What is the treatment for viral conjunctivitis that causes the eyes to feel shut or closed?

Treatment for Viral Conjunctivitis with Eyes Shut Closed

For viral conjunctivitis causing eyes to feel shut or closed, treatment should focus on supportive care including cold compresses, artificial tears, and in severe cases with significant lid swelling or membrane formation, a short course of topical corticosteroids may be considered. 1

Diagnosis and Identification

Before initiating treatment, confirm that the conjunctivitis is viral in nature:

• Typically presents with:
  • Abrupt onset
  • Unilateral initially, often becoming sequentially bilateral
  • Watery discharge (not purulent)
  • Follicular reaction of inferior tarsal conjunctiva
  • Preauricular lymphadenopathy
  • Chemosis and eyelid swelling (causing eyes to feel shut)

Treatment Algorithm

First-Line Management (Mild to Moderate Cases)

1. Supportive Care:

   • Cold compresses to reduce swelling and discomfort
   • Refrigerated artificial tears (preservative-free) to dilute viral particles and soothe irritation
   • Oral analgesics for pain if needed

2. Hygiene Measures (Critical):

   • Frequent handwashing
   • Separate towels and pillows
   • Avoid touching or rubbing eyes
   • Avoid close contact with others for 10-14 days from onset

For Severe Cases (Eyes swollen shut or with membrane formation)

1. Topical Corticosteroids:

   • Consider a brief course (1-2 weeks) of topical corticosteroids with a low side-effect profile
   • Options include fluorometholone, rimexolone, or loteprednol
   • CAUTION: Only use if confirmed NOT to be herpes simplex virus (HSV) conjunctivitis

2. Membrane Management:

   • If membranes or pseudomembranes have formed, gentle debridement may be necessary to prevent corneal epithelial abrasions or permanent cicatricial changes 1

For Specific Viral Etiologies

Adenoviral Conjunctivitis (Most Common)

• Self-limited, typically resolves in 5-14 days
• Avoid antibiotics as they provide no benefit and may cause toxicity 1
• Monitor for development of subepithelial infiltrates 1+ weeks after onset

Herpes Simplex Virus Conjunctivitis

• Requires specific antiviral treatment:
  • Topical ganciclovir 0.15% gel three to five times daily OR
  • Trifluridine 1% solution five to eight times daily
  • Consider oral antivirals: acyclovir (200-400mg five times daily), valacyclovir (500mg two to three times daily), or famciclovir (250mg twice daily) 1
  • AVOID topical corticosteroids as they potentiate HSV infection

Varicella Zoster Virus Conjunctivitis

• May require topical antibiotics to prevent secondary infection of vesicles
• For persistent cases, oral antivirals may be beneficial 1

Follow-up Recommendations

• Severe cases with corneal epithelial ulceration or membranous conjunctivitis: re-evaluate within 1 week
• Patients on topical corticosteroids: monitor IOP and pupillary dilation periodically
• Patients not on corticosteroids: return if symptoms persist beyond 2-3 weeks
• Monitor for development of subepithelial infiltrates, which may require additional treatment

Important Cautions

1. Avoid indiscriminate use of antibiotics - viral conjunctivitis will not respond to antibacterial agents 1

2. Corticosteroid precautions:

   • Never use in suspected HSV without antiviral coverage
   • Monitor for IOP elevation and cataract formation
   • Taper once inflammation is controlled

3. Recognize when to refer to ophthalmology:

   • Visual loss
   • Moderate or severe pain
   • Severe purulent discharge
   • Corneal involvement
   • Lack of response to therapy
   • Recurrent episodes
   • History of HSV eye disease
   • Immunocompromised status 1

By following this treatment approach, most cases of viral conjunctivitis with swollen eyelids will resolve without permanent visual impairment or structural damage.