Conjunctivitis in Novel Coronavirus Disease (COVID-19)

Sir,

This is with reference to the review article by Ramesh N, Siddaiah A, and Joseph B.[1] The article gives an overview of the highly infectious coronavirus disease (COVID-19), caused by a severe acute respiratory syndrome coronavirus (SARS-CoV2), first reported in China in 2019. The article aptly highlights the WHO proposal suggesting human-to-human transmission of this virus through droplets, contact, and fomites. However, what needs attention is the transmission of this novel virus through contact of infected aerosols with the conjunctival surface, which like any other mucosal surface is clinically and epidemiologically relevant to general physicians and practicing ophthalmologists.[2,3] Conjunctivitis has now been reported as the first presenting sign of this disease and has been observed in 9 of 1099 patients (0.8%) with laboratory-confirmed COVID-19 from 30 hospitals across China.[2] Li Wenliang, a young Chinese ophthalmologist from Wuhan Central Hospital in Wuhan, China is the first reported case of a patient to ophthalmologist transmission of this novel virus. Ophthalmologists may be the first point of contact in the health care system to attend the infected individuals. Screening for fever at the point of entry must be done along with eliciting an additional history of travel and quarantine. In event of the absence of telltale points in the history, a patient with pink-eye should be treated as a COVID suspect. Triaging of non-emergency ophthalmic cases must be the rule.[4] American Academy of Ophthalmology (AAO) guidelines clearly emphasize the importance of the use of personal protective equipment (PPE) with special attention for covering mouth, nose, and eyes while attending to the patients with conjunctivitis and respiratory manifestations along with accompanying fever and a travel history.[3] The tears of patients infected with COVID-19 have shown the presence of the virus; therefore, asymptomatic carriers may be a potential source for transmitting this illness.[4,5] Murine and animal studies have reported conjunctivitis, anterior uveitis, retinitis, and optic neuritis due to coronaviruses; therefore, future studies may report these manifestations in humans attributable to COVID-19.[6] In the meantime, all contact and aerosol generating procedures that involve handling the ocular surface must be avoided. Patients must wear a triple layer surgical mask before examination and indirect ophthalmoscopy should be the preferred modality for emergency fundus examinations. All necessary examination must be finished preferably under torchlight in less than 10 minutes.[7] Endoscopic procedures and those involving general anesthesia must be limited except in emergency situations which include pediatric cases, traumatic open globe injury to the eye, or where there may be a need to remove intraocular foreign body.[4,8] Conjunctival swabs must be transported appropriately on ice (like throat and nasal swabs) to assess the presence of the virus. Topical antibiotics are advised and a follow-up visit should be scheduled in 2 weeks. In view of worsening pain or discomfort in the next 4 to 5 days, oral Azithromycin 500 mg once daily for 3 days may be added to the treatment.[3,4,6,9] Topical low potency steroid may benefit in reducing inflammation and aid in early resolution of signs. No specific antivirals have been proven to be effective as per current literature.[9]

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