Could viral conjunctivitis be a symptom of Covid-19 infection? Alan Nathan investigates...
An elderly long-term patient who takes medication for hypertension has phoned up the Casebook Pharmacy. He asks to speak to the pharmacist, Eve. “It’s nothing to do with my prescription,” he says, “but in the current situation I’m a bit worried.”
Eve asks why and he replies: “I’ve got a problem with my eye - it’s inflamed and itchy and I’m worried that it might be the Covid virus.” Eve asks him if he has any other symptoms, to which he replies no. She suspects that he probably has bacterial or viral conjunctivitis.
“What should I do?” the patient asks. “I’ve contacted the GP practice, but they’re not seeing patients at the moment and told me to contact you. And you know that in my situation I’m advised not to go out. So can you help me?”
1. Can the Covid-19 virus cause conjunctivitis?
2. Is there any extra significance because this patient has hypertension?
3. Is there any specific advice you could give to contact lens wearers who may ask you for advice in the current situation?
4. What are the characteristic features of conjunctivitis?
5. What treatments are available OTC for infectious conjunctivitis?
6. How can you help the patient in this situation?
1. There is a small possibility, estimated at 1-3 per cent, that the Covid-19 virus can cause conjunctivitis. The College of Optometrists has stated that it is recognised that any upper respiratory tract infection may result in viral conjunctivitis as a secondary complication, and this is also the case with Covid-19. But it is unlikely that someone would present with viral conjunctivitis secondary to Covid-19 without other symptoms of fever or a continuous cough, as conjunctivitis seems to be a late feature when infection has occurred.
2. Yes. Early research has shown that patients with hypertension may be more likely to contract Covid-19, have more symptoms and die from the infection. Data from China and Italy, countries hit early by the virus, show higher risk of Covid-19 infections and complications in hypertensive patients.
In China, 25-50 per cent of people who attended hospitals with coronavirus had hypertension or another serious health condition such as cancer, diabetes, or lung disease. In Italy, more than 99 per cent of patients who died from the virus had one of these conditions, and 76 per cent of them had hypertension.
People with this condition are also slightly more likely to die from coronavirus: their risk is about 6 per cent higher than the overall population.
3. Advice for contact lens wearers should include:
· Wash hands thoroughly before inserting or removing lenses
· Be aware that daily lenses are the safest type to use
· Change solution in the contact lens case daily
· Change contact lens storage cases weekly
· Never share contact lenses. Some people may use tinted lenses for cosmetic purposes and possibly share them with others. This must be avoided in the current situation.
· Avoid rubbing the eyes. Virus particle on the hands can be transferred in this way.
· Do not wear lenses for more than 12-16 hours per day, at most. Try to avoid wearing at all for a day or two per week, if possible.
· If possible switch to wearing glasses, as this may be a way of reducing infected droplets in the air from accessing the eye. It may also reduce irritation and cause a person to pause before touching their eye.
4. The characteristic features of bacterial, viral and allergic conjunctivitis are set out below:
|Eyes affected||Both||Viral or allergic conjunctivitis|
|Both, but one before the other||Bacterial conjunctivitis|
|Discharge||Watery||Viral or allergic conjunctivitis|
|Pain/discomfort||No pain||All conjunctivitis|
|Itching/gritty||Bacterial or viral conjunctivitis|
|Itching only||Allergic conjunctivitis|
|Redness||Generalised, diffuse||All conjunctivitis|
|Duration||2–3 days||Infective conjunctivitis|
|Variable, depending on exposure to allergen||Allergic conjunctivitis|
|Associated factors||None||Bacterial conjunctivitis|
|Cough and cold symptoms||Viral conjunctivitis|
|Allergic rhinitis symptoms||Allergic conjunctivitis|
5. Bacteria and viruses are both causes of infective conjunctivitis and it may be clinically difficult to distinguish between them. Over-the-counter treatment of any superficial infective conjunctivitis with an antibacterial agent is considered appropriate, as it may help prevent secondary bacterial infection.
Non-prescription antimicrobial compounds available for the treatment of these infections are:
· propamidine isetionate
Chloramphenicol eye drops
Chloramphenicol is active against a wide range of ocular pathogens. It is licensed for use for adults and children aged 2 years and over. Dosage is one drop into the infected eye every 2 hours for the first 48 hours and then every 4 hours, during waking hours only. Treatment should be continued for 5 days if symptoms improve.
Chloramphenicol eye drops should not be used in patients hypersensitive to chloramphenicol, who have experienced myelosuppression during previous exposure to chloramphenicol or with a family history of blood dyscrasias, and it is not recommended for pregnant or breastfeeding women. Prolonged or frequent intermittent use should be avoided, as it may increase the likelihood of sensitisation and emergence of resistant organisms.
The drops should not be used for more than 5 days, and patients should be referred if symptoms do not improve within 48 hours of starting treatment. As with all ocular antibiotics and most other eye preparations, contact lenses should not be worn during treatment and soft contact lenses should not be replaced for 24 hours after completing treatment.
In the pharmacy, chloramphenicol eye drops should be stored in a refrigerator at 2–8°C. Once opened, the drops should be discarded after 5 days.
Propamidine isetionate eye drops
Propamidine is an aromatic diamidine antiseptic. It can be used for adults and children. One or two drops are instilled into the affected eye(s) up to four times daily. It should be stored at room temperature and discarded not more than 1 month after opening.
6. Ask the patient if he can get someone to come to the pharmacy to pick up an OTC eye treatment. Advise him that if the condition is not clearing up within 5 days or if he develops any respiratory or other symptoms associated with Covid-19 infection - which you could outline to him - that he should contact his GP again or a hospital.
The information in this article was up to date as at 1 April 2020.