- 1 American Academy of Ophthalmology Update
- 2 Disease Entity
- 3 Diagnosis
- 4 Management
- 4.1 General treatment
- 4.2 Medical therapy
- 4.3 Medical follow up
- 4.4 Surgery
- 4.5 Surgical follow up
- 4.6 Complications
- 4.7 Prognosis
- 4.8 Guidelines for Ophthalmologists and Staff
- 4.8.1 General guidelines
- 4.8.2 Consultation and examination
- 188.8.131.52 Rapid Treat and Release
- 184.108.40.206 Rapid Treat and Release general principles
- 220.127.116.11 External Ocular Disease Rapid Treat and Release
- 18.104.22.168 Tele-Ophthalmology
- 22.214.171.124 For all patients with conjunctivitis
- 126.96.36.199 For patients with conjunctivitis who screen positive for COVID-19
- 188.8.131.52 For patients with conjunctivitis who screen negative for COVID-19 infection
- 184.108.40.206 For all patients who screen positive for possible COVID-19 or who have tested positive for COVID-19 (COVID-19 patients) who require ophthalmic evaluation
- 220.127.116.11 For examination of COVID-19 patients, follow the CDC Interim guidelines (referenced below) with the following amendments and clarifications
- 4.8.3 Diagnostic Procedures
- 4.8.4 Surgical Procedures
- 4.9 Additional Resources
- 5 References
American Academy of Ophthalmology Update
The Academy has daily updates on this evolving situation: Important coronavirus updates for ophthalmologists (American Academy of Ophthalmology, San Francisco, 2020).
Coronavirus Disease 2019 (COVID-19) is the official name given by the World Health Organization (WHO) for the infectious disease caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). The disease started in Wuhan, China in December 12 2019, then rapidly spread worldwide and was declared a pandemic on March 11, 2020.  It has been reported that ophthalmologists and ENT doctors in Wuhan, China were at increased risk of acquiring COVID-19.  Six New York City ophthalmologists (one on a respirator) and five ophthalmology trainees are COVID-19 positive. Others are symptomatic and awaiting test results and many are symptomatic but do not have access to testing. 
Signs and symptoms
After a patient is exposed to SARS-CoV-2, the incubation period typically lasts for 1-14 days (with an estimated mean of 5-6 days) before they develop symptoms. According to the WHO-China Joint Mission on Coronavirus Disease 2019, the most common signs and symptoms in 55,923 cases were:
- Dry cough (67.7%)
- Fatigue (38.1%)
- Sputum production (33.4%)
- Shortness of breath (18.6%)
- Sore throat (13.9%)
- Headache (13.6%)
- Myalgia or arthralgia (14.8%)
- Chills (11.4%)
- Nausea or vomiting (5.0%)
- Nasal congestion (4.8%)
- Diarrhea (3.7%)
- Hemoptysis (0.9%)
- Conjunctivitis or conjunctival congestion (0.8%)
COVID-19 is caused by an infection with SARS-CoV-2. This β-coronavirus is an enveloped positive-sense single-stranded RNA virus of the subfamily Orthocoronavirinae of the Coronaviridae family. Bat was thought to be the natural reservoir of this virus, as the outbreak began in a seafood market in Wuhan, China, where several wild animal species including bat were sold on a daily basis. Of note, bat was also reported to be the culprit of SARS and MERS epidemics in 2002 and 2012, respectively. Direct contact with intermediate hosts or consumption of wild animals is likely the initial route of SARS-CoV-2 transmission. Human-to-human transmission is the key factor for rapid spread of SARS-CoV-2, while nosocomial transmission was the most common route of infection for SARS and MERS.
Advanced age is the primary risk factor for developing COVID-19. Older patients also have higher mortality.  Zhou et al. show that patients who required admission for COVID-19 at a hospital in Wuhan more likely presented with systemic co-morbidities including hypertension (30%), diabetes (19%), coronary artery disease (8%), COPD (3%).
As above, the first transmission is thought to take place at a seafood market in Wuhan, China. Afterward, person-to-person transmission via respiratory droplets is believed to be the primary method, similarly to other Coronavirus and other comparable viruses such as influenza.
