Ocular screening in severe acute respiratory syndrome.

PURPOSE: To investigate the ocular manifestations of patients with severe acute respiratory syndrome (SARS) and to monitor the possible ocular complications arising from the treatment regimen with high-dose systemic corticosteroid drugs.
DESIGN: Prospective, observational cohort case series.
METHODS: Ninety eyes from 45 patients with the diagnosis of SARS during an epidemic outbreak in Hong Kong were analyzed. Relevant medical and ophthalmic histories were taken. Ophthalmic examinations, including best-corrected visual acuity, intraocular pressure, slit-lamp, and indirect ophthalmoscopy examination, were performed at baseline and at 2-month and 3-month follow-up.
SETTING: Faculty practice in university hospital.
RESULTS: Only two patients had mild elevated intraocular pressure at baseline and at subsequent follow-up. There was no loss of visual acuity, cataract progression, or increased cup-disk ratio. Fundus examinations were unremarkable in all patients.
CONCLUSIONS: Our study did not demonstrate any ocular manifestations in patients with SARS. The treatment regimen of high-dose corticosteroid also did not show any significant ocular complications. Routine ocular screening of patients with SARS for diagnosis or for complications might not be indicated.

Severe acute respiratory syndrome (SARS) is a newly recognized but highly contagious disease entity that has recently been reported in Asia, North America, and Europe.1, 2 Within a short period of time, the outbreak afflicted more than 30 countries and became a global health threat. The infectious agent of this “modern plague” was suspected to be caused by a novel coronavirus strain (SARS-Cov),3 and coronavirus has been previously reported to be associated with retinitis and a breakdown of the blood–retinal barrier in animal studies.4, 5 The ocular involvements of this novel coronavirus strain, SARS-Cov, and its disease, SARS, in humans were not known.

Methylprednisolone pulse therapy and high-dose oral prednisolone constituted the major part of the treatment regimen for SARS. Prolonged use of a corticosteroid drug is associated with glaucoma, cataract, central serous chorioretinopathy, and papilloedema.6 There is little information in the literature on the significance of routine ocular monitoring during the acute phase in prescribing pulse or high-dose corticosteroid therapy.

In March 2003, Hong Kong was seriously affected by a massive outbreak of SARS, and we took that opportunity to conduct a prospective observational study to investigate the probable ocular manifestations arising from SARS and the possible short-term complications resulting from the pulse or high-dose corticosteroid therapy. The results are important to physicians and ophthalmologists in determining whether a routine ocular examination should be arranged in suspected cases for diagnosis and in probable or confirmed cases for monitoring of complications.

Patients with the diagnosis of SARS who had been managed in the Prince of Wales Hospital, Hong Kong, were recruited. We only included cases that were probable and therefore fit the case definition issued by the World Health Organization.1 Cases were excluded if an alternative diagnosis could fully explain their illness. Patients physically unfit for ophthalmic examinations or those who failed to give informed consent were also excluded. The study was approved by the Ethics Committee of the Chinese University of Hong Kong. Relevant medical and ocular histories, including diabetes mellitus, hypertension, glaucoma, high myopia, previous ocular disease, and surgery, were recorded. Patients were assessed with a comprehensive ocular examination including best-corrected visual acuity, intraocular pressure (IOP) by noncontact tonometer ([NCT] Xpert Noncontact Tonometer Plus; Reichert Ophthalmic Instruments, New York, New York, USA), slit-lamp, and binocular indirect ophthalmoscopy at baseline and at 2 months and 3 months. Use of personal protective equipment recommended by the Infectious Control Unit of the hospital was strictly maintained throughout the examination.

A total of 45 patients (90 eyes) were recruited; 28 (62.2%) were female and 17 were male. Their age ranged from 22 to 74 years (mean, 39 years). Most patients were recruited during the first week (n = 17, 37.8%) or second week (n = 18, 40.0%) of their diseases. Four patients had been admitted to the intensive care unit, and 1 of them died during the follow-up, but no postmortem study on the eye was made. The mean ± standard deviation of the IOP at baseline was 14.2 ± 3.6 mm Hg. Two patients had IOP higher than 21.0 mm Hg. One was 21.7 mm Hg, and the other was 23.7 mm Hg. Both had a normal visual field with Humphrey central 24-2 threshold test and had no other glaucomatous features.

Twenty-seven patients (60%) completed the second-month follow-up and 15 patients (33%) completed the third-month follow-up. Only 15 patients (55%) were still on prednisolone by the second month (dosage ranged from 5 to 15 mg), and none required any by the third month. No visual acuity loss, cataract progression, or anterior uveitis was observed. Fundus examinations were unremarkable in all patients, with particular emphasis on any vitritis, retinitis, vaculitis, central serous chorioretinopathy, and changes at the optic disks. For the 2 patients with mildly elevated IOP in both eyes, the IOP was persistent elevated at the same level 2 months after corticosteroid cessation. There was no statistically significant difference between IOP at baseline and month 2 (t test, P = .904; SPSS 10.0 for Windows). At month 3, when no patient was on corticosteroid, the mean IOP was 13.8 ± 2.9 mm Hg. There was only one case with IOP greater than 21.0 mm Hg. This patient had an IOP of 22.0 mm Hg at month 3 and IOP of 21.3 mm Hg at baseline. None of the cases had an IOP rise of at least 2.0 mm Hg compared with the baseline IOP.

Our study did not demonstrate any ocular manifestations resulting from SARS or the novel coronavirus. No significant elevation in IOP or other corticosteroid-related ocular complications was observed in the short-term follow-up. Coronavirus-associated atypical pneumonia is extremely infectious, and the transmission appears to be through direct contact or contact with respiratory droplets in close vicinity to an infected person. Health care workers are particularly at risk for infection, as reflected by the numbers of those involved. Among the total number of 8,422 cases worldwide, 1,725 (20%) were health care workers.2 With the unremarkable ophthalmologic findings of this study, routine ocular screening in patients with SARS for diagnosis or for complications may not be worthwhile.