The COVID-19 pandemic: Important considerations for contact lens practitioners
Identifieur interne : 000F17 ( Pmc/Corpus ); précédent : 000F16; suivant : 000F18The COVID-19 pandemic: Important considerations for contact lens practitioners
Auteurs : Lyndon Jones ; Karen Walsh ; Mark Willcox ; Philip Morgan ; Jason NicholsSource :
- Contact Lens & Anterior Eye [ 1367-0484 ] ; 2020.
Abstract
A novel coronavirus (CoV), the Severe Acute Respiratory Syndrome Coronavirus - 2 (SARS-CoV-2), results in the coronavirus disease 2019 (COVID-19). As information concerning the COVID-19 disease continues to evolve, patients look to their eye care practitioners for accurate eye health guidance. There is currently no evidence to suggest an increased risk of contracting COVID-19 through contact lens (CL) wear compared to spectacle lens wear and no scientific evidence that wearing standard prescription spectacles provides protection against COVID-19 or other viral transmissions.
During the pandemic there will potentially be significant changes in access to local eyecare. Thus, it is imperative CL wearers are reminded of the steps they should follow to minimise their risk of complications, to reduce their need to leave isolation and seek care. Management of adverse events should be retained within optometric systems if possible, to minimise the impact on the wider healthcare service, which will be stretched. Optimal CL care behaviours should be the same as those under normal circumstances, which include appropriate hand washing (thoroughly with soap and water) and drying (with paper towels) before both CL application and removal. Daily CL cleaning and correct case care for reusable CL should be followed according to appropriate guidelines, and CL exposure to water must be avoided. Where the availability of local clinical care is restricted, practitioners should consider advising patients to reduce or eliminate sleeping in their CL (where patients have the appropriate knowledge about correct daily care and access to suitable lens-care products) or consider the option of moving patients to daily disposable lenses (where patients have appropriate lens supplies available). Patients should also avoid touching their face, including their eyes, nose and mouth, with unwashed hands and avoid CL wear altogether if unwell (particularly with any cold or flu-like symptoms).
Url:
DOI: 10.1016/j.clae.2020.03.012
PubMed: 32273245
PubMed Central: 7129028
Links to Exploration step
PMC:7129028Le document en format XML
<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">The COVID-19 pandemic: Important considerations for contact lens practitioners</title><author><name sortKey="Jones, Lyndon" sort="Jones, Lyndon" uniqKey="Jones L" first="Lyndon" last="Jones">Lyndon Jones</name><affiliation><nlm:aff id="aff0005">School of Optometry & Vision Science, Centre for Ocular Research & Education (CORE), University of Waterloo, Waterloo, Ontario, Canada</nlm:aff></affiliation></author><author><name sortKey="Walsh, Karen" sort="Walsh, Karen" uniqKey="Walsh K" first="Karen" last="Walsh">Karen Walsh</name><affiliation><nlm:aff id="aff0010">Centre for Ocular Research & Education (CORE), University of Waterloo, Waterloo, Ontario, Canada</nlm:aff></affiliation></author><author><name sortKey="Willcox, Mark" sort="Willcox, Mark" uniqKey="Willcox M" first="Mark" last="Willcox">Mark Willcox</name><affiliation><nlm:aff id="aff0015">School of Optometry and Vision Science, UNSW, Sydney, Australia</nlm:aff></affiliation></author><author><name sortKey="Morgan, Philip" sort="Morgan, Philip" uniqKey="Morgan P" first="Philip" last="Morgan">Philip Morgan</name><affiliation><nlm:aff id="aff0020">The University of Manchester, Manchester, UK</nlm:aff></affiliation></author><author><name sortKey="Nichols, Jason" sort="Nichols, Jason" uniqKey="Nichols J" first="Jason" last="Nichols">Jason Nichols</name><affiliation><nlm:aff id="aff0025">University of Alabama at Birmingham, Birmingham, AL, USA</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">32273245</idno><idno type="pmc">7129028</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7129028</idno><idno type="RBID">PMC:7129028</idno><idno type="doi">10.1016/j.clae.2020.03.012</idno><date when="2020">2020</date><idno type="wicri:Area/Pmc/Corpus">000F17</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000F17</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">The COVID-19 pandemic: Important considerations for contact lens practitioners</title><author><name sortKey="Jones, Lyndon" sort="Jones, Lyndon" uniqKey="Jones L" first="Lyndon" last="Jones">Lyndon Jones</name><affiliation><nlm:aff id="aff0005">School of Optometry & Vision Science, Centre for Ocular Research & Education (CORE), University of Waterloo, Waterloo, Ontario, Canada</nlm:aff></affiliation></author><author><name sortKey="Walsh, Karen" sort="Walsh, Karen" uniqKey="Walsh K" first="Karen" last="Walsh">Karen Walsh</name><affiliation><nlm:aff id="aff0010">Centre for Ocular Research & Education (CORE), University of Waterloo, Waterloo, Ontario, Canada</nlm:aff></affiliation></author><author><name sortKey="Willcox, Mark" sort="Willcox, Mark" uniqKey="Willcox M" first="Mark" last="Willcox">Mark Willcox</name><affiliation><nlm:aff id="aff0015">School of Optometry and Vision Science, UNSW, Sydney, Australia</nlm:aff></affiliation></author><author><name sortKey="Morgan, Philip" sort="Morgan, Philip" uniqKey="Morgan P" first="Philip" last="Morgan">Philip Morgan</name><affiliation><nlm:aff id="aff0020">The University of Manchester, Manchester, UK</nlm:aff></affiliation></author><author><name sortKey="Nichols, Jason" sort="Nichols, Jason" uniqKey="Nichols J" first="Jason" last="Nichols">Jason Nichols</name><affiliation><nlm:aff id="aff0025">University of Alabama at Birmingham, Birmingham, AL, USA</nlm:aff></affiliation></author></analytic><series><title level="j">Contact Lens & Anterior Eye</title><idno type="ISSN">1367-0484</idno><idno type="eISSN">1476-5411</idno><imprint><date when="2020">2020</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><p>A novel coronavirus (CoV), the Severe Acute Respiratory Syndrome Coronavirus - 2 (SARS-CoV-2), results in the coronavirus disease 2019 (COVID-19). As information concerning the COVID-19 disease continues to evolve, patients look to their eye care practitioners for accurate eye health guidance. There is currently no evidence to suggest an increased risk of contracting COVID-19 through contact lens (CL) wear compared to spectacle lens wear and no scientific evidence that wearing standard prescription spectacles provides protection against COVID-19 or other viral transmissions.</p><p>During the pandemic there will potentially be significant changes in access to local eyecare. Thus, it is imperative CL wearers are reminded of the steps they should follow to minimise their risk of complications, to reduce their need to leave isolation and seek care. Management of adverse events should be retained within optometric systems if possible, to minimise the impact on the wider healthcare service, which will be stretched. Optimal CL care behaviours should be the same as those under normal circumstances, which include appropriate hand washing (thoroughly with soap and water) and drying (with paper towels) before both CL application and removal. Daily CL cleaning and correct case care for reusable CL should be followed according to appropriate guidelines, and CL exposure to water must be avoided. Where the availability of local clinical care is restricted, practitioners should consider advising patients to reduce or eliminate sleeping in their CL (where patients have the appropriate knowledge about correct daily care and access to suitable lens-care products) or consider the option of moving patients to daily disposable lenses (where patients have appropriate lens supplies available). 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<front><journal-meta><journal-id journal-id-type="nlm-ta">Cont Lens Anterior Eye</journal-id><journal-id journal-id-type="iso-abbrev">Cont Lens Anterior Eye</journal-id><journal-title-group><journal-title>Contact Lens & Anterior Eye</journal-title></journal-title-group><issn pub-type="ppub">1367-0484</issn><issn pub-type="epub">1476-5411</issn><publisher><publisher-name>British Contact Lens Association. Published by Elsevier Ltd.