Multiple respiratory droplets may be released when an infected person coughs, sneezes or speaks. Once a respiratory droplet exits an infected individual it can be directly inhaled by another person. Droplets can also contaminate surfaces which may be touched by another person. Transmission occurs when viral particles from the respiratory droplets contact host mucus membranes. Upon contact an epithelial cell, the virus particle gains entry inside using the SARS-CoV-2 spike (S) glycoprotein which binds to the cell membrane protein angiotensin-converting enzyme 2 (ACE2). The S glycoprotein is composed of 2 subunits S1 and S2. The S2 subunit is shown to be highly conserved with a fusion peptide, a transmembrane domain and a cytoplasmic domain. This could serve as a target for producing antiviral drugs.
Once inside, the virus starts to transcribe its genome and synthesize many proteins required for rapid replication. Among the protein products, the non-structural proteins (nsp) are particularly important for pathophysiology of COVID-19, as they have the ability to disable the host's innate immune response. 
Currently there is no vaccination approved for SARS-CoV-2. In America, a clinical trial studying an investigational vaccine (called mRNA-1273) has started at Kaiser Permanente Washington Health Research Institute (KPWHRI) in Seattle on March 16, 2020. This trial is funded by National Institute of Allergy and Infectious Diseases (NIAID), a branch of the National Institute of Health (NIH). Phase 1 is currently underway with 45 healthy volunteers.
At the same time, it is crucial to keep hand hygiene and practice "social distancing" to stop the spread of SARS-CoV-2. It has been shown that SARS-COV-2 remained viable in aerosol for up to three hours, so airborne precautions with full personal protective equipment (PPE) is strongly recommended, particularly in case requiring aerosol generating procedure. Additionally, the researchers have shown that SARS-CoV-2 survives on stainless steel and plastic for up to 72 hours, cardboard for up to 24 hours, and copper for up to 4 hours.
A detailed history should include documentation of risk factors such as:
- Presence of fever or any respiratory symptoms including but not limited to cough, sputum production, hemoptysis, sore throat, headache, fatigue, myalgia.
- Presence of conjunctivitis symptoms including red eye, itchiness, tearing, foreign body sensation, photosensitivity, swollen eyelids.
- Close contact with an individual with known or suspected COVID-19 or pneumonia of unknown cause
- Residence in—or travel to—an area with widespread ongoing transmission, including: New York, New Jersey, California, Washington, New Orleans, as well as China, Iran, South Korea, and most of Europe.
- History of chronic systemic diseases including hypertension, diabetes, or immunocompromised state.
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Conjunctivitis has been identified as an infrequent ophthalmologic sign of Covid-19, with the virus being isolated from tears and conjunctival secretions.
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The CDC is distributing real-time RT PCR (rRT-PCR) assays for the in vitro qualitative detection of SARS-CoV-2 in respiratory specimens and sera.  There are also at least 8 additional commercial tests based on similar technology that are available through the FDA Coronavirus Disease 2019 (COVID-19) Emergency Use Authorizations for Medical Devices. 
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There are no proven therapies for COVID-19 and management consists mainly of supportive care. There are some emerging studies suggesting benefit of treatment with hydroxychloroquine. For patients with severe disease, there are active clinical trials investigating the use of remdesivir.
In a review of published guidelines for the use of these 2 drugs as treatment for COVID-19, a working group (Ruamviboonsuk P, Lai T, Chang A, Lai C, Mieler W, Lam D) from the Asia-Pacific Vitreo-retina Society found that proposed doses in many of the ongoing studies worldwide exceeded the maximum daily dose considered safe for long-term therapy (generally <5mg/kg of real weight for hydroxychloroquine) for rheumatic and other chronic diseases.
The risk of irreversible maculopathy at these higher doses for short periods of time is unknown. Patients should be informed of the potential for macular toxicity before starting therapy. Furthermore, the need for baseline fundus examination and/or imaging is also unknown in cases with high doses over a relatively short duration. Additional diagnostic testing, such as an ERG, prior to placing a patient on hydroxychloroquine for treatment of COVID-19 is likely unnecessary due to the short treatment duration. Additionally, performing an ERG in this setting carries an unnecessary risk of virus transmission.
Until more is learned about the toxicity associated with current regimens, decisions should be made on an individual basis, taking into consideration any pre-existing retinal disease. 
