Acute Onset of Bilateral Follicular Conjunctivitis in two Patients with Confirmed SARS-CoV-2 Infections.

To report bilateral follicular conjunctivitis in two confirmed Coronavirus (COVID-19) patients with the presence of Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2) in conjunctival swab specimens. Two unrelated patients with confirmed SARS-CoV-2 infection and bilateral acute conjunctivitis were examined. Conjunctival swabs were assessed for the presence of SARS-CoV-2 by quantitative real-time polymerase chain reaction (RT-PCR) and viral culture. Both patients developed eye redness 3 days after the onset of COVID-19 symptoms. Slit lamp examination showed bilateral acute follicular conjunctivitis, which was resolved within 6 days. RT-PCR demonstrated the presence of viral RNA in conjunctival specimens from both eyes, which was unrelated to viral RNA from throat swabs. SARS-CoV-2 may cause ocular manifestations such as viral conjunctivitis. Conjunctival sampling may be useful for infected patients with conjunctivitis and fever. Precautionary measures are recommended when examining infected patients throughout the clinical course of the infection.

Keywords: Coronavirus; Conjunctivitis; COVID-19; SARS-COV2

Since December 31, 2019, when the first reported cases of a novel coronavirus disease (COVID-19) were reported in Wuhan, China,[1] this disease has been declared a pandemic. As of 20 May 2020, worldwide there have been more than 4.9 million confirmed cases and more than 330,000 deaths.[2]

In addition to upper and lower respiratory tract infections, coronaviruses have also been associated with conjunctivitis in humans.[3] Given that Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2), the virus which causes COVID-19 disease, is postulated to originate from zoonotic transmission from bats[4], other coronavirus ocular complications that have been reported in mouse models such as pyogranulomatous anterior uveitis, choroiditis with retinal detachment, and retinal vasculitis[5] may also occur in humans. However, as yet, the ocular manifestations of SARS-CoV-2 infections have not been well described. Rates of conjunctivitis have varied between 0.8% and 31.6%,[1],[[5]] while viral detection by positive real-time polymerase chain reaction (RT-PCR) conjunctival swab ranges between 3% and 5%.[6],[7]

We report the ocular presentations of two patients with confirmed COVID-19 who developed bilateral redness of the eyes and had positive RT-PCR conjunctival swabs and throat swabs within 5 days of the onset of symptoms. We hope these findings will further facilitate the understanding of ocular manifestations in patients with COVID-19 and its subsequent clinical course.

Institutional review board approval was obtained for this study and we strictly followed the Declaration of Helsinki in all procedures. Written informed consent was obtained from the two COVID-19-positive patients admitted at our hospital who developed redness of the eyes during the course of the disease. Conjunctival swabs were taken from both the patients at two time points. The conjunctival swab technique consisted of first pulling the lower eyelid of each patient downwards and using a disposable swab to wipe the palpebral conjunctiva of the lower eyelid without topical anesthesia. Then, the sampling swabs were then placed into a preservation solution. Samples from both eyes were taken and analyzed separately. The first swab was examined at the hospital laboratory by RT-PCR for SARS CoV-2. The second swab taken 2 days after the initial swab was evaluated at a research laboratory by RT-PCR and viral isolation was attempted.

RNA extraction was done using NucliSENS® easyMAG® system (bioMérieux) at the hospital laboratory. Fifty-five microliters of the elute (200 µl) was then used to perform RT-PCR as per the manufacturer's instructions using the A*STAR FORTITUDE kit (Accelerate Technologies Pte. Ltd, Singapore; http://www.accelerate.tech). The limit of detection of the test was estimated to be <25 copies of RNA.

At the research laboratory, conjunctival swab samples were used to inoculate Vero-E6 cells (ATCC/ Manassas, Virginia, United Stated of America). Cells were observed for the presence of cytopathic effect (CPE) after 4 days of incubation and a total of three blind passages were done for the samples from both eyes of the two patients. Total RNA was extracted from all samples using EZNA. Total RNA Kit I (Omega Bio-tek, Georgia, Atlanta, United States of America) according to the manufacturer's instructions and samples were analyzed by RT-PCR for the detection of SARS-CoV-2. The limit of detection for the research lab was 50 copies of RNA.

