question: Background:SARS CoV-2 is a novel coronavirus, the causative agent of COVID-19. Airborne respiratory droplet transmis- sion is well recognized;however, transmission by methods, such as ocular secretions, is yet to be proven. The objective of the study was to investigate the presence of SARS-CoV-2 RNA in tears of patients with moderate to severe coronavirus disease 2019. Methods:Tears were collected within 48 hours of laboratory confirmation using 3 methods: conjunctival swab plus Schirmer’s test strips (group 1), conjunctival swab (group 2), and Schirmer’s test strips (group 3). Samples from both the eyes of each patient were transported in a single viral transport media for real-time RT- PCR. Demographic profiles, sys- temic symptoms, comorbidities, and ocular manifestations were noted. Viral load of a sample was determined using cycle threshold (Ct) value of E gene. Results:Out of 75 patients 48% (36) had moderate disease, while 52% (39) had severe disease. RT -PCR analysis of tears showed positive results in 18 patients (24%). Positive results were found in 11 (14.7%), 11 (14.7%), and 7 (9.3%) patients in groups 1, 2, and 3, respectively (P=0.3105). Mean Ct values in groups 1, 2, and 3 were 28.36+6.15, 29.00 +5.58, and 27.86+6.46 (P= 0.92), respectively. Five patients showed positive RT-PCR results by all 3 methods (mean Ct value, 25.24+6.33), and 12 patients showed positive results by any of the 3 methods (mean Ct value, 32.16+1.94), the differ- ence in Ct values being statistically significant (P=0.029). The median value of symptomatology in patients with positive RT-PCR results from tears was 5 days (range, 4-9 days). Conclusions:SARS-CoV-2 RNA was detected in tears of 24% of patients with laboratory-proven moderate to severe COVID-19. Conjunctival swab remains the gold standard of tear collection for RT-PCR assay. A significantly higher possi- bility of viral transmission exists through tears in patients with moderate to severe COVID-19.