Treatment of Viral Conjunctivitis
Viral conjunctivitis is primarily managed with supportive care as it is typically self-limiting, with specific antiviral treatments reserved for certain viral types such as herpes simplex virus (HSV) and varicella zoster virus (VZV). 1
Types of Viral Conjunctivitis and Their Management
Adenoviral Conjunctivitis (Most Common)
- Treatment approach: Supportive care only
- Specific measures:
- Artificial tears for symptomatic relief
- Cold compresses to reduce inflammation and discomfort
- Antihistamine eye drops for itching
- No role for antibiotics unless secondary bacterial infection 2
- For severe cases with subepithelial infiltrates:
- If vision is affected, topical corticosteroids at minimum effective dose may be considered 3
- Corticosteroids with poor ocular penetration (fluorometholone) or site-specific corticosteroids (rimexolone, loteprednol) are preferred to minimize IOP elevation and cataract formation 1
- Regular monitoring of IOP required if steroids are used
Herpes Simplex Virus Conjunctivitis
- Treatment required upon high suspicion or corneal involvement 1
- Topical options:
- Ganciclovir 0.15% gel three to five times per day (preferred due to lower ocular toxicity)
- Trifluridine 1% solution five to eight times per day (limit to 2 weeks due to epithelial toxicity)
- Oral options:
- Acyclovir 200-400 mg five times daily
- Valacyclovir 500 mg two or three times daily
- Famciclovir 250 mg twice daily
- Important caution: Avoid topical corticosteroids as they potentiate HSV infection 1
- Follow-up: Within 1 week of treatment with visual acuity measurement and slit-lamp examination
Varicella Zoster Virus Conjunctivitis
- For persistent/recalcitrant disease:
- Oral antivirals: Acyclovir 800 mg five times daily for 7 days, valacyclovir 1000 mg every 8 hours for 7 days, or famciclovir 500 mg three times daily for 7 days 1
- Topical antibiotics may be used to prevent secondary infection of vesicles
- Note: Topical antivirals alone are not effective but may be used as adjunctive therapy in unresponsive cases
Molluscum Contagiosum-Associated Conjunctivitis
- Treatment: Remove the eyelid lesions causing viral shedding onto the ocular surface
- Removal techniques:
- Incision and curettage (aggressive enough to cause bleeding)
- Simple excision
- Excision and cautery
- Cryotherapy
- Follow-up: Not usually necessary unless conjunctivitis persists after lesion removal
Prevention of Transmission
- Strict hygiene measures are essential to prevent spread:
- Frequent handwashing
- Avoid sharing towels and pillowcases
- Change pillowcases frequently during infection
- Avoid touching or rubbing eyes 3
- Return to work/school: Patients with viral conjunctivitis should minimize contact with others for 10-14 days from symptom onset 3
When to Refer to an Ophthalmologist
- Visual loss
- Moderate to severe pain
- Corneal involvement
- Conjunctival scarring
- Lack of response to therapy after 3-4 days
- Recurrent episodes
- History of herpes simplex virus eye disease
- Immunocompromised status 3, 2
- Neonates with conjunctivitis (requires immediate consultation) 1
Common Pitfalls to Avoid
- Inappropriate use of antibiotics for viral conjunctivitis
- Prolonged use of corticosteroids without ophthalmology supervision
- Failure to recognize potentially serious causes of conjunctivitis
- Inadequate hygiene education
- Delayed referral for severe or non-responsive cases 3
Remember that viral conjunctivitis accounts for approximately 80% of all acute conjunctivitis cases, with adenovirus being the most common causative agent 4. While most cases are self-limiting, early diagnosis and appropriate management can help alleviate symptoms and prevent complications.