What is the treatment for viral conjunctivitis?

Treatment of Viral Conjunctivitis

Most viral conjunctivitis is self-limited and requires only supportive care with artificial tears, cold compresses, and patient education about transmission prevention for 10-14 days from symptom onset. 1

Supportive Care for Common Viral Conjunctivitis (Adenoviral)

The majority of viral conjunctivitis cases resolve spontaneously without specific antiviral treatment. 2

Symptomatic management includes:

• Artificial tears to provide comfort and dilute viral particles on the ocular surface 1
• Cold compresses to reduce inflammation 1
• Topical antihistamines for itching and discomfort 1
• Oral analgesics for pain management 1

Critical pitfall: Avoid topical antibiotics as they provide no benefit for viral infections and may cause adverse effects. 1 Antibiotics should only be used if secondary bacterial infection develops, not prophylactically. 3

Transmission Prevention (Essential Component)

Patient education is paramount given adenovirus can survive for weeks on surfaces without proper disinfection. 1

Specific measures:

• Minimize contact with others for 10-14 days from symptom onset in the last affected eye 1
• Strict handwashing and personal hygiene 4
• Disinfect exposed surfaces with sodium hypochlorite 1

When to Consider Topical Corticosteroids

For severe adenoviral keratoconjunctivitis with subepithelial infiltrates causing blurred vision, photophobia, or decreased visual acuity, topical corticosteroids may be warranted. 1

If using corticosteroids:

• Use the minimum effective dose and taper slowly 1
• Prefer agents with poor ocular penetration (such as loteprednol) to minimize intraocular pressure elevation and cataract formation 5
• Monitor intraocular pressure and examine for cataracts at regular follow-up visits 5, 1
• Be aware that animal models suggest corticosteroids may prolong viral shedding 1

Important caveat: For membranous conjunctivitis, debride membranes to prevent corneal epithelial abrasions or permanent cicatricial changes. 1

Herpes Simplex Virus (HSV) Conjunctivitis

HSV conjunctivitis requires specific antiviral treatment, unlike adenoviral conjunctivitis. 5

Treatment options:

• Topical: Ganciclovir 0.15% gel 3-5 times daily (less toxic to ocular surface) OR trifluridine 1% solution 5-8 times daily (causes epithelial toxicity if used >2 weeks) 5
• Oral antivirals: Acyclovir 200-400 mg five times daily, valacyclovir 500 mg 2-3 times daily, or famciclovir 250 mg twice daily 5
• Oral antivirals alone may be inadequate; adding topical antiviral treatment is more effective 5

Critical warning: Topical corticosteroids potentiate HSV epithelial infections and must be avoided. 5

Special population: Neonates require immediate consultation with pediatrician or primary care physician due to risk of life-threatening systemic HSV infection. 5

Varicella Zoster Virus (VZV) Conjunctivitis

For persistent or recalcitrant acute/subacute VZV disease in immunocompetent patients, oral antivirals are beneficial. 5

Oral antiviral dosing:

• Acyclovir 800 mg five times daily for 7 days 5, 1
• Valacyclovir 1000 mg every 8 hours for 7 days 5, 1
• Famciclovir 500 mg three times daily for 7 days 5, 1

Adjunctive measures:

• Topical antibiotics to prevent secondary bacterial infection as vesicles undergo necrosis 5, 1
• Topical antivirals alone are not helpful but may be added in unresponsive cases 5, 1

Caution: Adjust dosing in patients with impaired renal clearance. 5, 1

Molluscum Contagiosum Conjunctivitis

The conjunctivitis results from viral shedding from eyelid lesions onto the ocular surface; treatment requires physical removal of the causative lesion. 5

Treatment options (all equally effective):

• Incision and curettage (aggressive enough to cause bleeding) 5, 1
• Simple excision 5
• Excision with cautery 5, 1
• Cryotherapy 5, 1

Important considerations:

• Identify and treat all nascent lesions simultaneously to reduce recurrence risk 5, 1
• Conjunctivitis may require weeks to resolve after lesion elimination 5, 1
• Multiple/large lesions with minimal conjunctival inflammation suggest immunocompromised state; consider HIV testing 5, 1

Follow-Up Recommendations

Timing varies by severity:

• Severe disease: Re-evaluate within 1 week 1
• Patients not on corticosteroids: Return if symptoms persist beyond 2-3 weeks 1
• HSV conjunctivitis: Follow-up within 1 week 5

Each visit should include: Interval history, visual acuity measurement, and slit-lamp biomicroscopy. 5, 1

Emerging Treatments (Not Yet Standard)

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