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Year : 2020  |  Volume : 68  |  Issue : 10  |  Page : 2308

Viral shedding in tears of COVID-19 cases presenting as conjunctivitis

Department of Ophthalmology (Guru Nanak Eye Centre), Maulana Azad Medical College, New Delhi, India

Date of Web Publication23-Sep-2020

Correspondence Address:
Dr. Ruchi Goel
Department of Ophthalmology (Guru Nanak Eye Centre), Maulana Azad Medical College, New Delhi - 110 002
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_2567_20

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How to cite this article:
Goel R, Arora R, Chhabra M, Kumar S. Viral shedding in tears of COVID-19 cases presenting as conjunctivitis. Indian J Ophthalmol 2020;68:2308

How to cite this URL:
Goel R, Arora R, Chhabra M, Kumar S. Viral shedding in tears of COVID-19 cases presenting as conjunctivitis. Indian J Ophthalmol [serial online] 2020 [cited 2020 Oct 31];68:2308. Available from: https://www.ijo.in/text.asp?2020/68/10/2308/295730

Dear Editor:

Conjunctivitis as a presenting feature of coronavirus disease (COVID-19) is well-known.[1],[2] All these cases may not develop respiratory symptoms.[3]

Herein, we present two patients of unilateral viral conjunctivitis; a 46-year-old female (case 1) and a 30-year-old male (case 2).

Nasopharyngeal (NP) and conjunctival swab (from the involved eye) were sent for detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) nucleotides by real-time polymerase chain reaction (RT-PCR) 2 days after the onset of conjunctivitis. A specimen was considered positive if the amplification curve for the E gene crossed the threshold line within 35 cycles and was positive for RdRp or ORF 1b gene assay.[4] The viral load was assessed using the cycle threshold (Ct) value of the E gene. The Ct value of genes E, ORF, and RdRp of NP swab and a conjunctival swab of case 1 and NP swab of case 2 were 16, 18, 24; 21, 21, 29; and 32, 35, 0, respectively. The conjunctival swab was negative in case 2.

Disturbance of conjunctival epithelial cells by respiratory pathogens can result in an adaptive immune response resulting in inflammation of the ocular surface.[5] The pathogens, while in tears, if not neutralized by the local mechanisms can infect the respiratory tissues. Subsequent systemic manifestation possibly depends upon the innate immunity of the patient.

Presence of viral RNA in the tears in case 1 could be related to the high viral load, evident by low Ct value of NP swab and absence in case 2, could be due to low viral load as indicated by high Ct value of NP swab. To our knowledge, this is the first report of tear positivity in COVID-19 case with conjunctivitis in the absence of systemic symptoms.

Therefore, patients of conjunctivitis with lower Ct values of NP swab could be silent spreaders of COVID-19 through tears and should be investigated for SARS-CoV-2 disease.


We are grateful to Dr Vikas Manchanda MD and Dr Sonal Saxena MD, Advanced Virology laboratory, Maulana Azad Medical College, New Delhi, India for conducting the RT-PCR for SARS-CoV-2.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Hong N, Yu W, Xia J, Shen Y, Yap M, Han W. Evaluation of ocular symptoms and tropism of SARS-CoV-2 in patients confirmed with COVID-19. Acta Ophthalmol 2020;10.1111/aos. 14445. doi: 10.1111/aos.14445.  Back to cited text no. 1
Shetty R, D'Souza S, Lalgudi VG. What ophthalmologists should know about conjunctivitis in the COVID-19 pandemic? Indian J Ophthalmol 2020;68:683-7.  Back to cited text no. 2
[PUBMED]  [Full text]  
Scalinci SZ, Trovato Battagliola E. Conjunctivitis can be the only presenting sign and symptom of COVID-19. IDCases 2020;20:e00774.  Back to cited text no. 3
SOP for detection of 2019 novel coronavirus (2019-nCoV) in suspected human cases by rRT-PCR: Confirmation assay ICMR NIV Pune. Available from: https://www.icmr.gov.in/pdf/covid/labs/2_SOP_for_Confirmatory_Assay_for_2019_nCoV.pdf. [last accessed on 2020 Aug 02].  Back to cited text no. 4
Creager HM, Kumar A, Zeng H, Maines TR, Tumpey TM, Belser JA. Infection and replication of influenza virus at the ocular surface. J Virol 2018;92:e02192-17.  Back to cited text no. 5


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