</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">32273245</article-id><article-id pub-id-type="pmc">7129028</article-id><article-id pub-id-type="publisher-id">S1367-0484(20)30055-2</article-id><article-id pub-id-type="doi">10.1016/j.clae.2020.03.012</article-id><article-categories><subj-group subj-group-type="heading"><subject>Article</subject></subj-group></article-categories><title-group><article-title>The COVID-19 pandemic: Important considerations for contact lens practitioners</article-title></title-group><contrib-group><contrib contrib-type="author" id="aut0005"><name><surname>Jones</surname><given-names>Lyndon</given-names></name><email>lwjones@uwaterloo.ca</email><xref rid="aff0005" ref-type="aff">a</xref><xref rid="cor0005" ref-type="corresp">⁎</xref></contrib><contrib contrib-type="author" id="aut0010"><name><surname>Walsh</surname><given-names>Karen</given-names></name><email>karen.walsh@uwaterloo.ca</email><xref rid="aff0010" ref-type="aff">b</xref></contrib><contrib contrib-type="author" id="aut0015"><name><surname>Willcox</surname><given-names>Mark</given-names></name><email>m.willcox@unsw.edu.au</email><xref rid="aff0015" ref-type="aff">c</xref></contrib><contrib contrib-type="author" id="aut0020"><name><surname>Morgan</surname><given-names>Philip</given-names></name><email>philip.morgan@manchester.ac.uk</email><xref rid="aff0020" ref-type="aff">d</xref></contrib><contrib contrib-type="author" id="aut0025"><name><surname>Nichols</surname><given-names>Jason</given-names></name><email>jjn@uab.edu</email><xref rid="aff0025" ref-type="aff">e</xref></contrib></contrib-group><aff id="aff0005"><label>a</label>School of Optometry & Vision Science, Centre for Ocular Research & Education (CORE), University of Waterloo, Waterloo, Ontario, Canada</aff><aff id="aff0010"><label>b</label>Centre for Ocular Research & Education (CORE), University of Waterloo, Waterloo, Ontario, Canada</aff><aff id="aff0015"><label>c</label>School of Optometry and Vision Science, UNSW, Sydney, Australia</aff><aff id="aff0020"><label>d</label>The University of Manchester, Manchester, UK</aff><aff id="aff0025"><label>e</label>University of Alabama at Birmingham, Birmingham, AL, USA</aff><author-notes><corresp id="cor0005"><label>⁎</label>Corresponding author. <email>lwjones@uwaterloo.ca</email></corresp></author-notes><pub-date pub-type="pmc-release"><day>3</day><month>4</month><year>2020</year></pub-date><pmc-comment> PMC Release delay is 0 months and 0 days and was based on .</pmc-comment>
<pub-date pub-type="epub"><day>3</day><month>4</month><year>2020</year></pub-date><elocation-id></elocation-id><history><date date-type="received"><day>26</day><month>3</month><year>2020</year></date><date date-type="rev-recd"><day>29</day><month>3</month><year>2020</year></date><date date-type="accepted"><day>29</day><month>3</month><year>2020</year></date></history><permissions><copyright-statement>© 2020 British Contact Lens Association. Published by Elsevier Ltd. All rights reserved.</copyright-statement><copyright-year>2020</copyright-year><copyright-holder></copyright-holder><license><license-p>Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.</license-p></license></permissions><abstract id="abs0005"><p>A novel coronavirus (CoV), the Severe Acute Respiratory Syndrome Coronavirus - 2 (SARS-CoV-2), results in the coronavirus disease 2019 (COVID-19). As information concerning the COVID-19 disease continues to evolve, patients look to their eye care practitioners for accurate eye health guidance. There is currently no evidence to suggest an increased risk of contracting COVID-19 through contact lens (CL) wear compared to spectacle lens wear and no scientific evidence that wearing standard prescription spectacles provides protection against COVID-19 or other viral transmissions.</p><p>During the pandemic there will potentially be significant changes in access to local eyecare. Thus, it is imperative CL wearers are reminded of the steps they should follow to minimise their risk of complications, to reduce their need to leave isolation and seek care. Management of adverse events should be retained within optometric systems if possible, to minimise the impact on the wider healthcare service, which will be stretched. Optimal CL care behaviours should be the same as those under normal circumstances, which include appropriate hand washing (thoroughly with soap and water) and drying (with paper towels) before both CL application and removal. Daily CL cleaning and correct case care for reusable CL should be followed according to appropriate guidelines, and CL exposure to water must be avoided. Where the availability of local clinical care is restricted, practitioners should consider advising patients to reduce or eliminate sleeping in their CL (where patients have the appropriate knowledge about correct daily care and access to suitable lens-care products) or consider the option of moving patients to daily disposable lenses (where patients have appropriate lens supplies available). Patients should also avoid touching their face, including their eyes, nose and mouth, with unwashed hands and avoid CL wear altogether if unwell (particularly with any cold or flu-like symptoms).</p></abstract><kwd-group id="kwd0005"><title>Keywords</title><kwd>COVID-19</kwd><kwd>Contact lens</kwd><kwd>lens care</kwd><kwd>lens wear</kwd></kwd-group></article-meta></front><body><sec id="sec0005"><label>1</label><title>Introduction</title><p id="par0005">A novel coronavirus (CoV), the Severe Acute Respiratory Syndrome Coronavirus - 2 (SARS-CoV-2), results in the coronavirus disease 2019 (COVID-19). The World Health Organisation (WHO) declared the rapid spread of cases of COVID-19 a pandemic on 11<sup>th</sup> March, 2020. The global response to COVID-19 has resulted in substantial changes to business and social practices around the world. With concerns existing around the pandemic, many reports relating to how best to limit the chance of infection have been shared via various news outlets and on social media, with significant amounts of misinformation and speculation being reported [<xref rid="bib0005" ref-type="bibr">1</xref>]. Among these, recent rumours have circulated stating that contact lens wear is unsafe, that wearers of contact lenses are more at risk of developing COVID-19, that certain contact lens materials are more “risky” than others and that contact lens wearers should immediately revert to spectacle wear to protect themselves. How true are these statements, and are they supported by evidence? Importantly, are contact lens wearers increasing their risk of contracting COVID-19 by wearing contact lenses? Furthermore, what are the ramifications of a potential reduction in the availability of local ophthalmic care for contact lens wearers during this pandemic?