Here’s the take-home message: The average corneal transplant recipient is not at increased risk for contracting COVID-19 because of their corneal transplants’ steroid eye drops. Let me walk you through why. There are 3 issues to consider.
The first issue is whether or not topical steroid eye drops are the same as systemic steroid medications. They are not.
The vast majority of CORNEAL transplant recipients take a maintenance steroid eye drop, or they do not take one at all. Steroid eye drops are considered locally immunosuppressive, meaning steroid eye drops, for all intents and purposes, do not depress the rest of the body’s immune system. Only local immune suppression is required for corneal transplants because the cornea is relatively sequestered from the body’s systemic immune system thanks to its tissue not having any blood vessels. This concept is central to modern keratoplasty; it is why your surgeon can transplant corneas without much, if any, concern for negative side effects on the rest of the body.
Corneal transplant recipients are categorically different from patients who have received solid or liquid ORGAN transplants and this is why: organ transplants are not at all sequestered from the body’s immune system (they have many blood vessels) and as a result, require SYSTEMIC immune suppression to prevent rejection in the short- and long-term. Any patient taking systemic immune suppression, which are typically taken by mouth or by vein, is at increased risk for COVID-19 as well as any other infectious entity. Organ transplants include but are not limited to: heart/lung transplants, kidney transplants, bone marrow transplants, etc.
Rarely, very rarely, certain corneal transplant recipients may require systemic immune suppression because they have had recurrent episodes of rejection despite the strongest of steroid eye drops. In these rare cases, the patient is at increased risk for COVID-19, just like anyone else taking systemic immune suppression medications.
There are many other medical reasons to be on systemic immune suppression, not just to prevent organ transplant rejection. For example, many patients take chronic immune suppressive therapy to manage their rheumatic and autoimmune conditions. Immune suppression can also be caused by entities other than immune-suppressing medications. For example, cancer treatment can suppress the immune system and certain medical conditions can suppress the immune system to varying degrees, too.
The second issue is whether a topical steroid eye drop taken once daily, or even four times daily, increases the risk of contracting COVID-19 through the eye route (vs. the nasal or oral routes) because it depresses the eye’s immune system.
And the answer to that question – based on consensus between me and 5 other corneal transplant surgeons on the East Coast, Midwest, Southwest, and West Coast – is that the answer is no – steroid eye drops should not increase COVID-19 infection risk for corneal transplant recipients. I say “should not” rather than “does not” because there is no definitive research data available to offer guidance on this matter, and almost certainly never will be because the study would be too difficult to conduct to generate reliable answers. However, in lieu of bonafide research data, our clinical experience offers meaningful guidance. Patients on chronic low dose topical steroid eye drops do not have an increased risk for common forms of viral conjunctivitis, the most common being adenovirus; meaning that in practice, corneal surgeons don’t see a greater frequency of viral conjunctivitis among corneal transplant patients. Anecdotally, it’s not talked about among corneal surgeons, or for that matter your membership, either. Having said all of that, COVID-19 is not adenovirus, and one of its characteristics is that is highly contagious, which might at least in theory invalidate the above rationale. But I don’t think it does and let me explain why in the next bullet point.
The third issue is one that your membership, and the rest of the world, should already understand by now, and if they don’t, they should absolutely visit www.CDC.gov/coronavirus. The World Health Organization and Centers for Disease Control both take the scientific position that COVID-19 is transmitted through droplets that come into contact with the oral, nasal, or ocular mucosa. Therefore, the main driver of risk for contracting COVID-19 is exposure of one’s mucosal membranes to droplets carrying the virus. My colleagues and I agree that whether or not one is taking a topical steroid eye drop pales in comparison to the risk carried by whether or not one is actually exposed to droplets carrying the virus.
In other words, if someone with COVID-19 coughs directly on your face and you’re wearing a mask but not wearing eye protection, your risk of contracting the virus through your eyes is high and would not be ‘made worse’ by being on a topical steroid eye drop. Likewise, and this is important, if no one ever coughs on your face because you are practicing appropriate social distancing and you never touch your face with unwashed hands, your risk of contracting the virus is somewhere in the theoretical range of zero, even if you are taking steroid eye drops.
So: Practice social distancing, frequent hand washing, and not touching your face with unwashed hands. To learn more about following the rules, go here: https://vimeo.com/399733860 (Dave Price, MD is a close friend of mine on the front lines in NYC. If you have N95 masks to donate to him and his team, please reach out to him directly.)
Finally, systemic immune suppression increases both the risk of contracting COVID-19 and the severity of the disease. As alluded to above, I have heard of no reports of steroid eye drops increasing risk of contracting COVID-19; I have also not heard of any reports of steroid eye drops worsening the severity of the disease. But if anecdotal accounts or a formal literature emerges to suggest otherwise, I’ll let you know.
Christopher Sales, MD, MPH
Associate Professor of Ophthalmology
Weill-Cornell Hospital, New York City, NY
