In age of COVID-19, ophthalmologists need a plan to deal with patients with red eye
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The SARS-CoV-2 RNA virus can infect a human through the conjunctiva. The ocular surface can also serve as a reservoir for replication and transmission of the disease to others. These facts affect practicing ophthalmologists in many ways.
First, ideal protection against infection not only requires facial masks, careful office and examining lane cleaning between patients, slit lamp screens and social distancing, but also ocular protection. Eyeglasses alone are helpful, but goggles and face shields are necessary when examining high-risk or known infected patients.
One challenge is the patient who presents with a red eye along with a fever, upper respiratory symptoms and a sore throat. COVID-19 infection of the eye causes a follicular conjunctivitis with conjunctival erythema, chemosis, epiphora and discharge. Patients will complain of a red eye along with itching, foreign body sensation, tearing and mattering. Clinicians must first decide whether they are going to see patients with red eye in their office, manage them by telehealth, or refer them to an emergency room or infectious disease specialist, whether ophthalmologist or internist.
Seeing the red eye patient with pharyngoconjunctival fever (PCF) or epidemic keratoconjunctivitis (EKC) in one’s office is itself high risk to the eye care provider, their staff and their other patients, but the patient with active COVID-19 infection is worse. If the individual doctor chooses to see these patients, it is important to have an isolated “red eye room,” access to appropriate culture tools including COVID-19 screening, and a plan for therapy and follow-up. Cultures should include a conjunctival swab sent for real-time RT-PCR. It is reasonable to do a QuickVue conjunctivitis screen for adenovirus (Quidel), and there is also a QuickVue SARS antigen test for COVID-19 (Quidel). If the patient is in respiratory distress, they require referral to a hospital.
Their eyes can be treated using an eye wash containing 0.01% benzalkonium chloride (BAK) supplemented with 1% povidone-iodine. This can easily be prepared by any ophthalmologist in the office, and the initial treatment can be applied in the office once or twice. A decongestant such as Lumify (Bausch + Lomb) or refrigerated artificial tears can be helpful for comfort and cosmesis. The patient can be sent home and told to socially isolate for 2 weeks unless respiratory distress intervenes, which will require a trip to a hospital-based emergency room. Eye bank studies confirm that a double immersion in povidone-iodine is effective in killing the COVID-19 virus, as is BAK.
The physician seeing these patients should consider double masking and wearing gloves and a face mask, and these PPE devices should be discarded or removed and cleaned after the patient examination. For most eye care providers, it is likely best to screen these patients at the practice entryway, keep them out of the office, and send them to the emergency room or infectious disease specialist. If the ER, hospital or infectious disease specialist calls the eye care provider and asks how to treat the patient’s eyes, treating as one would for PCF or EKC is reasonable. I mentioned my preference above.
Another challenge facing the corneal surgeon who does keratoplasty is donor tissue safety. With current corneal and eye tissue screening and preparation methods, the risk for COVID-19 transmission by keratoplasty is remote, although not impossible. Even the corneal endothelium can be a reservoir for COVID-19.
This nasty and potentially fatal disease will likely be with us forever. COVID-19 follicular conjunctivitis and keratoconjunctivitis are now part of the red eye differential diagnosis and require even more vigilance than the more common PCF and EKC we are used to treating. It behooves each of us to have a plan in place as to how patients with red eye will be managed by our practices in the COVID-19 era.
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