What is the treatment for viral conjunctivitis?

Treatment of Viral Conjunctivitis

Viral conjunctivitis is primarily managed with supportive care including artificial tears, cold compresses, and patient education about transmission prevention, as most cases are self-limited and resolve without specific antiviral therapy. 1

General Management Principles

The cornerstone of treatment is symptomatic relief while the infection runs its natural course:

• Artificial tears provide comfort and help dilute viral particles on the ocular surface 1
• Cold compresses reduce inflammation and provide symptomatic relief 1
• Topical antihistamines may alleviate itching and discomfort 1
• Oral analgesics can be used for pain management 1
• Avoid topical antibiotics as they provide no benefit for viral infections and may cause adverse effects 1

Infection Control Measures

Given that adenovirus accounts for approximately 80% of viral conjunctivitis cases and is highly contagious, transmission prevention is critical 2, 3:

• Patients should minimize contact with others for 10-14 days from symptom onset in the last affected eye 1
• Strict hand hygiene is essential, as adenovirus can survive for weeks on surfaces without proper disinfection 1
• Disinfect exposed surfaces with appropriate disinfectants such as sodium hypochlorite 1
• In clinical settings, consider abbreviated exams in dedicated rooms with limited physical interaction 1

Management of Severe Adenoviral Keratoconjunctivitis

For severe cases with significant corneal involvement, a more aggressive approach may be warranted:

• Topical corticosteroids may be considered, but only with mandatory close follow-up 1
• Prefer corticosteroids with poor ocular penetration or site-specific options to minimize systemic side effects 1
• Monitor for increased intraocular pressure and cataract formation during corticosteroid use 1
• Taper slowly to the minimum effective dose 1
• Be aware that animal models suggest corticosteroids may prolong viral shedding 1

Important Caveat

Corticosteroids should never be used unless herpes simplex virus (HSV) conjunctivitis has been ruled out, as steroids can worsen HSV disease and lead to permanent vision loss 4.

Management of Specific Complications

Membranous conjunctivitis:

• Debridement of membranes may prevent corneal epithelial abrasions or permanent cicatricial changes 1

Subepithelial infiltrates:

• Mild cases require only observation 1
• Cases with blurring, photophobia, and decreased vision may require topical corticosteroids at minimum effective dose 1

Specific Viral Etiologies Requiring Different Management

HSV conjunctivitis:

• Consider ganciclovir 0.15% gel, trifluridine 1% solution, or oral antivirals 1
• Avoid corticosteroids in HSV disease 1
• If dendrites are seen on examination, trifluridine is preferred and ophthalmology referral is advisable due to risk of recurrence with scarring and permanent vision loss 4

VZV (Varicella Zoster Virus) conjunctivitis:

• Topical antibiotics may be used to prevent secondary bacterial infection as vesicles undergo necrosis 5
• Topical antivirals alone have not been shown to be helpful but may be used as additive treatment in unresponsive patients 5
• For persistent or recalcitrant acute/subacute disease in immunocompetent patients, oral antivirals are beneficial: 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 5
• Caution is advised in patients with impaired renal clearance 5

Molluscum contagiosum-related conjunctivitis:

• Treatment requires removal of the causative eyelid lesions through incision and curettage (aggressive enough to cause bleeding), simple excision, excision and cautery, or cryotherapy 5, 1
• The conjunctivitis may require weeks to resolve after elimination of the lesion 5

Emerging Treatments (Not Yet Standard of Care)

• Povidone-iodine has been investigated and may reduce viral titers and shorten clinical course 1
• Off-label topical ganciclovir 0.15% gel has shown potential benefit against specific adenovirus serotypes, but further research is needed 1

Follow-up Recommendations

Patients with severe disease:

• Should be re-evaluated within 1 week with interval history, visual acuity measurement, and slit-lamp biomicroscopy 1

Patients not treated with corticosteroids:

• Should return if symptoms persist beyond 2-3 weeks 1

Red Flags Requiring Ophthalmology Referral

Immediate referral is indicated for 5, 6:

• Visual loss
• Moderate or severe pain
• Corneal involvement
• Conjunctival scarring
• Lack of response to therapy
• History of HSV eye disease
• History of immunocompromise
• Vesicular rash on the eyelids or nose