Medical follow up
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Surgical follow up
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In the United States, between February 12 and March 16, 2020, 12% of diagnosed cases required hospitalization. 18% of cases requiring hospitalization were patients 45–54 years, and 20% were patients 20–44 years. Mortality ranged from 10%–27% in patients aged ≥85 years to <1% in patients aged 20–54 years. In Washington state, the first epicenter of America, between February 20, 2020, and March 5, 2020, Evergreen Hospital in Kirkland, WA treated 21 patients with COVID-19. Mechanical ventilation was initiated in 15 of the 21 patients (71%). Cardiomyopathy was observed in 7 patients (33%). As of March 17, 2020, mortality was 67% while another 24% remained critically ill, and 9.5% had been discharged from the ICU.
Emerging data from China suggests that most cases (around 80%) are mild and do not require hospitalization. Individuals with severe disease have up to 28% in-hospital mortality. For hospitalized patients, risk of death is increased with older age, higher Sequential Organ Failure Assessment (SOFA) score, and d-dimer greater than 1 μg/mL. Median duration of viral shedding was 20 days, and the longest observed duration of viral shedding in survivors was 37 days.
Guidelines for Ophthalmologists and Staff
Triage and Scheduling Staff
As of March 18, 2020, the American Academy of Ophthalmology recommends all ophthalmologists to cease non-urgent eye care until further notice.
Ophthalmology Patient Triage
The following is meant as a guide to assist with decision making. Patients must be evaluated on a case-by-case basis.
|Ophthalmology Patient Triage|
|Specialty||High Risk (In person visit)||Telemedicine or Phone Visit (Note: all patients require telephonic triage before telemedicine consultation)||Low risk (Rebook in 3-6 months)|
|New||None||None||Can be delayed|
|Follow-up||Pain, redness, photophobia (needs risk assessment)||Delays acceptable in other patients|
|Cornea and Cataract|
|New||Patient by patient triage but likely delayed||Patient by patient triage but likely delayed||all routine, dry eye|
Eye pain, discomfort
|Follow-up||Phone/video consultation as necessary||Postponement or discharge from phone/video triage|
|Follow-up||All patients unless exceptional circumstances|
||Patient by patient triage of new referrals needed|
|New||All new referrals but with enhanced triage by team|
|Follow-up||Patients on less than 12 month follow-up interval||Patients on greater 12 month follow-up interval||Patients with no issues on video/telephone triage could be delayed further|
|Surgery||Expected to continue unless extenuating circumstances|
|Surgery||Tumor cases or orbital conditions with visual loss||Most other surgery could be postponed|
|Pediatrics and Strabismus|
||Case by case basis for failed vision screen age 5 or less||
Patient by patient triage by attending
|Surgery||Cataract, glaucoma, dacryocele, severe ptosis in baby|
|New||Referral for RD, tear, CNVM, CRVO, Retinopathy noted on Diabetic screening, community optometry, A&E||
|Surgery||New Detachments, monocular hemorrhage in good eye, endophthalmitis, ruptured globe, uncontrolled IOP, acute subfoveal hemorrhage, dislocated lens with inflammation and elevated IOP||ERM, macular hole, VMT with no change, lens dislocations|
|New||Patient by patient triage needed||Neuromuscular disorders|
|Follow-up||Patient by patient triage needed||Neuromuscular disorders||Stable followup on a patient by patient basis|
||Unlikely to be helpful in new uveitis patients||Anterior uveitis in A&E could be given an 8-10 week tapering course of drops then review in 3 months|
|Follow-up||Reviewed on a patient by patient basis but potentially 1/3 of patients may have to continue to attend||
|Surgery||Cataract surgery for uveitis patients could be delayed|
- Reschedule outpatient visits, follow-ups or procedures that are not urgent should be postponed (as above).
- For urgent cases, these questions should be asked before any patient or visitor enters the building or waiting room:
- Presence of fever or respiratory symptoms: cough, sputum production, hemoptysis, sore throat, headache, fatigue, myalgia.
- Travel history or exposure to somebody who traveled to the high-risk areas (China, South Korea, Iran, Italy, Washington, New York or California) in the past 14 days.
- If a patient answers yes to either of the above questions, they should be sent home and encouraged to speak to their primary care provider
- If symptoms are severe, they should be sent to the Emergency Department of a hospital capable of handling COVID-19.