</p><p id="par0010">Before answering these questions, it first is important to review the known structural biology and pathophysiological mechanism of an infection caused by SARS-CoV-2. All CoVs contain ribonucleic acid (RNA) as their genetic material, which is surrounded by a protein shell called a nucleocapsid. Like other CoVs, SARs-CoV-2 is an enveloped virus, meaning its nucleocapsid is surrounded by a lipid bilayer. SARs-CoV-2 has three proteins which are anchored into and protrude from the envelope, including an envelope, membrane and spike proteins [<xref rid="bib0010" ref-type="bibr">2</xref>]. These proteins form the corona that can be seen by electron microscopy and gives the name to the CoVs. The spike proteins are glycoproteins that have high affinities for angiotensin converting enzyme 2 (ACE2), a component of the renin-angiotensin system (RAS) found in many human tissues [<xref rid="bib0015" ref-type="bibr">3</xref>]. This affinity is believed to allow entry of the virus into host cells, where the virus releases its RNA into the host cell, leading to viral replication and further infection. Patients taking ACE inhibitors for hypertension may be at increased risk for adverse outcomes as taking this medication may increase ACE2 in cardiac tissues [<xref rid="bib0020" ref-type="bibr">4</xref>]; there may also be concerns about patients with chronic renal disease [<xref rid="bib0025" ref-type="bibr">5</xref>]. While many components of the RAS are found in the eye and many of its tissues, there appears to be inconsistency in the literature regarding ACE2, and more specifically, if it is present in the cornea, conjunctiva, or tears [<xref rid="bib0030" ref-type="bibr">[6]</xref>, <xref rid="bib0035" ref-type="bibr">[7]</xref>, <xref rid="bib0040" ref-type="bibr">[8]</xref>, <xref rid="bib0045" ref-type="bibr">[9]</xref>]. This may relate to the infrequent findings to date of SARS-CoV-2 presence in COVID-19 disease on the cornea, conjunctiva, or tear film of humans that is discussed later in this review. It is acknowledged that CoVs can cause a variety of infections in animals, including conjunctivitis, anterior uveitis, retinitis, and optic neuritis, many of which are severe [<xref rid="bib0050" ref-type="bibr">10</xref>].</p><sec id="sec0010"><label>1.1</label><title>Coronavirus and contact lens wear</title><p id="par0015">Contact lenses represent a highly effective form of vision correction for an estimated 140 million people worldwide, with a very low incidence of either microbial keratitis or symptomatic inflammatory keratitis in strict daily wear of contact lenses [<xref rid="bib0055" ref-type="bibr">11</xref>,<xref rid="bib0060" ref-type="bibr">12</xref>]. It is well established that contact lens wear, and particularly overnight contact lens wear, increases the risk of bacterial keratitis [<xref rid="bib0060" ref-type="bibr">[12]</xref>, <xref rid="bib0065" ref-type="bibr">[13]</xref>, <xref rid="bib0070" ref-type="bibr">[14]</xref>, <xref rid="bib0075" ref-type="bibr">[15]</xref>, <xref rid="bib0080" ref-type="bibr">[16]</xref>]. It is also well established that viral conjunctivitis is the overall most common type of conjunctivitis [<xref rid="bib0085" ref-type="bibr">17</xref>]. Yet, the eye, ocular surface and tear film employ a variety of host-defense mechanisms such as physical barriers and immunological strategies that help reduce the chance of infection in the cornea and conjunctiva.</p><p id="par0020">A PubMed search on 24<sup>th</sup> March 2020 found no evidence that contact lens wearers are more likely to contract COVID-19 than spectacle wearers. The likely belief for this being a concern relates to the fact that SARS-CoV-2 has been isolated in tears, albeit to date, infrequently [<xref rid="bib0090" ref-type="bibr">18</xref>] and also that the virus is known to be transferred by hand contact, and thus could be transferred to contact lenses during their application and removal. In one report, positive tear and conjunctival secretions occurred in a single patient who developed conjunctivitis from a cohort of thirty patients with novel coronavirus pneumonia [<xref rid="bib0090" ref-type="bibr">18</xref>]. In another report, [<xref rid="bib0095" ref-type="bibr">19</xref>] 64 samples of the tear film from 17 patients with COVID-19 showed no evidence of SARS-CoV-2 by viral culture or reverse transcriptase polymerase chain reaction (RT-PCR). Further, the frequency of conjunctivitis in patients with COVID-19 reported to date is low, at <3% [<xref rid="bib0090" ref-type="bibr">18</xref>,<xref rid="bib0100" ref-type="bibr">20</xref>], although it has been suggested that CoVs could possibly be transmitted by aerosol contact with the conjunctiva in patients with active disease [<xref rid="bib0090" ref-type="bibr">18</xref>,<xref rid="bib0100" ref-type="bibr">[20]</xref>, <xref rid="bib0105" ref-type="bibr">[21]</xref>, <xref rid="bib0110" ref-type="bibr">[22]</xref>, <xref rid="bib0115" ref-type="bibr">[23]</xref>, <xref rid="bib0120" ref-type="bibr">[24]</xref>]. However, the question of whether COVID-19 can occur through conjunctival exposure remains unknown [<xref rid="bib0035" ref-type="bibr">7</xref>]. Recent papers concluded that <italic>“The eye is rarely involved by human CoV infection, nor is it a preferred gateway of entry for human CoVs to infect the respiratory tract</italic> [<xref rid="bib0125" ref-type="bibr">25</xref>].” and that <italic>“The results from this study suggests that the risk of SARS-CoV-2 transmission through tears is low</italic> [<xref rid="bib0095" ref-type="bibr">19</xref>].<italic>”</italic> Thus, to date, there are no findings that support concerns that healthy patients are more at risk of contracting COVID-19 if they are contact lens wearers.</p><p id="par0025">It could be argued that COVID-19 is so new that such data would not yet exist. However, the lack of evidence from previous outbreaks of coronavirus disease, including SARS, suggests that the risk of developing COVID-19 from contact lens wear is low. It is informative to consider viral diseases that are transmitted by direct contact and which could be used as a surrogate for evaluating the risks of COVID-19 in contact lens wearers. Viruses that are associated with human infections have been found on ocular surface tissues or in the tear film. These include, but are not limited to, both DNA and RNA viruses such as adenovirus, other coronaviruses, herpes virus, human immunodeficiency virus, influenza virus, and Zika virus [<xref rid="bib0090" ref-type="bibr">18</xref>,<xref rid="bib0110" ref-type="bibr">22</xref>,<xref rid="bib0130" ref-type="bibr">[26]</xref>, <xref rid="bib0135" ref-type="bibr">[27]</xref>, <xref rid="bib0140" ref-type="bibr">[28]</xref>, <xref rid="bib0145" ref-type="bibr">[29]</xref>]. That said, these viruses are typically found at low levels and it is generally believed that they are not transmitted from the ocular surface (with the exception of adenoviral infections).</p><p id="par0030">One ocular viral infection to consider is epidemic keratoconjunctivitis (EKC), caused by the non-enveloped DNA virus adenovirus. This disease is highly contagious, spreads rapidly through direct contact, accounts for 65-90% of viral conjunctivitis cases [<xref rid="bib0150" ref-type="bibr">30</xref>,<xref rid="bib0155" ref-type="bibr">31</xref>] and has been implicated in actively transmitted disease in eyecare clinics and other common healthcare settings where there is close contact between healthcare providers and patients [<xref rid="bib0160" ref-type="bibr">[32]</xref>, <xref rid="bib0165" ref-type="bibr">[33]</xref>, <xref rid="bib0170" ref-type="bibr">[34]</xref>, <xref rid="bib0175" ref-type="bibr">[35]</xref>, <xref rid="bib0180" ref-type="bibr">[36]</xref>, <xref rid="bib0185" ref-type="bibr">[37]</xref>, <xref rid="bib0190" ref-type="bibr">[38]</xref>]. A review of the literature appears to show no increased risk for EKC in those wearing contact lenses versus non-lens wearers, with a reported frequency of 3-15% in contact lens wearers [<xref rid="bib0160" ref-type="bibr">32</xref>,<xref rid="bib0180" ref-type="bibr">36</xref>]. Indeed, it has been proposed that bandage silicone hydrogel contact lenses can be used to help treat adenoviral infection in patients [<xref rid="bib0195" ref-type="bibr">39</xref>]. There are conflicting data on herpes simplex keratitis (HSK, another DNA virus, but one that is enveloped) and contact lens wear. One prospective cohort study and one retrospective case control study showed no association between contact lens wear and HSK occurrence or reoccurrence, whereas one retrospective study and a case report did suggest an association [<xref rid="bib0200" ref-type="bibr">[40]</xref>, <xref rid="bib0205" ref-type="bibr">[41]</xref>, <xref rid="bib0210" ref-type="bibr">[42]</xref>, <xref rid="bib0215" ref-type="bibr">[43]</xref>].