Conjunctivitis as initial presenting symptom in a COVID-19 patient.

1. Discussion

SARS-CoV-2 is a new strain of coronavirus that started at the end of 2019 in China and spread worldwide. Patients infected with SARS-CoV-2 can have variable presentations. Fever, shortness of breath, throat pain, and coughing continue to be the most common symptoms.¹ An affected patient can be asymptomatic or extra-pulmonary symptoms could be the leading cause of presentation.² The disease spreads mostly through respiratory droplets during close contact. Other modes of transmission, such as the ocular route, should not be overlooked as SARS‐CoV‐2 RNA has been detected in tears and conjunctival secretions of patients with COVID‐19. Different ocular symptoms may appear in a patient with COVID-19 or, rarely, conjunctivitis may be the only presenting sign and symptom.³

The conjunctiva is a loose connective tissue covering the eyeball's surface (bulbar conjunctiva). It reflects upon itself to form the eyelid's inner layer (palpebral conjunctiva). Conjunctivitis is one of the most common non-traumatic eye complaints resulting in presentation to the emergency department. Conjunctivitis describes any inflammatory process that involves the conjunctiva. Classification is usually based on cause, including viral, bacterial, fungal, parasitic, toxic, chlamydial, chemical, and allergic agents. Viral etiologies are more common than bacterial, and the incidence of viral conjunctivitis increases in late fall and early spring. Treatment is often supportive. Artificial tears help the discomfort of keratitis and photophobia. Cold, moist compresses improve the swelling and discomfort of the lids. Antibiotic drops help prevent secondary bacterial infection. The topical corticosteroids are used by an ophthalmologist when substantial inflammation is present and herpes simplex is excluded. Conjunctivitis can be prevented by washing hands frequently, avoiding touching the eyes with hands, using a clean towel and washcloth daily, not sharing towels or washcloths, throwing away eye cosmetics (ex: mascara), and not sharing eye cosmetics or personal eye-care items.⁴

Inflammation of the conjunctiva in a patient with COVID-19 could represent an inflammatory response to the disease. Nevertheless, the degree of inflammation contribution and the exact responsible mechanism are still vague.³

2. Visual case discussion

A 27-year-old patient presented to the emergency department complaining of right eye redness. The patient also complained of foreign body sensation and increased lacrimation in the same eye. He denied any past medical history. He claimed that his eye problem started two days back and became more irritative to him. On further questioning, he gave a history of close contact with a COVID-19 positive patient before six days and denied fever or any respiratory symptoms.

Moreover, he did a nasopharyngeal swab before three days as a screening test and appeared negative for SARS-CoV-2 virus. The patient's vital signs showed a blood pressure of 119/72 mmHg; a heart rate of 75 beats per minute; a respiratory rate of 19 breaths per minute; a temperature of 37.1 C; and an oxygen saturation of 99% on room air. His-chest was clear with no abnormal heart sounds. No lymph nodes were appreciated in the head or the neck. On eye examination, the right eye appeared pinkish with circumcorneal injection and some eyelid swelling (Fig. 1 ). Thus, the patient was referred to the ophthalmologist, who did a more detailed assessment. The slit-lamp examination revealed a red, watery eye and corneal lesions in the form of superficial punctate keratitis (Fig. 2 ). Additionally, there were conjunctival injections and multiple follicles in the lower fornix (Fig. 3 ). The left eye was normal on examination. The visual acuity was intact in both eyes. These findings rose the suspicion of COVID-19 infection. Consequentially, the ophthalmologist took a swab by sweeping the lower eyelid fornices and sent it to the laboratory to confirm the diagnosis. The right eye was irrigated with saline and topical povidone-iodine 3% was applied. The patient was discharged on topical steroids and antibiotics. Two days later, he followed with the ophthalmology clinic, where his right eye redness decreased. However, he developed subepithelial haze and preauricular lymph nodes enlargement. The right eye was irrigated again, and the patient was instructed to continue his prescribed medications. The conjunctival swab came positive for the SARS-COV-2 virus and confirmed the diagnosis of COVID-19.

Fig. 1.

(A & B) The right eye appeared pinkish with generalized redness (in comparison to the left eye nasal part) and circumcorneal injection (arrows).

Fig. 2.

Slit-lamp examination revealed a red, watery eye (dark red arrows) and corneal lesions in the form of superficial punctate keratitis (red arrows).

Fig. 3.

(A) The right eye lower lid revealed conjunctival injection and multiple follicles in the lower fornix. (B) Zoom in to the image to illustrate multiple follicles in the lower fornix (black circles).

3. Questions and answers

Question 1

Please choose one option:

What is the most common cause of viral conjunctivitis?

• 1Adenovirus.
• 2Herpes simplex virus.
• 3Picornavirus.
• 4Poxvirus.
• 5Varicella-zoster virus.

The correct answer is (1- Adenovirus)

4. Explanation

Viruses are a common cause of conjunctivitis in patients of all ages. A variety of viruses can be responsible for conjunctival infection; however, adenovirus is by far the most common cause, and herpes simplex virus (HSV) is the most problematic. Less common causes include varicella-zoster virus (VZV), picornavirus (enterovirus 70, Coxsackie A24), poxvirus (molluscum contagiosum, vaccinia), and human immunodeficiency virus (HIV).⁴

5. Question 2

Please choose one option:

How is viral conjunctivitis transmitted?

• 1Contaminated swimming pools.
• 2Patients touching their eyes.
• 3Shaking hands.
• 4Sharing towels
• 5All the above.

The correct answer is (5- All the above)

Explanation: Viral conjunctivitis is highly contagious, usually for 10–12 days from the onset as long as the eyes are red, in addition to a prodromal period of 3–7 days. Patients should avoid touching their eyes, shaking hands, and sharing towels, among other activities. Transmission may occur through accidental inoculation of viral particles from the patient's hands or by contact with infected upper respiratory droplets, fomites, or contaminated swimming pools.⁴

Conflict of Interest

I have no conflicts of interest to disclose.