- Waiting room should be as empty as possible, and patients should be encourage to sit at least 6 ft from each other.
All Clinical Staff
- Registration clerks are to wear procedural masks.
- Wash your hands before and after each patient. When cleaning your hands with soap and water, wet your hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub your hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers. Rinse your hands with water and use disposable towels to dry.
- Use a towel to turn off the faucet. Avoid using hot water, to prevent drying of skin.
Technicians and Optometrists
- Technicians assess each patient by taking a history, measuring spectacles, recording vision, and refracting.
- Gloves are recommended for all technicians and providers.
- Technicians should not perform slit lamp exams.
- Lanes need to be cleaned after each patient. Scrub of room should include faucets.
- Phoropters should be cleaned before and after each use and covered when not being used.
- Be on alert for patients who present with conjunctivitis, especially with flu-like symptoms (fever, cough, sore throat, runny or stuffy nose, head congestion, headache, nausea, shortness of breath, fatigue). Please alert the nursing staff if you identify such a patient.
- All patients with conjunctivitis are to be considered at risk for COVID-19.
- One visitor is allowed to accompany each patient to an appointment, unless an aide or assistant is required.
- All patient movement through the practice should be as limited as possible.
- Hand-sanitize frequently.
Consultation and examination
Rapid Treat and Release
- Rapid Treat and Release is the expeditious performance, with minimal use of instrumentation, of the minimally necessary medically appropriate evaluation and treatment in order to
- minimize the risk of COVID-19 transmission by reducing waiting room time, reducing provider contact time with patient, and minimizing use of instrumentation, and
- conserve resources.
- Rapid Treat and Release should be considered in areas with incidence of COVID-19 infection.
Rapid Treat and Release general principles
- Some conditions (e.g., non-traumatic subconjunctival hemorrhage, chalazion) may not require slit-lamp examination.
- Do not dilate all patients. If chief complaint is anterior or exterior, only examine the anterior segment.
- Use the Tonopen or a disposable tip on Goldmann tonometer for taking pressures.
- Save retinal exams and accessory lens use for patients who really need it, i.e., if something is not explained by anterior segment findings.
- Residents, technicians, nurses, and physician assistants should have lower threshold for asking supervising physicians when they are not sure if a patient should be rescheduled for later.
- Defer routine visits, especially for more vulnerable patients with pre-existing conditions at this time.
- All should have a low threshold for wearing gloves and procedure mask. Reuse masks until soiled or damaged in order to conserve supplies.
External Ocular Disease Rapid Treat and Release
- Rapid Treat and Release is especially suited to complaints related to external ocular irritation. These complaints include:
- Foreign body sensation/scratchiness
- Fluctuating blur
- Lid tenderness/swelling
- Non-traumatic subconjunctival hemorrhage
- The following conditions must be ruled out either by history or examination:
- Conjunctivitis associated with COVID-19
- Herpes simplex infection
- Varicella zoster infection
- Acute angle closure glaucoma
- Deeper processes (orbital inflammation, temporal arteritis)
- Complaints/conditions that are less amenable to Rapid Treat and Release and require more in depth evaluation
- New onset flashes and floaters
- Retinal tear or detachment
- Painless acute vision loss
- Venous occlusion
- Arterial occlusion
- Retinal detachment
- Central serous retinopathy
- Macular degeneration/CNV/hemorrhage
- Vitreous hemorrhage
- Optic neuritis/neuropathy
- Painful vision loss
- Corneal ulcer
- Foreign body
- Optic neuritis
- Chronic eye disease requiring frequent monitoring/treatment
- Proliferative diabetic retinopathy
- Diabetes with significant macular edema
- Vein occlusion with macular edema
- Macular degeneration with CNV
- Glaucoma with poor disease control
- Pediatric amblyopia monitoring
- Acute onset diplopia
- Neurological disease
- Muscle entrapment
- Muscle paralysis
- Postop patients
- Those in the immediate postoperative period
- Those with concern for elevated IOP, retinal detachment, inflammation, rejection, etc)
- Ocular trauma
- Possible cornea or conjunctival abrasion or laceration
- Possible cornea or conjunctival foreign body
- Any blunt trauma to the globe
- Contact lens wearer with redness, pain, or visual symptoms
- New onset flashes and floaters
Using telemedicine for remote consultations or appointment alternatives can help curb the COVID-19 outbreak by serving as an effective triage mechanism, decreasing patient travel and limiting provider exposure. In some cases, telehealth information may be sufficient to make treatment recommendations. In other cases, telemedicine may allow providers to direct a patient to the appropriate location and specialist within a suitable timeframe and plan appropriate infection control measures. Telemedicine consultations may be directly between the ophthalmologist and the patient, or between the ophthalmologist and a consulting provider in a primary care office, emergency center, nursing home, or inpatient hospital setting. Telemedicine options include the patient uploading digital photos of their eye to their patient portal in the EMR or videoconferencing with live interaction.