</p><p id="par0035">Another virus for which there has been concern as it relates to the ocular surface is the human immunodeficiency virus (HIV), which causes acquired immunodeficiency syndrome (AIDS), with an estimated prevalence of 1.1 million in the US [<xref rid="bib0220" ref-type="bibr">44</xref>]. HIV is an RNA virus, but a different form of RNA virus called a retrovirus, and has an envelope. HIV has been detected in most ocular tissues, including the cornea, conjunctiva and tear film of patients with AIDS [<xref rid="bib0225" ref-type="bibr">45</xref>]. It has also been recovered from the surface of a contact lens [<xref rid="bib0230" ref-type="bibr">46</xref>]. It is presently believed, however, that HIV has not been transmitted via ocular surface tissues or the tear film. The CDC specifically states, <italic>“HIV is not spread by saliva, tears, or sweat that is not mixed with the blood of an HIV-positive person.”</italic> [<xref rid="bib0235" ref-type="bibr">47</xref>] Research has also indicated that with appropriate rubbing of contact lenses, most contact lens care systems would likely prevent the chance of the lens transferring the virus to the eye and resulting in HIV [<xref rid="bib0240" ref-type="bibr">48</xref>]. However, because of the immunodeficiency and compromise, it is recognized that AIDS is associated with opportunistic infections that can put an individual at risk for ocular infection [<xref rid="bib0245" ref-type="bibr">49</xref>]. HIV has been identified as a risk factor for hospitalization for corneal ulceration. While daily contact lens wear (not overnight wear) can be safe in a patient with AIDS, it is important that the eyecare practitioner play an active role in managing the patient and their ocular health as it relates to safe contact lens wear. A CD4+ count indicating immunocompetence may be key in guiding these decisions. On March 20, 2020, the CDC released information related to patients with AIDS and precautions as it relates to COVID-19 [<xref rid="bib0250" ref-type="bibr">50</xref>]. Of course, there are many differences in these viruses in terms of their structural biology, vectors and other factors. However, with limited current data comparing contact lens wearers versus non-lens wearers in patients with COVID-19, this remains the best evidence available of disease spread via viral contaminants that are highly infectious and potentially spread by direct contact, and an exhaustive literature search would not support the apprehension that contact lens wear is a concern.</p><p id="par0040">Coronaviruses are capable of producing a wide spectrum of ocular disease, including anterior segment diseases such as conjunctivitis and anterior uveitis, and posterior segment conditions like retinitis and optic neuritis [<xref rid="bib0255" ref-type="bibr">51</xref>]. Current understanding about how SARS-CoV-2 spreads is based largely on what is known about other similar coronaviruses. Currently, two types of SARS-CoV-2 have been detected (L and S) [<xref rid="bib0260" ref-type="bibr">52</xref>]. The L form is suspected to be the derived variant of the ancestral S type, which is suggested to be more aggressive and is significantly more prevalent in Wuhan, China (where COVID-19 was first reported) than other places, although its frequency of isolation has decreased since January 2020 [<xref rid="bib0260" ref-type="bibr">52</xref>]. The virus spreads primarily via person-to-person contact through respiratory droplets produced when an infected person coughs or sneezes [<xref rid="bib0265" ref-type="bibr">53</xref>,<xref rid="bib0270" ref-type="bibr">54</xref>]. However, it also could be spread if people touch an object or surface with virus present from an infected person, and then touch mucosal surfaces such as their mouth, nose or eyes [<xref rid="bib0270" ref-type="bibr">[54]</xref>, <xref rid="bib0275" ref-type="bibr">[55]</xref>, <xref rid="bib0280" ref-type="bibr">[56]</xref>]. Given that contact lens wearers must touch their eyes when applying and removing their contact lenses, it is understandable this has been raised as a potential concern for increasing their risk of exposure to the virus. The consistent, unambiguous advice to protect individuals from the virus is to employ frequent handwashing with soap and water. The lipid envelope of the virus can be emulsified by surfactants such as those found in simple soap, which kills the virus [<xref rid="bib0270" ref-type="bibr">54</xref>,<xref rid="bib0285" ref-type="bibr">57</xref>]. Best practice advice for contact lens wearers includes the same instructions that should be imparted under all situations, regardless of the COVID-19 pandemic. When using contact lenses, careful and thorough hand washing with soap and water followed by hand drying with unused paper towels (generally known as ‘kitchen roll’ in the United Kingdom) is paramount. For contact lens wearers, this should occur before every contact lens application and removal, and such practice reduces the risks of infection and inflammatory responses and is highly effective [<xref rid="bib0290" ref-type="bibr">58</xref>]. It follows that as long as contact lens wearers are using correct hand hygiene techniques, they should be limiting any virus transmission to their ocular surface, and indeed, as already stated, there is currently no evidence that they are at any higher risk of developing COVID-19 infection than non-wearers.</p></sec><sec id="sec0015"><label>1.2</label><title>Coronavirus and spectacle lens wear</title><p id="par0045">A systematic review of the literature shows that there is no scientific evidence that wearing spectacles provides protection against SARS-CoV-2 or other viral transmissions, although this concept has been recently proposed in the media [<xref rid="bib0295" ref-type="bibr">[59]</xref>, <xref rid="bib0300" ref-type="bibr">[60]</xref>, <xref rid="bib0305" ref-type="bibr">[61]</xref>]. This belief around the safety of spectacles likely exists because of the guidance to use approved personal protective eyewear (medical masks, goggles or face shields) in certain settings involved in the care of infected patients [<xref rid="bib0310" ref-type="bibr">62</xref>]. However, these goggles and shields provide very different protection to that afforded by standard spectacles, a difference recognised by the U.S. Centers for Disease Control and Prevention (CDC), who state that <italic>“personal eyeglasses are NOT considered adequate eye protection</italic> [<xref rid="bib0315" ref-type="bibr">63</xref>]<italic>.”</italic></p><p id="par0050">Despite the CDC’s clear delineation between standard spectacles and approved personal protective eyewear, it is understandable that a misplaced belief still exists for spectacles being preferable to contact lenses. There are a number of confounding factors, however, which do not support this theory. Consider firstly, part-time wearers of spectacles who only use their spectacles for occasional distance use or for reading. Their assumed ‘protection’ is intermittent, and additionally their increased frequency of putting on and removing their spectacles adds to the potential of touching their face each time, possibly in the absence of hand washing. Another point to consider is that some viruses such as SARS-CoV-2 can remain on hard plastic surfaces (similar to those found in spectacle frames and lenses) for hours to days [<xref rid="bib0320" ref-type="bibr">[64]</xref>, <xref rid="bib0325" ref-type="bibr">[65]</xref>, <xref rid="bib0330" ref-type="bibr">[66]</xref>, <xref rid="bib0335" ref-type="bibr">[67]</xref>]. Upon touching their spectacles, any virus particles could potentially be transferred to the wearers’ fingers and face and thus adequate hand hygiene practices should also extend to the regular handling of spectacle and sunglass frames to prevent transmission of viral particles to the fingers and subsequently to the face. Spectacles should be regularly cleaned with soap and water and dried with paper towel to remove any adhered viral particles.