How acute viral keratoconjunctivitis change the ocular tear film

Conjunctivitis is one of the most common causes of red-eye that affects many people and imposes burdens. It is estimated that acute conjunctivitis affects 6 million people annually in the United States. Its prevalence varies according to the underlying cause. Viral conjunctivitis by adenovirus is the most common cause of infectious conjunctivitis. Adenoviral infection can affect the conjunctiva, corneal, and make changes to the tear film. Its highly contagious nature, long incubation period, and lack of gold standard testing or treatment cause adenoviral conjunctivitis to be a significant global economic burden [1],[2],[3][4],[5],[6].

A 32-year-old woman complained of bilateral eye redness for one week with a teary eye, sensitivity to light, and watery discharge but without blurred vision. She did not feel like scratching her eye. She complained of a productive cough, stuffy nose, but without fever or pain in her eyes. She works at the bank using a computer, and she had a ractive lens exchange operation two years ago because of high myopia. There was no systemic condition such as immunocompromised or allergy. Her visual acuity was 6/6 on both eyes. Anterior segment examination revealed conjunctival hyperemia, edema, pseudomembrane, CVI, and PCVI on both eyes with filament on the left eye (Figure 1). She was given non-preservatives artificial tears eye drop and told to keep hygiene. She planned for several tests: ST 1, TBUT, Oxford Ocular Staining Score, and Ocular Surface Disease Index (OSDI) questionnaire. The following-up symptoms worsen on both eyes. She had membrane peeling with fluorometholone 0.1%, ofloxacin, non-preservative artificial tears eye drop. The Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) rapid test came with positive IgG (Immunoglobulin G) result. After 14 days follow-up she had pseudomembrane with PCVI on both eyes (Figure 2). She had abnormal ST 1 and TBUT test evaluation on both eyes (Figure 3), with grade A-B Oxford Ocular Staining Score and high to low OSDI score up to 28 days follow-up (Figure 4). She achieved complete resolution after 28 days on both eyes (Figure 5).

The conjunctiva covers two-thirds of the ocular surface from the corneal rim to the lid margin. The epithelium of conjunctiva has barrier function, mucin secretion, and immune defense [1],[2]. Characteristics of viral conjunctivitis include redness, blood vessel engorgement, ocular discharge, photophobia, and pseudomembranes [1],[2],[3]. The patients had characteristics like conjunctival hyperemia and edema because of proinflammatory cytokines like TNF-α (Tumor Necrosis Factor α) that induced conjunctival vasodilatation and capillary leakage, a follicular reaction which appears as avascular, round, or oval clusters of lymphocytes [4],[5],[6],[7],[8].

Those presenting with viral conjunctivitis usually have a recent history of upper respiratory tract infection or recent contact with a sick individual. Visual acuity is usually at or near their baseline vision. The cornea can have subepithelial infiltrates that can decrease the vision and cause light sensitivity [3],[6],[8]. This patient had a recent history of upper respiratory tract infection with normal visual acuity when she came to the hospital.

The incidence rate of pseudomembranous conjunctivitis is 3.47/10,000 people-year with approximately 20% of it caused by adenoviral conjunctivitis and had a mean duration of 7.86 days [6], same as this patient who occurred at seven days. Pseudomembrane should be removed by membrane peeling because it could potentially form a conjunctival scar and symblepharon, and given an antimicrobial cover of infective cause. Complications that can occurred: 16.7% subepithelial infiltrates, 20.81% corneal erosions, 3.5% filamentary keratitis, and 6.1% subtarsal fibrosis [7],[8].

Filamentary keratitis (FK) describes a condition in which filaments are adherent complexes of mucus and corneal epithelium that are present on the corneal surface. Three main factors that contribute to corneal filament formation are abnormal epithelium acting as mucus receptors, abnormal tear movement, and the abnormal shear relationship between the upper lid and globe [9],[10],[11]. Filamentary keratitis in this patient happened because she has keratoconjunctivitis and post-ractive lens surgery because of high myopia. These risk factors can make alternation of the tear film.

We had SARS-CoV-2 rapid test because it had shown common clinical aspects with another viral conjunctivitis, such as follicular reaction, and conjunctival hyperemia and discharge. A study found distinctive clinical findings defining conjunctivitis in COVID-19 (Coronavirus) patients. 54.29% of COVID-19 conjunctivitis were completely unilateral. The degree of conjunctival hyperemia was mild or very mild, no pseudomembrane or membrane formation, and self-limited within 2–4 days [12],[13].

Acute conjunctivitis cases can make several changes on the tear film. First, change of lipid or mucin composition which affects antimicrobial enzymes and anti-inflammatory mediators. Second, lower TBUT results because the mucin layer and the conjunctival goblet cells that secrete this layer have been affected [14],[15],[16],[17]. Third, had normal or lower Schirmer’s test result because lexive tear secretion is stimulated, and the aqueous component rate increased. Fourth, higher OSDI score where index demonstrates sensitivity and specificity in distinguishing between normal subjects and patients with a dry eye disease [18],[19],[20],[21]. In this patient, there were changes on it, which means that lower amounts of mucin and lipid composition bring about a decrease in tear stability [20],[21],[22],[23],[24].

Conjunctivitis treatment includes using artificial tears for lubrication four times a day or up to ten times a day with preservative-free tears because preservatives induce toxic epithelial damage and accentuate inflammation. Cool compresses with a wet washcloth to the periocular area may provide symptomatic relief [1],[2],[3],[6],[22]. Corticosteroids served as an anti-inflammatory component and alleviated patient symptoms but were advised to be reserved until patients present with pseudomembrane or symptomatic subepithelial infiltrates, because of potential side effects: promotion of viral replication and exacerbation of unrecognized herpes simplex infection [17],[20],[21]. The patient was given artificial tears with preservatives free combination with steroid and achieved a resolution in 28 days.

Conjunctivitis is one of the most common causes of red-eye that affects many people and imposes burdens. Adenoviral conjunctivitis is the most common cause of viral conjunctivitis infection. This patient had acute viral infection based on symptoms and clinical signs that make ocular tear film instability up to 28 days. We can conclude that the lack of clinical signs of viral replication is an important sign of disease improvement, but it does not imply complete resolution of the infection.