Common ophthalmic issues that have the potential to be managed remotely include:
- Foreign body sensation/scratchiness
- Fluctuating, blurred vision
- Lid tenderness/swelling/chalazion/preseptal cellulitis
- Subconjunctival hemorrhage
- Follow-up on oculoplastics procedures with routine healing
Fundus photos, MRI and CT imaging can also be shared for decision making
For practices that do not currently have a direct-to-patient telemedicine program, WebEx or Zoom are two commonly used video conference systems that are HIPAA compliant. Numerous other compliant telemedicine platforms are available, such as VSee, Eyecarelive, and Chiron. The office would schedule the virtual visit as normal and send the video conference link via email to both the provider and patient for the appointment time. To help with the COVID-19 outbreak many platforms are discounting subscription fees.
Additionally, mobile versions of Epic (Haiku and Canto) can be used for inpatient rounding while Vidyo can be used to connect with inpatients who are in isolation/quarantine.
Because commercial payers do not consistently reimburse for telemedicine services, the practice will need to decide how to bill patients for these telemedicine services. If it is decided to bill, the office should communicate the maximum out of pocket cost to patients before scheduling. Visits can be scheduled for a preset duration (i.e. $X for 15 minutes).
In response to the COVID-19 outbreak, on March 6, 2020, Congress has waived or modified requirements for reimbursement for telehealth services within any identified emergency area during the current emergency period with the Coronavirus Preparedness and Response Supplemental Appropriations Act. This will allow physicians to bill Medical and Medicaid. Specific new time-based service codes have been created: 99421, 99422 , 99423.
For all patients with conjunctivitis
- Once a patient is identified by any staff member as having conjunctivitis, the patient should wear a procedural mask.
- All staff interacting with a conjunctivitis patient should wear a procedural mask and eye protection.
- The conjunctivitis patient should be screened for COVID-19.
For patients with conjunctivitis who screen positive for COVID-19
- Follow the Instruction for handling suspected COVID-19
- If ophthalmic evaluation is necessary, please follow the guidelines that follow.
For patients with conjunctivitis who screen negative for COVID-19 infection
- The patient should wear a procedural mask.
- All staff interacting with the patient should wear a procedural mask and eye protection.
- Isolate the patient in an examination room immediately.
- The examining physician should wear a procedural mask.
- The physician will use his/her best medical judgement in evaluating and treating the patient, including deciding if slit lamp examination is appropriate and necessary.
- If during or after evaluating the patient, the designated physician has a strong suspicion of COVID-19, follow standard COVID-19 protocol.
For all patients who screen positive for possible COVID-19 or who have tested positive for COVID-19 (COVID-19 patients) who require ophthalmic evaluation
If in the unlikely event that an ophthalmology consultation on a COVID-19 patient is requested, the ophthalmologist responsible for handling the consultation should ask the following questions of the requesting physician to ascertain if ophthalmology consultation is medically necessary:
- Did the patient have any recent ocular procedure/surgery? (we don't want to miss the rare event of endophthalmitis)
- Has patient vision changed?
- Does the patient have photophobia (light sensitivity)?
- Is the patient a contact lens wearer, and, if so, is the patient wearing contact lenses?
- Did the patient have recent ophthalmic trauma (including any risk of a cornea/conjunctiva foreign body)?
- Is the patient complaining of double vision?
The ophthalmologist responsible for handling the consultation request then makes recommendations to the requesting physician regarding management of the patient. The ophthalmologist will follow standard consultation policy and will perform a consultation if, after discussion with the requesting physician, the requesting physician still requests a consultation.