</p></sec><sec id="sec0020"><label>1.3</label><title>The importance of hand hygiene</title><p id="par0055">Hands are a common vector for the transmission of respiratory infection [<xref rid="bib0340" ref-type="bibr">68</xref>,<xref rid="bib0345" ref-type="bibr">69</xref>]. An observational study of medical students examined the frequency with which they touched their face [<xref rid="bib0350" ref-type="bibr">70</xref>]. On average, each of the students touched their face 23 times per hour. Of all face touches, 44% involved contact with a mucous membrane (eyes, nose or mouth) versus 56% that involved contact with non-mucosal areas (ears, cheeks, chin, forehead or ear). Of the mucous membrane touches, 36% involved the mouth, 31% the nose, 27% the eyes, and 6% were a combination of these regions. Given this very high number of face touches, hand washing becomes extremely important as a method to prevent transmission of any pathogenic organism from the fingers to the mucous membranes of the face. It is also important to remember that the generally younger demographic of contact lens wearers are often seen to practice more “risky” behaviors (such as the non-observance of social distancing seen recently during Spring break in the US) [<xref rid="bib0355" ref-type="bibr">71</xref>], which poses an inherent increased risk for SARS-CoV-2 infection. Hence, it remains important to remind this age group of the role of hand hygiene in preventing both ocular and systemic infection, regardless of their mode of vision correction.</p><p id="par0060">In addition to commons soaps used in hand washing, the SARS-CoV-2 virus is very likely susceptible to the same alcohol- and bleach-based disinfectants that eye-care practitioners commonly use to disinfect ophthalmic instruments and office furniture [<xref rid="bib0330" ref-type="bibr">66</xref>]. To prevent SARS-CoV-2 transmission, the same disinfection practices already used to prevent office-based spread of other viral pathogens are recommended before and after every patient encounter. Many of these steps have been summarised in a recent editorial [<xref rid="bib0360" ref-type="bibr">72</xref>], which covers a number of important considerations for conducting safe clinical practice during the pandemic.</p><p id="par0065">The CDC and WHO recommend that people clean their hands often to reduce their risk of contracting the virus. Specifically, they advise all people to:<list list-type="simple" id="lis0005"><list-item id="lsti0005"><label>•</label><p id="par0070">Wash their hands often with soap and water for at least 20 seconds especially after they have been in a public place, or after blowing their nose, coughing, or sneezing.</p></list-item><list-item id="lsti0010"><label>•</label><p id="par0075">If soap and water are not readily available, they should use a hand sanitizer that contains at least 60% alcohol. They should cover all surfaces of their hands and rub them together until they feel dry.</p></list-item><list-item id="lsti0015"><label>•</label><p id="par0080">They should avoid touching their eyes, nose, and mouth with unwashed hands.</p></list-item></list></p></sec><sec id="sec0025"><label>1.4</label><title>Contact lens material considerations</title><p id="par0085">The use of daily disposable contact lenses substantially reduces the risks of many inflammatory complications [<xref rid="bib0365" ref-type="bibr">73</xref>]. Contact lens wearers should always either dispose of their daily disposable lenses each evening, or regularly disinfect their monthly or two-week lenses according to manufacturer and eye care professional instructions.</p><p id="par0090">A point to consider is whether there are differences in the risk of SARS-CoV-2 infection between the various contact lens materials available. Suggestions have been made that siloxane-based materials (silicone hydrogels) are more likely to bind SARS-CoV-2 than hydrogels, [<xref rid="bib0305" ref-type="bibr">61</xref>] and that these contact lens materials are particularly “risky” to wear. A recent study showed that the aerosol and surface stability of both SARS-Cov-2 and its predecessor, SARS-CoV-1 (the viral strain associated with the prior SARS epidemic of 2002 and 2003) was similar [<xref rid="bib0370" ref-type="bibr">74</xref>]. Specifically, both viruses could be detected in aerosols for up to three hours, on cardboard for 24 hours, and on plastic and stainless steel for 2-3 days. To date, there have been no laboratory studies reported on the ability of coronaviruses to adhere to contact lenses, and none on the ability of disinfectants to kill coronaviruses adhered to contact lenses.</p><p id="par0095">There is no evidence of the presence of SARS-CoV-2 in the tears or conjunctival tissue of asymptomatic patients and even in those with confirmed disease, the presence of SARS-CoV-2 on the ocular surface is low [<xref rid="bib0090" ref-type="bibr">[18]</xref>, <xref rid="bib0095" ref-type="bibr">[19]</xref>, <xref rid="bib0100" ref-type="bibr">[20]</xref>]. Thus, binding of SARS-CoV-2 to contact lenses from the ocular surface in asymptomatic wearers would be unlikely. It is advisable that patients with COVID-19 should not wear contact lenses and if a patient were to develop COVID-19 any contact lenses that were being worn at that time should be immediately disposed of as should any remaining disinfecting solutions and contact lens cases that the patient possess, the patient must revert to spectacle lens wear and when fully recovered should recommence wear with a new pair of lenses.</p><p id="par0100">The issues that influence bacterial, viral, fungal and amoebic binding to contact lens materials are highly complex and variable, with confounding data on the factors that impact microbial binding [<xref rid="bib0375" ref-type="bibr">[75]</xref>, <xref rid="bib0380" ref-type="bibr">[76]</xref>, <xref rid="bib0385" ref-type="bibr">[77]</xref>, <xref rid="bib0390" ref-type="bibr">[78]</xref>, <xref rid="bib0395" ref-type="bibr">[79]</xref>, <xref rid="bib0400" ref-type="bibr">[80]</xref>]. To date, no studies have addressed this issue specifically for the virus that causes COVID-19. A recent paper [<xref rid="bib0330" ref-type="bibr">66</xref>] has been cited as suggesting that silicone hydrogels are more likely to bind SARS-CoV-2 than hydrogels [<xref rid="bib0305" ref-type="bibr">61</xref>]. However, this paper did not examine contact lens materials. The inanimate surfaces described in the paper [<xref rid="bib0330" ref-type="bibr">66</xref>] which most closely resemble contact lens materials were “plastic” and silicon rubber [<xref rid="bib0320" ref-type="bibr">64</xref>,<xref rid="bib0405" ref-type="bibr">81</xref>,<xref rid="bib0410" ref-type="bibr">82</xref>]. Neither of these materials appropriately represents the complex bulk and surface chemistry of contemporary contact lens materials [<xref rid="bib0415" ref-type="bibr">[83]</xref>, <xref rid="bib0420" ref-type="bibr">[84]</xref>, <xref rid="bib0425" ref-type="bibr">[85]</xref>] and cannot be used to reflect the likely binding of any pathogenic organism to modern day contact lenses. Soft lens material surfaces are far more hydrophilic than the plastic and silicon rubber surfaces examined in this manuscript and the binding of virus particles to substrates is complex, depending upon the charges and topographic characteristics of the virus and the characteristics of the surface in question [<xref rid="bib0430" ref-type="bibr">86</xref>]. The factors governing the binding of SARS-CoV-2 to inanimate surfaces are so far unknown, but for a variety of waterborne viruses the major driving factors were electrostatic interactions (charge driven), followed by hydrophobic interactions, with only minor impact from van der Waals interactions [<xref rid="bib0430" ref-type="bibr">86</xref>].</p><p id="par0105">Other factors of note in the paper by Kampf et al. are that the high concentration of inoculum used to examine the potential viral binding rates (10<sup>3</sup> – 10<sup>5</sup>) are likely very much higher than those encountered on the ocular surface in asymptomatic wearers, and potentially much higher than that encountered following contamination transferred via fingertip application or removal of contact lenses. The viability time quoted is that found at room temperature, but the time for which viruses remain viable at ocular surface temperatures is significantly lower [<xref rid="bib0405" ref-type="bibr">81</xref>,<xref rid="bib0410" ref-type="bibr">82</xref>] and to date the time for which SARS-CoV-2 remains viable on hydrophilic substrates such as contact lens materials remains unknown. Finally, these studies took place in a dry, static environment, which in no way reflect the moist condition of the ocular surface and did not take into consideration the impact of blinking on removal of potential viral contaminants from a lens surface. Furthermore, no evidence exists that would support the contention that silicone hydrogel lenses are more likely to be contaminated with SARS-CoV-2 (or indeed any virus) than hydrogel lenses.