A 38-year-old Bangladeshi male presented to the National Center for Infectious Diseases (NCID) with fever and sore throat that started about 2 days prior. He was part of a local COVID-19 cluster of 11 workers who shared living quarters.

On initial examination, his temperature was 37.4°C and other vitals were stable. Examination of his nasopharynx revealed mild congestion. His lungs were clear on auscultation and chest radiograph revealed no abnormalities. He had no significant past medical history. Nasopharyngeal swab samples collected at admission were positive for SARS-CoV-2 by PCR with a cycle threshold (CT) of 22.96. The systemic condition of the patient was stable and his fever and symptoms abated. Laboratory investigations were grossly normal other than mildly elevated transaminases. His serum lactate dehydrogenase (LDH) level was significantly elevated to 440 IU/L.

On the second day of his admission, the patient developed bilateral eye redness. This progressed over a duration of 3 days and a referral was made to the Ophthalmology department. Other than symptoms of progressive eye redness (left worse than right), he was otherwise asymptomatic. His vision was 20/20 in both eyes with normal intraocular pressure and unremarkable anterior and posterior segment examination. Portable slit lamp examination at bedside revealed bilateral follicular conjunctivitis with mild chemosis over the left eye. There were no pseudo-membranes and no tender or enlarged pre-auricular or cervical lymph nodes. Conjunctival swabs performed for this patient on the same day revealed an RT-PCR CT of 24.07 at the hospital laboratory. The patient was treated conservatively with preservative-free lubricants. The patient recovered well as shown in the photos in Figure 1. Two days after the initial swab, a second conjunctival swab was taken from both the eyes and was sent to the research laboratory for viral isolation and RT-PCR. The samples were negative for SARS-CoV-2 by RT-PCR and virus isolation was unsuccessful after three blind passages. The conjunctivitis resolved in 6 days.

PHOTO (COLOR): Figure 1. (a) Shows patient on day 2 of presentation with left more than right conjunctival injection and mild chemosis. (b and c) Shows subsequent resolution of conjunctival injection and chemosis on day 3 and day 4

A 27-year-old Bangladeshi man presented to NCID with fever accompanied with bilateral eye redness and discomfort for 1 day. He was a close contact with a COVID-19-positive patient and was part of a COVID-19 cluster that was unrelated with Case 1.

He presented with a temperature of 38°C and other vitals were stable. Lungs were clear on auscultation and chest radiograph revealed no abnormalities. He had no other significant past medical history. Nasopharyngeal swab for SARS-CoV-2 PCR was positive on admission with a CT value of 19.07. Lab investigations were normal apart from mild elevation in transaminases.

Patient 2 was referred to the Ophthalmology department 3 days after the onset of bilateral eye redness as well as discomfort. There was no epiphora or discharge. His vision was 20/20 in both eyes with normal intraocular pressure and unremarkable anterior and posterior segment examination. Slit lamp examination revealed bilateral follicular conjunctivitis which was worse in the right eye. There were no pseudo-membranes. Like Case 1, there were no tender or enlarged pre-auricular or cervical lymph nodes. Conjunctival swabs from both eyes performed for this patient on the same day revealed an RT-PCR CT of 34.85 at the hospital laboratory. Like case 1, his serum LDH level was also significantly elevated to 372 IU/L.