For examination of COVID-19 patients, follow the CDC Interim guidelines (referenced below) with the following amendments and clarifications
- For ophthalmologic evaluations not necessitating slit lamp or direct ophthalmoscopy examination, standard CDC-recommended personal protective (facemask, eye shield/goggles, gowns and gloves) equipment is mandatory. Shoe covers (not addressed in CDC recommendations) are mandatory.
- N95 respirators and eye shields, along with all other recommended personal protective equipment (listed above) are to be worn for:
- Portable or standard slit lamp evaluation (this extremely close contact examination is not addressed in CDC guidelines),
- Direct ophthalmoscopy (this extremely close contact examination is not addressed in CDC guidelines), which should only be performed if slit lamp 78 or 90 diopter fundoscopy or funduscopic imaging is unavailable, and
- All ophthalmic procedures, including injections, laser surgery, and incisional surgery
As per CDC guidelines, only designated equipment should be used when caring for patients with known or suspected COVID-19. If dedicated equipment is unavailable, all equipment used in the evaluation of a COVID-19 patient is to undergo disinfection (please see above for cleaning protocol)
Non-essential imaging/testing should be deferred, and equipment use should be kept at a minimum.
- Tonometry: Intraocular pressure will be checked using a Tonopen with a disposable tip. If Goldmann tonometry is needed, a disposable tip must be used.
- Gonioscopy: Should only be performed with a strong medical indication. If performed, a disposable gonioprism should be used. If a disposable gonioprism is not available, the reusable gonioprism should undergo high level disinfection.
- Ultrasound Pachymetry: Should not be performed
- Direct ophthalmoscopy: Should only be performed if there is a strong medical indication. High magnification fundoscopy should be performed with 90 or 78 diopter lenses at the slit lamp.
- Slit Lamp: Should be used with commercially available slit-lamp barriers or breath shield.
- Humphrey Visual Fields: The need for visual field testing should be determined for each patient by his/her doctor. Our goal is to use perimetry for those patients at high risk for progression, surgical decision-making, and new patients. Routine perimetry should be deferred to the next visit if possible.
- Optical Coherence Tomography (OCT): The need for imaging testing should be determined for each patient by his/her doctor. Our goal is to use imaging for those patients at high risk for progression, surgical decision-making, and new patients. Routine imaging should be deferred to the next visit if possible.
Therapeutic procedures requiring contact lenses
- Ophthalmic laser treatments should be kept to a minimum. Elective lasers (e.g., for posterior capsulotomy in a patient with adequate visual function) should be deferred.
- Ophthalmic lasers that cannot be deferred should be performed with single use disposable laser lenses. If a single-use lens is not available, the reusable lens should undergo high level disinfection.
- Front desk workstations and waiting room furniture should be cleaned hourly with an EPA recommended disinfectant. Additional cleans should be done after patients who present with conjunctivitis or with flu-like symptoms.
- All imaging equipment should be cleaned before and after each patient, using the technique recommended by each manufacturer.
- Rooms and instruments should be thoroughly disinfected after each patient encounter. Wear disposable gloves when cleaning and disinfecting surfaces. Slit lamps, including controls and accompanying breath shields, should be disinfected, particularly wherever patients put their hands and face. The current CDC recommendations for disinfectants specific to COVID-19 include:
- Diluted household bleach (5 tablespoons bleach per gallon of water)
- Alcohol solutions with at least 70% alcohol.
- Common EPA-registered household disinfectants currently recommended for use against SARS-CoV-2 include Clorox brand products (e.g., disinfecting wipes, multi-surface cleaner + bleach, clean up cleaner + bleach), Lysol brand products (e.g., professional disinfectant spray, clean and fresh multi-surface cleaner, disinfectant max cover mist), Purell professional surface disinfectant wipes and more. The EPA offers a full list of antimicrobial products expected to be effective against COVID-19 based on data for similar viruses.
In order to prevent unnecessary exposure to asymptomatic patients with COVID-19, as well as to conserve the limited supply of masks, face shields, and other protective equipment, the CDC recommends the cancellation and reduction of all elective surgeries, particularly in Seattle (Washington), Santa Clara (California), New Rochelle (New York), Florida, and Massachusetts as of March 14, 2020.
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