</p><p id="par0110">To date, no evidence exists of the ability of currently marketed contact lens solutions to disinfect SARS-CoV-2, and evidence concerning the ability of contemporary care solutions to disinfect viruses remains equivocal [<xref rid="bib0435" ref-type="bibr">87</xref>,<xref rid="bib0440" ref-type="bibr">88</xref>] and future work in this area is required. Over 30 years ago it was recognized that contact lens care systems of that time, based on chemical and thermal disinfection approaches, were effective at inactivating both herpes simplex and human immunodeficiency virus (HIV) [<xref rid="bib0445" ref-type="bibr">89</xref>,<xref rid="bib0450" ref-type="bibr">90</xref>]. Another study showed that common commercial contact lens care systems were capable of “safely decontaminating” HIV-1 from contact lenses, particularly when a rub step was included [<xref rid="bib0240" ref-type="bibr">48</xref>]. A recent paper showed that benzalkonium chloride, a common ophthalmic preservative, could slow or halt adenovirus [<xref rid="bib0455" ref-type="bibr">91</xref>]. Another paper reported that a rub-and-rinse technique was more effective at removing viruses from contact lenses than one in which no rubbing occurred [<xref rid="bib0440" ref-type="bibr">88</xref>]. Most modern lens care systems include a surfactant [<xref rid="bib0460" ref-type="bibr">92</xref>], and given that SARS-CoV-2 has a lipid envelope, it is plausible that a rub-and-rinse of the lens with such a care system may well be effective at killing the virus, but further work in this area is required to confirm this. Finally, one study demonstrated that thorough cleansing of virus-infected contact imaging lenses (such as retinal and fundus lenses) with both bleach and water/detergent was possible [<xref rid="bib0465" ref-type="bibr">93</xref>], although this is not suggested as a suitable option for contact lens disinfection.</p><p id="par0115">A potentially important finding from the review paper by Kampf et al. [<xref rid="bib0330" ref-type="bibr">66</xref>] was their investigation of the inactivation of coronaviruses by various biocidal agents. These studies included examining the effect of disinfectants such as benzalkonium chloride, chlorhexidine digluconate, hydrogen peroxide and povidone iodine, which are (or have been) used in contact lens solutions. Chlorhexidine digluconate was a relatively weak biocide when tested against mouse hepatitis virus or canine coronavirus, benzalkonium chloride had improved activity, 0.5% hydrogen peroxide (a concentration substantially less than that used in contact lens solutions) caused a >4 log<sub>10</sub> reduction in human coronavirus within 1 minute, and povidone iodine at concentrations as low as 0.23% (much less than found in contact lens disinfection systems) caused >4log<sub>10</sub> reduction in the coronaviruses that cause SARS or MERS (middle east respiratory syndrome) within 15 seconds.</p></sec><sec id="sec0030"><label>1.5</label><title>Areas for further study</title><p id="par0120">Clearly, this is a fast moving situation, with information and advice being produced based on the best available evidence at the time each manuscript, news report and social media post is written. There are many areas where further study could extend current knowledge of the interaction of SARS-CoV-2 with both the ocular surface and contact lenses. Already mentioned above, further study is required to investigate the interaction of SARS-CoV-2 with contact lens materials, and the ability of contact lens disinfecting systems to kill the virus. The tear film is another area of interest. The tear film has antiviral properties [<xref rid="bib0470" ref-type="bibr">94</xref>,<xref rid="bib0475" ref-type="bibr">95</xref>] and it is plausible that the tear film could inactivate viruses that were to come in contact with the tears. For instance, the tear film contains the protein lactoferrin, which is thought to prohibit adenoviral entry into corneal epithelial cells [<xref rid="bib0480" ref-type="bibr">96</xref>]. However, this is unknown for SARS-CoV-2, but given the low frequency thus far of patients infected with COVID-19 that demonstrate the virus in the tears [<xref rid="bib0095" ref-type="bibr">19</xref>] this is an area also worthy of study. What is missing at this time is the minimum infectious dose of SARS-CoV-2 that can cause COVID-19 and such information would be valuable. This dose would likely differ depending upon where that viral dose was delivered (for example, on the conjunctiva versus into the respiratory tract), or indeed whether there is true evidence to date that COVID-19 could indeed occur through conjunctival transmission [<xref rid="bib0035" ref-type="bibr">7</xref>].</p></sec><sec id="sec0035"><label>1.6</label><title>Access to clinical care and considerations for contact lens wear during the pandemic</title><p id="par0125">The evidence presented in this paper suggests the safety of contact lens wear has not altered due to the pandemic and that appropriate hygiene considerations for contact lens wear and care should be the same as that always recommended. However, with local access to eyecare being different at this time of social distancing, and potentially severely compromised during the height of the pandemic, what should eye care professionals bear in mind when discussing contact lens wear with their patients?</p><p id="par0130">A key consideration is for practitioners to be cognizant of local clinical care facilities during the course of the pandemic and to act to minimise the impact of contact lens-related adverse events on the wider healthcare system, which may be very stretched as staff are moved from providing ophthalmic care to other areas more directly related to COVID-19 patients. The implications here will necessarily vary according to local and regional considerations. For example, as of March 24, 2020, routine eyecare has been suspended in many countries, with optometric practices moving to provide scaled-back provision, telephone-only consultations and/or emergency services. For example, in the United Kingdom, practitioners should work to manage cases within an optometric framework rather than refer into the National Health Service where possible. This could include telephone contact with patients reporting contact lens problems and/or a video consultation using a suitable mobile phone app to enable rapid triage and management, reducing the need for burdening other clinical colleagues. Some cases may be best managed by referral to optometric colleagues licensed to practice as Independent Prescribers (therapeutically qualified optometrists) and who can treat more significant contact lens adverse events. In other cases, local Minor Eye Conditions Services (MECS) may be an alterative care pathway. Under this service patients are sent to local optometrists who have undergone accredited training in advanced optometric care that can triage whether referral to ophthalmology is required and, where possible and within their scope of practice, treat minor eye conditions. It is imperative that eyecare professionals avail themselves of the relevant options as early as possible in order to act quickly in the interests of both their patients and the wider healthcare system, and not begin to investigate the possibilities only after a contact lens wearer reports having some form of adverse event.