Conjunctival swab taken 2 days after the initial conjunctival swab was evaluated at the research laboratory. The second conjunctival swab samples were negative for SARS-CoV-2 by RT-PCR, and virus isolation was unsuccessful following three blind passages at the research laboratory. Similar to case 1, patient 2 was treated conservatively with lubricants and conjunctivitis resolved in 5 days. Table 1 summarizes results from the nasopharyngeal and conjunctival swabs for each patient. The conjunctival swabs performed at the hospital laboratory within the first 3 days of onset of eye redness tested positive for SARS-CoV-2 RNA. However, CT values were higher than nasopharyngeal swabs performed at the same time point. The conjunctival swabs performed 2 days after the initial PCR-positive conjunctival swabs were PCR negative, and virus isolation in Vero-E6 cells was unsuccessful. Virus-induced CPE indicative of viral replication after blind passaging of supernatant CPE was not observed in any passage and RNA extracted at each passage was RT-PCR negative.

Table 1. Chronological illustration for ocular findings, real-time polymerase chain reaction (RT-PCR) from ocular surface secretions, and nasopharyngeal swab for SARS CoV-2 for both the cases

We have described and recorded the ocular manifestations of two patients with confirmed COVID-19 within 5 days of onset of illness. Both patients presented with acute follicular conjunctivitis which spontaneously resolved within 1 week of the onset of symptoms. RT-PCR demonstrated the presence of viral RNA with negative virus culture in conjunctival specimens from both eyes, which was unrelated to viral RNA from throat swabs. The results from our reports suggest a reduction in virus shedding in the conjunctiva as the patient recovers.

The presence of SARS-CoV-2 in the conjunctiva represents a potential source of transmission when patient is seen at the slit lamp, and efforts should be made to minimize spread to others after examining the patient.[8] In addition, a case report[9] from Italy which suggested prolonged viral RNA detection from conjunctival swabs even after nasopharyngeal swabs were negative suggests that SARS-CoV-2 may persist in the conjunctiva longer than expected. An alternate explanation for the PCR-positive swabs is the shedding of dead virus or cells containing viral RNA. As there is no definitive answer, infection control is imperative during ocular examination of patients to prevent possible transmission.

Currently, little is known about the natural history of ocular complications of SARS-CoV-2 infection and isolation of virus from the conjunctiva. Table 2 summarizes the current understanding related to conjunctival the findings from COVID-19-positive patients.[6],[7],[[9]] During second quarter of the year 2020, numerous researchers reported ocular surface manifestations of SARS CoV-2 from across the world;[6],[7],[[9]] however, there were limited number of cases with ocular swab positive for PCR and not even a single reported case of virus culture positive reported in the literature (Table 2). Furthermore, there were even no reports about any attempt to perform virus culture or virus-induced CPE.

Table 2. Overview of studies documenting conjunctival and microbiologic findings from COVID-19 patients

Lu et al. described a patient with acute viral conjunctivitis and positive conjunctival swab 13 days after the onset of illness.[10] Another retrospective study which tested the conjunctival sample for SARS-CoV-2 RNA in 30 infected patients revealed one positive conjunctival swab 3 days after the onset of illness.[6] This was similar to our findings where both of our patients had positive conjunctival swabs within 3 days of onset of illness. This would suggest that SARS-CoV-2 can cause ocular complications anytime during the course of the disease and may be the first signs of COVID-19 infection as seen in Case 2.

A study from Hubei, China[6], showed that patients with ocular symptoms tended to have higher white blood cell and neutrophil counts as well as higher level of procalcitonin, C-reactive protein, and LDH than patients without ocular symptoms. Though this case series was not designed to look for risk factors for developing ocular complications, we have noticed that both cases also had high LDH.

This case series has described two patients with ocular manifestations secondary to SARS-CoV-2 early in the course of the disease. As we learn more about SARS-CoV-2 and its ocular complications, it highlights the importance of understanding the natural history of the infection as this would affect treatment and infectious disease protocols and it is still controversial if conjunctival secretions are a potential mode of transmission of virus. We also believe further viral studies with conjunctival biopsy should be performed as it may prove crucial for understanding the pathophysiology of the disease and possibly assist in the early diagnosis of SARS-CoV-2 in infected patients who present acutely with conjunctivitis or other ocular manifestations.

All authors contributed to the study conception and design.

The authors have no financial interests to declare.