The primary causes of conjunctivitis in the United States are viral and bacterial etiologies. The primary cause of viral conjunctivitis is adenovirus. Other viral culprits include
Conjunctivitis symptom onset can be hyperacute, acute, or chronic, with 4 weeks being the cutoff for an acute classification. Patients generally present with a combination of eye redness, irritation, photophobia, blurred vision, and tearing with or without purulence. Ophthalmologists further categorize conjunctivitis as follicular or papillary depending on physical exam findings.
In Western countries,
Coronavirus conjunctivitis can be unilateral or bilateral and generally causes chemosis, watery discharge with or without systemic symptoms [
A study in China previously reported conjunctivitis in 0.8% COVID-19 patients (9 of 1099) [
A 25-year-old male presented with a 2-month history of bilateral eye redness, irritation, and tearing. One month prior to presentation, he was treated with a course of moxifloxacin eye drops but symptoms recurred 2 days thereafter. He had been diagnosed with COVID-19 using a nasopharyngeal specimen collected and analyzed via RT-PCR (LabCorp Inc., Raritan, NJ) in March 2020.
On exam, the patient had normal vision and intraocular pressure in both eyes and one 1.0 mm follicle on the right inferior tarsal of the right eye (OD) without discharge or injection. The left eye (OS) had one 1.5 mm follicle on the left inferior tarsal and ptosis of the left upper eyelid. There was bilateral bulbar and palpebral conjunctival injection.
Past medical history included a history of LASIK and genital herpes controlled with oral valacyclovir.
A 19-year-old male presented with 1-month history of irritation and tearing in the left eye (OS) and redness in bilateral eyes (OU). The patient was initially treated with ciprofloxacin eye drops and erythromycin ointment, but his condition continued to worsen. He had been diagnosed with COVID-19 using a nasopharyngeal specimen collected and analyzed via RT-PCR. He had been diagnosed with COVID-19 via RT-PCR (Abbott Laboratories Inc., Lake Forest, IL) July 2020.
On exam, visual acuity was 20/60 bilaterally with normal intraocular pressure and bilateral redness of the bulbar conjunctiva. A prominent follicular reaction of the lower conjunctiva was seen, and superficial episcleral injection in both eyes without pain was noted (Figure
Clinical findings show prominent follicular reaction with conjunctival mucosa (a). Microscopically, a mixed chronic inflammatory infiltrate is seen within the subepithelium (b: H&E, 20x). Immunohistochemical studies highlight a mixture of B cells (c: CD20, 20x) and T cells (d: CD3; 20x).
Both patients had conjunctival biopsy and were tested for coinfections of chlamydia, HSV, adenovirus, and gonorrhea (Table
Patient-specific data that depicts coinfection of COVID-19 and chlamydia.
Pathogen tested | COVID-19 | Chlamydia | HSV PCR | Adenovirus | Gonorrhea PCR |
---|---|---|---|---|---|
Case #1 | Positive |
Positive |
Negative | Negative | Negative |
Case #2 | Positive |
Positive |
Positive |
Negative | Negative |
Both patients’ symptoms resolved with a course of oral doxycycline and erythromycin.
Both patients recovered without recurrence or lasting visual complications. Of note, case 2 also had a biopsy-positive diagnosis of HSV and was started on a course of acyclovir.
Viral and bacterial conjunctivitis often presents with many overlapping symptoms. Patients have redness, chemosis, and tearing. Physicians may be likely to attribute acute conjunctivitis to COVID-19 in patients with this as a preexisting diagnosis. However, like COVID-19, chlamydial conjunctivitis can also be spread via eye secretion and can also progress to a chronic form. Although supportive treatment is the current standard for COVID-19 conjunctivitis, chlamydia necessitates the use of oral antibiotics and, without proper treatment, it can cause conjunctival scarring, xerosis, and entropion trichiasis. As such, physicians must be cognizant of maintaining a broad differential for acute conjunctivitis in the post-COVID world [
Consider tissue diagnosis via conjunctival biopsy when empiric therapy fails to resolve cases of acute or chronic conjunctivitis Secondary causes of conjunctivitis must be treated systemically along with assessing it from an ocular standpoint
The literature review data used to support the findings of this case report are included within the article.
This is a retrospective report that has no patient identifiable data included in this case report.
The authors declare that they have no conflicts of interest.