</p><p id="par0135">In North America, Australia and other regions/countries, therapeutically-endorsed optometrists are more likely to be the first port of call for contact lens patients with clinical adverse events, although again, most health authorities have required deferral of non-emergent, routine care. Here also, appropriate pathways need to be considered and enacted where a reduced level of routine eyecare is available. In countries where contact lens fitters and practitioners are less likely to offer clinical care to patients with clinically significant adverse events, management pathways and advice should again be considered to minimise the impact on the wider healthcare system.</p><p id="par0140">It is particularly imperative during the ongoing pandemic that practitioners redouble their efforts to provide clinical advice to their patients to minimise contact lens complications, not least because many parts of the world are in forms of ‘lockdown’ and even leaving home to seek attention may not be straightforward. The simplest approach, as recommended by the American Academy of Ophthalmology, would be to cease contact lens wear and return to spectacles during this time [<xref rid="bib0485" ref-type="bibr">97</xref>]. However, given the personal motivation individuals may have for wearing contact lenses, or indeed those wearing lenses for a clinical reason (keratoconus for example), this suggestion is likely not practical for many contact lens wearers. In the UK, the General Optical Council have taken a pragmatic approach to contact lens wear and supply during the pandemic. Releasing a joint statement with a number of other health care regulators, they recognise the highly challenging circumstances and the need to depart from established procedures [<xref rid="bib0490" ref-type="bibr">98</xref>]. They have offered guidance which enables practitioners to exercise their professional judgement on whether patients need to be seen, or whether, following remote consultation, that the best course of action is to continue to supply lenses, even in the case of an expired specification [<xref rid="bib0490" ref-type="bibr">98</xref>]. This action will act to ensure a continual supply of new lenses to wearers and significantly reduce any temptation from patients to use lenses beyond the recommended replacement interval. Practitioners should also act to ensure patients receive a supply of their prescribed lens type and communicate this appropriately, to dissuade patients from sourcing alternative (non-prescribed) lens brands via online lens retailers.</p><p id="par0145">It is important to remember that by any absolute measure, contact lens wear is a safe form of vision correction for millions of people around the world. A review of 1,276 soft contact lens wearers records, across 4,120 visits, found eighty-two percent did not present with any complications during the observation period of more than two years [<xref rid="bib0495" ref-type="bibr">99</xref>]. The frequency of more significant complications such as corneal infiltrative events (CIEs) and microbial keratitis are well understood. The annual incidence of symptomatic CIEs in daily reusable soft lens wear is around 3%, and nearly zero in daily disposable wear [<xref rid="bib0500" ref-type="bibr">100</xref>]. The incidence of symptomatic CIEs in extended wear is higher, with a 2-7x increased risk compared to daily wear [<xref rid="bib0505" ref-type="bibr">[101]</xref>, <xref rid="bib0510" ref-type="bibr">[102]</xref>, <xref rid="bib0515" ref-type="bibr">[103]</xref>]. Annual incidence of microbial keratitis (MK) varies by modality, and is around 2 per 10,000 wearers with daily wear of soft lenses, [<xref rid="bib0065" ref-type="bibr">13</xref>,<xref rid="bib0075" ref-type="bibr">15</xref>,<xref rid="bib0520" ref-type="bibr">104</xref>] increasing to around 20 per 10,000 wearers in extended soft lens wear, irrespective of material type [<xref rid="bib0065" ref-type="bibr">13</xref>,<xref rid="bib0070" ref-type="bibr">14</xref>,<xref rid="bib0525" ref-type="bibr">105</xref>,<xref rid="bib0530" ref-type="bibr">106</xref>].</p><p id="par0150">However, a valid concern arises that any contact lens complication that warrants a visit to a healthcare facility at this time of limited resources is potentially an issue. To put these risks into context it is helpful to consider the incidence of contact lens issues in relation to accidental home-based injuries that also require medical care. In the U.S in 2012, a total of 19.4 million home injuries occurred that required medical attention, representing a rate of 24.17 per 100,000 of population [<xref rid="bib0535" ref-type="bibr">107</xref>]. A study across two years in Belgium estimated the annual incidence of home incidents requiring management by general practitioners to be 2,194 per 100,000 people [<xref rid="bib0540" ref-type="bibr">108</xref>]. Within the context of these figures, contact lens wear, with a rate for microbial keratitis of 0.2-2 per 100,000 (i.e. 2-20 per 10,000) wearers does not represent a significant additional burden on the healthcare system compared to the inherent dangers of living within the home, which based on their incidence as quoted above, would result in a far greater number of injuries that may require medical attention during the pandemic.</p><p id="par0155">How could the risks of contact lens wear be further minimised to reduce any potential burden on hospital visits at this time? The risk factors that result in CIEs and infectious keratitis are well understood. The relative risks of developing CIEs are summarised in the comprehensive review by Steele and Szczotka-Flynn, [<xref rid="bib0055" ref-type="bibr">11</xref>] and include non-modifiable factors such as younger age (1.75-2.61x), higher prescription (≥5D) (1.21-1.6x) and history of a previous event (2.5-6.1x), along with modifiable risks such as overnight wear (2.5-7x), bacterial bioburden on the lens and lid margins (5-8x), and lens replacement schedule - reusable compared to daily disposable (12.5x). MK is associated with many similar factors, including overnight wear [<xref rid="bib0065" ref-type="bibr">13</xref>,<xref rid="bib0525" ref-type="bibr">105</xref>,<xref rid="bib0530" ref-type="bibr">106</xref>], and for daily wear, poor lens and storage case hygiene, infrequent lens case replacement, exposure to water and smoking [<xref rid="bib0545" ref-type="bibr">109</xref>,<xref rid="bib0550" ref-type="bibr">110</xref>]. Risk factors for MK in daily disposable wearers are more frequent use, any overnight wear, less frequent handwashing, and smoking [<xref rid="bib0555" ref-type="bibr">111</xref>]. While it is not possible to change a non-modifiable risk factor such as the age of a patient, there are significant opportunities to address modifiable behaviours. Given the reduced incidence of CIEs in wearers of daily disposable lenses [<xref rid="bib0495" ref-type="bibr">99</xref>,<xref rid="bib0500" ref-type="bibr">100</xref>], this form of lens wear seems ideal in a time of reduced clinical provision. Some patients hold supplies of both reusable and daily disposable contact lenses, with the latter normally used for sports or holidays. With appropriate practitioner discussion, a move to using daily disposable lenses could be recommended at the current time.</p><p id="par0160">Ceasing planned or accidental overnight wear significantly lowers the risk of contact lens complications. Some patients may principally use their lenses on an extended wear basis for occupational reasons and the same benefits may no longer be present if they are currently working from home. In such situations, reverting to a daily wear schedule could be merited – although only if the patient has an appropriate care regimen and is suitably compliant in its correct use. In the same way, patients who habitually alter from daily wear to extended wear over time (for work or other reasons) may be best advised to adopt a routine daily wear modality until normal clinical provision is available. Such changes to contact lens wearing schedules should be undertaken only after consultation between the patient and their contact lens practitioner.