,10,11 SARS-CoV-2 was detected in tears or the conjunctival sacs of patients with COVID-19,12 and some ophthalmologists were reported to be infected during routine treatment.13 Therefore, the eyes are considered an important channel for SARS-CoV-2 to enter the human body.11 For daily wearers of eyeglasses, who usually wear eyeglasses on social occasions, wearing eyeglasses may become a protective factor, reducing the risk of virus transfer to the eyes and leading to long-term daily wearers of eyeglasses being rarely infected with COVID-19. Presently, many COVID-19 guidelines state the need to pay attention to preventing infections through the eyes,14 but most people only focus on wearing masks and home isolation, ignoring recommendations such as washing hands frequently and avoiding touching the eyes with the hands.15 The results of this study can be used as evidence of the importance of these 2 recommendations.

    Limitations

    Our study had some notable limitations. First, it was a single-center study with a small sample size. The numbers of patients who wear eyeglasses and long-term wearers were limited, which limits the extension of the results to a larger population, so our results need to be verified by large-sample multicenter studies. Second, the proportion of wearers of eyeglasses was based on data from previous literature and was not calculated from current local populations. Third, the myopia rate obtained in previous studies included a small number of people with myopia who did not wear eyeglasses. Information on these people was lacking and partly affected the integrity and validity of our data. Fourth, none of our research participants wore contact lenses, so the association between wearing contact lenses and susceptibility to COVID-19 remains to be studied. In addition, further studies are needed to clarify the reasons that wearing eyeglasses may decrease susceptibility to COVID-19.

    Conclusions

    Our study found that the proportion of inpatients with COVID-19 who wear eyeglasses for extended daily periods was lower than that of the general population, suggesting that daily wear of eyeglasses is associated with less susceptibility to COVID-19 infection. These findings suggest that the eye may be an important infection route for COVID-19, and more attention should be paid to preventive measures such as frequent hand washing and avoiding touching the eyes.

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    Article Information

    Accepted for Publication: July 28, 2020.

    Corresponding Author: Yiping Wei, MD, PhD (weiyip2000@hotmail.com), and Jianjun Xu, MD, PhD (xujianjun3526@163.com), Department of Thoracic Surgery, The Second Affiliated Hospital of Nanchang University, 1 Min De Road, Nanchang 330006, China.

    Published Online: September 16, 2020. doi:10.1001/jamaophthalmol.2020.3906

    Author Contributions: Drs Wei and Xu had full access to the study data and take responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Xu, Yiping.

    Acquisition, analysis, or interpretation of data: Zeng, Xiaolin, Junyu, Qiu, Yong, Song, Yiping.

    Drafting of the manuscript: Zeng, Xiaolin, Junyu, Qiu, Song, Yiping.

    Critical revision of the manuscript for important intellectual content: Zeng, Yong, Xu, Yiping.

    Statistical analysis: All authors.

    Obtained funding: Zeng, Xu, Yiping.

    Administrative, technical, or material support: Zeng, Junyu, Yong, Xu, Yiping.

    Supervision: Yong, Xu, Yiping.

    Conflict of Interest Disclosures: None reported.

    Additional Contributions: We thank the physicians who supported Suizhou Zengdu Hospital, Suizhou, China, in the fight against coronavirus disease 2019 for their contribution to patient management and data collection for this study.

    References
    1.
    Wu  Z, McGoogan  JM.  Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention.   JAMA. 2020. doi:10.1001/jama.2020.2648 PubMedGoogle Scholar
    2.
    Pongpirul  WA, Pongpirul  K, Ratnarathon  AC, Prasithsirikul  W.  Journey of a Thai taxi driver and novel coronavirus.   N Engl J Med. 2020;382(11):1067-1068. doi:10.1056/NEJMc2001621 PubMedGoogle ScholarCrossref
    3.
    Chen  M, Wu  A, Zhang  L,  et al.  The increasing prevalence of myopia and high myopia among high school students in Fenghua City, eastern China: a 15-year population-based survey.   BMC Ophthalmol. 2018;18(1):159. doi:10.1186/s12886-018-0829-8 PubMedGoogle ScholarCrossref
    4.
    General Office of National Health Commission. Diagnosis and treatment protocols for novel coronavirus pneumonia (trial version 5, revised) [in Chinese]. Published February 4, 2020. Accessed March 15, 2020. http://www.gov.cn/zhengce/zhengceku/2020-02/09/content_5476407.htm
    5.
    Chinese Student Physique and Health Research Group.  Research on Chinese Students' Physique and Health [in Chinese]. People's Education Press; 1987.
    6.
    van Doremalen  N, Bushmaker  T, Morris  DH,  et al.  Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1.   N Engl J Med. 2020;382(16):1564-1567. doi:10.1056/NEJMc2004973 PubMedGoogle ScholarCrossref
    7.
    Kwok  YL, Gralton  J, McLaws  ML.  Face touching: a frequent habit that has implications for hand hygiene.   Am J Infect Control. 2015;43(2):112-114. doi:10.1016/j.ajic.2014.10.015 PubMedGoogle ScholarCrossref
    8.
    Holappa  M, Vapaatalo  H, Vaajanen  A.  Many faces of renin-angiotensin system—focus on eye.   Open Ophthalmol J. 2017;11:122-142. doi:10.2174/1874364101711010122 PubMedGoogle ScholarCrossref
    9.
    Xiao  X, Chakraborti  S, Dimitrov  AS, Gramatikoff  K, Dimitrov  DS.  The SARS-CoV S glycoprotein: expression and functional characterization.   Biochem Biophys Res Commun. 2003;312(4):1159-1164. doi:10.1016/j.bbrc.2003.11.054 PubMedGoogle ScholarCrossref
    10.
    Guan  WJ, Ni  ZY, Hu  Y,  et al; China Medical Treatment Expert Group for Covid-19.  Clinical characteristics of coronavirus disease 2019 in China.   N Engl J Med. 2020;382(18):1708-1720. doi:10.1056/NEJMoa2002032 PubMedGoogle ScholarCrossref
    11.
    Wu  P, Duan  F, Luo  C,  et al.  Characteristics of ocular findings of patients with coronavirus disease 2019 (COVID-19) in Hubei Province, China.   JAMA Ophthalmol. 2020;138(5):575-578. doi:10.1001/jamaophthalmol.2020.1291 PubMedGoogle ScholarCrossref
    12.
    Seah  IYJ, Anderson  DE, Kang  AEZ,  et al.  Assessing viral shedding and infectivity of tears in coronavirus disease 2019 (COVID-19) patients.   Ophthalmology. 2020;127(7):977-979. doi:10.1016/j.ophtha.2020.03.026 PubMedGoogle ScholarCrossref
    13.
    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 PubMedGoogle Scholar
    14.
    World Health Organization. Coronavirus disease (COVID-19) advice for the public. Updated June 4, 2020. Accessed April 1, 2020. https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public
    15.
    Machida  M, Nakamura  I, Saito  R,  et al.  Adoption of personal protective measures by ordinary citizens during the COVID-19 outbreak in Japan.   Int J Infect Dis. 2020;94:139-144. doi:10.1016/j.ijid.2020.04.014 PubMedGoogle ScholarCrossref
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