Conjunctivitis and COVID: What is the connection?

In recent years, the SARS-CoV-2 virus that causes COVID-19 has evolved to overcome the defenses of our immune system. As with any other viral infection, when our immune system is weakened or compromised, other infections have the same chance of taking hold. Pink eye (conjunctivitis) is no different.

Studies have shown that 1 in 10 people who become infected with COVID-19 develop eye symptoms such as redness, dry eyes, conjunctivitis, and more. And cases of conjunctivitis in particular are steadily increasing among those infected with COVID-19, both in children and adults.

Optometrist Alexandra Williamson, OD, explains what may be causing COVID conjunctivitis and how to ease your symptoms if you or your child gets a double dose of COVID-19 and conjunctivitis.

Is conjunctivitis a symptom of COVID-19?

Conjunctivitis is the most common eye symptom in children with COVID-19 and tends to be more common in children who have other serious systemic diseases, such as Kawasaki disease. Although research is still ongoing to determine the exact cause-and-effect relationship between COVID-19 and conjunctivitis, there is a large body of research showing that there is a pre-existing link between conjunctivitis and other viral infections.

“There is a well-established association between viral respiratory infections and a pink eye appearance,” says Dr. Williamson. “Viral infections cause pink eye, but other eye symptoms such as watering or redness may also occur, as younger children rub their eyes because they are irritated.”

Like other respiratory viruses, COVID-19 enters your body through airborne respiratory droplets that come into contact with your eyes, nose, or mouth. Therefore, your risk of infection increases when you touch your face or wipe your eyes. Researchers have even found traces of the SARS-CoV-2 virus in the tears of people who have tested positive for COVID-19, suggesting there is a potential risk of transmission through the eyes.

“Anatomically, the eye is connected to the nasal passages via the nasolacrimal duct, through which our tears drain into the sinuses,” explains Dr. Williamson. “This connection makes it possible for viruses to cause problems in both places.”

It is therefore not uncommon for conjunctivitis to also occur with a range of other viral infections – from the common cold to measles, RSV and COVID-19. However, COVID-19 brings additional complications because it does not always affect everyone in the same way. With a COVID-19 infection, people's symptoms can range from asymptomatic (or with no symptoms) to severe.

Do you always get conjunctivitis with COVID-19?

Having conjunctivitis does not mean you have COVID-19, and being infected with COVID-19 does not mean you will always get conjunctivitis. However, there is a possibility for children and adults to develop conjunctivitis and test positive for COVID-19 at the same time.

In the early stages of the pandemic, a study examined 216 children who were hospitalized with COVID-19 in Wuhan, China, between late January and mid-March 2020. Forty-nine of these children (22.7%) showed “ocular manifestations, including conjunctival discharge, eye rubbing, and conjunctival congestion.”

A total of 123 children in the study showed a range of COVID-19 symptoms, and of these, 36 (or 29.3%) also had eye problems. Of the 93 children (or 43%) who were asymptomatic, only 13 (or 14%) showed eye symptoms.

“They found that most children who actually had eye problems also had symptoms such as fever or cough,” notes Dr. Williamson, “which is consistent with what we already know about respiratory viruses in the eyes.”

Recent research suggests that the prevalence of dual infection with COVID-19 and conjunctivitis ranges from 2% to 32%, depending on the study and other varying factors. Many of these studies discuss that the increased number of these types of eye diseases could be attributed to several other causes, such as increased hand-eye contact during illness.

“These studies are helping eye doctors understand more about COVID-19, but that doesn't mean we need to be seriously concerned that every child who has a red or pink eye may have COVID-19,” Dr. Williamson clarifies, pointing out that even these studies have their own limitations. “It's possible that these people were already infected with another virus, or that their eye was red because of something else, and that COVID-19 wasn't even the reason they had symptoms or clinical signs.”

How long does COVID-related conjunctivitis last?

Viral conjunctivitis usually goes away within five to seven days and may last up to two weeks or longer if additional symptoms of COVID-19 and/or other eye symptoms continue to occur, such as:

Treatment of COVID conjunctivitis

If you have COVID-19 and conjunctivitis, you should monitor the severity of your symptoms during each illness until you are no longer infected.

Home remedies for conjunctivitis, such as cold water rinses and over-the-counter medications such as ibuprofen (Advil® and Motrin®), can help relieve inflammation and other symptoms associated with the condition until it runs its course.

Antibiotics are also available if you have bacterial pink eye, and antiviral medications if your pink eye is caused by chickenpox or shingles, the herpes simplex virus, or another infectious agent. Seasonal allergies are also a common cause of red eyes and can often be treated with over-the-counter antihistamine eye drops.

Mild cases of COVID-19 usually heal on their own with rest, plenty of fluids, and managing your pain with over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) such as naproxen sodium (Aleve®). Other treatment options for more severe cases of COVID-19 include corticosteroids such as prednisone and antiviral medications such as Paxlovid™.

The most important thing to know about COVID-19 and pink eye is that while these two problems are sometimes linked, they can persist and cause complications the longer they are left untreated. If you are experiencing symptoms of COVID-19 or pink eye, you should seek immediate medical attention for a diagnosis of your symptoms and the treatment options that may be right for you.

“If you have access to an eye doctor, it's better to get checked out rather than trying to wait, as some causes of eye redness, irritation, tearing and other phenomena commonly referred to as conjunctivitis can lead to vision loss,” warns Dr. Williamson. “If you can't get to an eye doctor, a primary care doctor or emergency room doctor may also be able to help.”