</p><p id="par0165">Scrupulous hand hygiene along with correct use of multipurpose solutions with rub and rinse cleaning of reusable lenses, daily case cleaning and regular replacement of the lens case are all positive changes about which eye care professionals should remind their patients at the current time. Likewise, an important point is to counsel on the avoidance of contact with water to reduce the risk of microbial keratitis, especially <italic>Acanthamoeba</italic> keratitis which has been increasing in recent years [<xref rid="bib0560" ref-type="bibr">112</xref>,<xref rid="bib0565" ref-type="bibr">113</xref>]. Finally, a patient who has access to both reusable and daily disposable contact lenses at home could be advised to switch to daily disposables, the modality with the lowest risk of complications in soft lens wear [<xref rid="bib0365" ref-type="bibr">73</xref>,<xref rid="bib0500" ref-type="bibr">100</xref>].</p><p id="par0170">Adherence to compliant lens wear and care practices is an important aim for the profession all of the time, however, it can be argued during the current outbreak of SARS-CoV-2 this should be an area of heightened focus. The attention on thorough hand washing is welcome and an important start, but for eye care practitioners it is reasonable to use this time to go much further, revisiting patient education on safe wear and care practices with the aim of reducing the chance of developing contact lens-related complications requiring clinical care.</p></sec></sec><sec id="sec0040"><label>2</label><title>Conclusions</title><p id="par0175">In conclusion, to date no evidence suggests that contact lens wearers who are asymptomatic should cease contact lens wear due to an increased risk of developing COVID-19, that wearing prescription spectacles provides protection against SARS-CoV-2 or that any one form of contact lens material is more likely to enhance or reduce the risk of future COVID-19 infection. However, information concerning this novel coronavirus is evolving at a rapid rate and eye care practitioners must remain attentive to new findings as they emerge.</p><p id="par0180">Practitioners must remain vigilant about reminding contact lens wearers of the need to maintain good hand hygiene practices when handling lenses. A focus on fully compliant contact lens wear and especially on the modifiable risk factors associated with contact lens complications are especially important during the height of the pandemic, where access to primary and secondary optometric care may be substantially different to normal, and practitioners should act to minimise the burden on the wider healthcare system by considering their local clinical pathway options. Patients must be reminded of the need to dispose of daily disposable lenses upon removal, the need for appropriate disinfection with reusable lenses, including the use of a rub-and-rinse step where indicated, and appropriate case cleaning and replacement. Finally, consistent with guidance for other types of illness, particularly those of the respiratory tract [<xref rid="bib0570" ref-type="bibr">[114]</xref>, <xref rid="bib0575" ref-type="bibr">[115]</xref>, <xref rid="bib0580" ref-type="bibr">[116]</xref>], no contact lens wearer with active COVID-19 should remain wearing their contact lenses. This is the time to cease contact lens wear and revert to spectacles.</p></sec><sec id="sec0045"><title>Declaration of Competing Interest</title><p id="par0185">Lyndon Jones and Karen Walsh are employees of the Centre for Ocular Research & Education (CORE) at the University of Waterloo. Over the past 3 years CORE has received research support or lectureship honoraria from the following companies: Alcon, Allergan, CooperVision, GL Chemtec, iMed Pharma, Johnson & Johnson Vision Care, Lubris, Menicon, Nature’s Way, Novartis, Ote, PS Therapy, Safilens, Santen, Shire, SightGlass and Visioneering.</p><p id="par0190">Lyndon Jones is a consultant and/or serves on an advisory board for Alcon, CooperVision, Johnson & Johnson Vision Care, Novartis and Ophtecs.</p><p id="par0195">Karen Walsh has received honoraria from Alcon, CooperVision and Johnson & Johnson.</p><p id="par0200">Mark Willcox is a consultant for Johnson & Johnson Vision Care, CooperVision and Ophtecs. In the past three years he has received research funding or honoraria from Alcon, Allergan, CooperVision, Ophtecs, Australian Biotechnologies, Lumicare, Botanix and EcoAid.</p><p id="par0205">Philip Morgan is Director of Eurolens Research at the University of Manchester. In the past three years, Eurolens Research has received research funding and/or honoraria from: Alcon, AMCo, CooperVision, Essilor, Johnson & Johnson Vision, Menicon, RB, Shire and Ultravision.</p><p id="par0210">Jason Nichols declares Alcon (research, consultant), Bruder Healthcare (research; spouse-consultant), Allergan (spouse-consultant, spouse-research), Kala pharmaceuticals (spouse-research, spouse-consultant), Olympic Ophthalmics (consultant), Shire (consultant), Johnson and Johnson Vision Care (research), Sun Pharmaceuticals (spouse-consultant), ScienceBased Health (spouse-consultant), Oyster Point (spouse-consultant), Sight Sciences (spouse-consultant), Silk Technologies (spouse-consultant), Topivert (spouse-consultant), TearSolutions (spouse-research), Tearfilm Innovations (spouse-stock/other equity).</p></sec></body><back><ref-list id="bibl0005"><title>References</title><ref id="bib0005"><label>1</label><element-citation publication-type="other" id="sbref0005"><person-group person-group-type="author"><name><surname>Miller</surname><given-names>G.</given-names></name></person-group><article-title>Researchers are tracking another pandemic, too—of coronavirus misinformation</article-title><ext-link ext-link-type="uri" xlink:href="https://www.sciencemag.org/news/2020/03/researchers-are-tracking-another-epidemic-too-misinformation" id="intr0005">https://www.sciencemag.org/news/2020/03/researchers-are-tracking-another-epidemic-too-misinformation</ext-link><year>2020</year><comment>Accessed 24 Mar 2020</comment></element-citation></ref><ref id="bib0010"><label>2</label><element-citation publication-type="journal" id="sbref0010"><person-group person-group-type="author"><name><surname>Wu</surname><given-names>C.</given-names></name><name><surname>Liu</surname><given-names>Y.</given-names></name><name><surname>Yang</surname><given-names>Y.</given-names></name><name><surname>Zhang</surname><given-names>P.</given-names></name><name><surname>Zhong</surname><given-names>W.</given-names></name><name><surname>Wang</surname><given-names>Y.</given-names></name><name><surname>Wang</surname><given-names>Q.</given-names></name><name><surname>Xu</surname><given-names>Y.</given-names></name><name><surname>Li</surname><given-names>M.</given-names></name><name><surname>Li</surname><given-names>X.</given-names></name><name><surname>Zheng</surname><given-names>M.</given-names></name><name><surname>Chen</surname><given-names>L.</given-names></name><name><surname>Li</surname><given-names>H.</given-names></name></person-group><article-title>Analysis of therapeutic targets for SARS-CoV-2 and discovery of potential drugs by computational methods</article-title><source>Acta Pharmaceutica Sinica B In press</source><year>2020</year></element-citation></ref><ref id="bib0015"><label>3</label><element-citation publication-type="journal" id="sbref0015"><person-group person-group-type="author"><name><surname>Chen</surname><given-names>Y.</given-names></name><name><surname>Guo</surname><given-names>Y.</given-names></name><name><surname>Pan</surname><given-names>Y.</given-names></name><name><surname>Zhao</surname><given-names>Z.J.</given-names></name></person-group><article-title>Structure analysis of the receptor binding of 2019-nCoV</article-title><source>Biochem Biophys Res Commun In press</source><year>2020</year></element-citation></ref><ref id="bib0020"><label>4</label><element-citation publication-type="journal" id="sbref0020"><person-group person-group-type="author"><name><surname>Perico</surname><given-names>L.</given-names></name><name><surname>Benigni</surname><given-names>A.</given-names></name><name><surname>Remuzzi</surname><given-names>G.</given-names></name></person-group><article-title>Should COVID-19 Concern Nephrologists? 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