If there is anything we have had enough of this year, it is stress. When we get run down, we are more likely to fall ill from a variety of ailments, including viral infections. Most of us are all too familiar with the typical symptoms of a viral infection, which include fatigue, congestion, fever, sore throat, and feeling pretty terrible overall. However, did you know that the immunity of your eyes may also have a hard time keeping up and that you can also develop ocular viral infections?

"Pink eye” is a term that is generally used to describe a red, angry looking eye that is suffering from conjunctivitis. Many people believe that pink eye is a bacterial infection that can be cleared up with topical antibiotic drops. In reality, conjunctivitis can result from many causes, including bacteria, viruses, allergens, chemicals, and certain diseases. Viral conjunctivitis manifests in many different ways, with red and excessively watery eyes being two hallmark signs of a viral infection. The yellow-green discharge that is typical for a bacterial infection is generally not seen in a viral one.

The most common causes of viral conjunctivitis are adenoviruses. There are over 50 types of adenoviruses that can wreck havoc in humans. They are responsible for the common cold, but can also cause more severe issues such as pneumonia, croup, bronchitis, and even neurological issues. When adenoviruses cause conjunctivitis, it is known as EKC. Symptoms of EKC usually develop within 14 days after exposure and commonly include a gritty sensation, excessive tearing, light sensitivity, and redness. It is not uncommon for it to develop initially in one eye and later in the other. You may have never heard of EKC, but if you remember watching the 2014 Winter Olympic Games in Sochi, hosted by Bob Costas, you have certainly seen it. For the eye care community, the Olympic athletes almost took second stage as we watched in amazement as poor Bob’s EKC infection unfolded before our very eyes. We were visibly pained by the infection that began in one eye, worsened by the day, and eventually took hold of his other eye. He said that when his symptoms first presented, he woke up with his “left eye swollen shut and just about as red as the old Soviet flag.” It took five days for symptoms to develop in the other eye and he was ultimately taken off of the air for six days. During that time, he hunkered down in a darkened hotel room because “the lights are obviously very bright in the studio and I was so light-sensitive that I couldn’t do it anymore.” He later reported that it took several months for his eyes to fully recover. EKC is a serious matter and requires prompt diagnosis, especially because those with it are highly contagious for up to two weeks after the onset of symptoms.

Another common cause of viral conjunctivitis is the virus that causes chicken pox and shingles – varicella-zoster. Once you have had chicken pox or shingles, the virus lies dormant in nerve tissue and can become reactivated due to age, illness, and a weakened immune system.

Shingles causes a painful rash or blisters on the skin. Often before the rash appears, you may feel burning, irritation, or tingling in the area. You may experience other symptoms as well, such as fever/chills, headache, stomach issues, and a generally unwell feeling. As this can mimic other illnesses, see your primary care doctor for a proper diagnosis.

If you have been diagnosed with shingles and have blisters around your eye, it is important to see an eye doctor right away to ensure you do not have shingles in your eye. Up to 20% of those with shingles can have ocular complications, which can cause permanent damage to your vision. Eye problems can occur when the rash appears, or weeks later. Symptoms of ocular involvement of shingles include eye pain, sensitivity to light, eye redness, blurry vision, and tearing.

The best way to protect yourself from shingles is prevention. The shingles vaccine, Shingrix, is recommended for anyone over 50, even if you have had chicken pox or shingles in the past. It is more than 90% effective at preventing shingles and helps reduce the severity of it and risk for developing ocular complications from shingles. It does not treat shingles, but is highly effective as a preventive strategy.

Nowadays, it seems that the only virus we can think of is the novel coronavirus SARS-CoV-2, which can cause COVID-19. Viral conjunctivitis is thought to occur in a very small number of people with COVID. Although, it is also thought to be underreported because the ocular symptoms are generally milder than the respiratory symptoms. It can be an initial sign of infection or it can develop after you have tested positive. If you have any symptoms of viral conjunctivitis – such as a red, watery eye – especially if they are in conjunction with any of the known symptoms of COVID, such as fever, loss of taste or smell, or cough, do not hesitate to get tested. During the early days of the pandemic, there was significant concern amongst eye care providers that the mucus membranes of the ocular surface could be a prime entry site into the body for the coronavirus. It was after all, an ophthalmologist named Dr. Li in Wuhan, China, who sounded the initial alarm about the patients he was seeing with viral conjunctivitis who also developed severe respiratory complications. He later succumbed to COVID and passed at the age of 33. Many eye doctors and their staff were apprehensive to return to work after the shutdown because of this concern. However, widespread infection of eye doctors and shutdowns of eye care clinics due to epidemic COVID infections never came to fruition. It is currently believed that the eye is a potential entry site, but much less so than the mouth and nasal passages. During the early days of the pandemic, there was also a lot of concern about wearing contact lenses and a possible increased risk of contracting COVID. There is currently no evidence that suggests that contact lens wearers are at higher risk for COVID than those who wear eyeglasses.

This is only a short list of the viruses that can cause viral conjunctivitis. When your eyes develop any symptoms of “pink eye,” don’t assume that an antibiotic will be the antidote to your red, watery eyes. Make sure that you are seen by a doctor who can properly evaluate your eyes to differentiate between a conjunctivitis caused by a bacteria, virus, or other cause, and get you started on the correct road to recovery. Some eye doctors have the valuable testing ability to immediately determine if your conjunctivitis is due to an adenovirus or not, which is significant for determining the best treatment plan. Treatments to reduce inflammation and combat the viral infection can bring you quicker relief and lower your risk of long-term ocular complications.