There is a growing body of evidence regarding links between COVID-19, eye health and ocular signs and symptoms. There has been conflicting, and sometimes contradictory advice on conjunctivitis as part of the suite of symptoms of COVID-19. Following is some of the most recent information, to assist you in making informed decisions about your patients. At the bottom are some important links.

General Advice

On the 28th March 2020, the American Academy of Ophthalmology acknowledged that “several reports suggest the virus can cause a mild follicular conjunctivitis otherwise indistinguishable from other viral causes, and possibly be transmitted by aerosol contact with conjunctiva”. We have learnt, from study of other coronavirus diseases, that conjunctivitis is within the realm of possible complications.

Patients who present to optometry or ophthalmology for conjunctivitis, who also have upper respiratory tract symptoms, fever, shortness of breath or whom have recently travelled could represent cases of COVID-19

It is suspected from some reports, that whilst conjunctivitis or red eye is unusual and not part of “classic” COVID-19, up to 1-3% of patients with COVID may have some form of red eye/conjunctivitis.

It is unlikely that a red eye will be the initial symptom of a COVID-19 patient, and it is not currently listed as a symptom by the Australian Department of Health. Patients are far more likely to present to GP or ED with respiratory symptoms being the main concern, but a high degree of suspicion of red eyes is required

On the 27th of March, the Royal Australian and New Zealand College of Ophthalmologists (RANZCO) released the following statement in a document titled “COVID-19 Patient Care: How do we deal with potentially high risk COVID-19 patients presenting in a private practice”:

“In Australia, and usually in New Zealand, patients coming to you would be expected to have a referral. If their presentation is for follicular conjunctivitis, and they fall under the definition of a ‘suspect case’, they should be asked to present to a COVID-19 dedicated testing site and have a negative result prior to review.  If you are asked to review a known positive case, you should do so only if you have the appropriate PPE.  In the absence of appropriate PPE you should make arrangements for a patient to go to a centre that can accommodate the patient requirements. You should liaise directly with that centre to ensure they are aware of the patient status.

Consider putting measures in place for immediate identification of suspect cases as they may present to clinics and private practices. Note that conjunctivitis may be a presenting symptom of COVID-19. Where suspect cases are identified and do not require emergency eye care, RANZCO recommends that these are isolated from other patients and instructed to proceed immediately to the nearest public assessment and testing facility.”

Also on the 27th of March, the American Academy of Ophthalmology released the following statement:

“While it appears conjunctivitis is an uncommon event as it relates to COVID-19, other forms of conjunctivitis are common. Affected patients frequently present to eye clinics or emergency departments. That increases the likelihood ophthalmologists may be the first providers to evaluate patients possibly infected with COVID-19.

Therefore, protecting your mouth, nose (e.g., an N-95 mask) and eyes (e.g., goggles or shield) is recommended when caring for patients potentially infected with COVID-19. In addition, slit-lamp breath shields (e.g., here ) are helpful for protecting both health care workers and patients from respiratory illness. Free slit-lamp breath shields are being offered by some manufacturers, including Topcon and Zeiss.”

Further research

In February 2020, a small scale study was published in China; Evaluation of coronavirus in tears and conjunctival secretions of patients with SARS‐CoV‐2 infection.
According to recent reports, a large number of ophthalmologists involved in the diagnosis and treatment of the disease on a daily basis accidentally acquired COVID-19. Thus, many doctors suspect that it is related to contact with tears or conjunctival secretions of patients.

The present study assessed the tears and conjunctival secretions in SARS‐CoV‐2‐infected patients. The results showed that the virus existed in the patients’ tears and conjunctival secretions only in those with conjunctivitis. No viral RNA was detected in the tear fluid and conjunctival secretions of the patients with COVID-19 without conjunctivitis symptoms. The low abundance of the virus in tear and conjunctival secretions does not eliminate the risk of transmission through conjunctival tissue.

This has impacts on transmissibility from patients, and suggests clinicians working with confirmed cases, especially those with conjunctivitis, should be cautious and wear eye protection as part of COVID-19 PPE.

For more information:

Support for our members

We realise this is a difficult and uncertain time for all of us. Optometry Australia’s optometry advisor helpdesk offers our members dedicated experienced optometrists ready to provide confidential support.

Optometry Australia’s advisor helpdesk
Email: national@optometry.org.au
Phone: (03) 9668 8500
Operating hours: Monday to Friday, 9.00am to 5.00pm AEST

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