What is the treatment for viral conjunctivitis?

Treatment of Viral Conjunctivitis

Viral conjunctivitis requires supportive care only, with artificial tears, cold compresses, and patient education about transmission prevention being the mainstays of treatment. 1

Primary Supportive Management

• 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
• Antibiotics should be avoided entirely as they provide no benefit for viral infections and may cause adverse effects 1

The American Academy of Ophthalmology emphasizes that most cases are self-limited, with the majority resolving without specific antiviral treatment 1, 2. The key is recognizing that approximately 80% of acute conjunctivitis cases are viral, with adenovirus being the most common causative agent 3, 4.

Infection Control Measures

• Patients must 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
• In clinical settings, disinfect exposed surfaces with sodium hypochlorite 1
• Consider abbreviated exams in dedicated rooms during epidemics 1

Management of Severe Adenoviral Keratoconjunctivitis

When patients develop severe disease with significant inflammation:

• 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 1
• Taper slowly to the minimum effective dose 1
• Be aware that animal models suggest corticosteroids may prolong viral shedding 1

Special Viral Etiologies Requiring Different Approaches

HSV Conjunctivitis

• Consider ganciclovir 0.15% gel, trifluridine 1% solution, or oral antivirals 1
• Avoid corticosteroids in HSV conjunctivitis 1
• Referral to ophthalmology is advisable due to risk of recurrence with scarring and permanent vision loss 5

VZV Conjunctivitis

• Topical antibiotics are recommended to prevent secondary bacterial infection as vesicles undergo necrosis 1
• 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) are beneficial for persistent or recalcitrant disease 1
• Exercise caution with oral antivirals in patients with impaired renal clearance 1

Molluscum Contagiosum-Related Conjunctivitis

• Treatment requires removal of causative eyelid lesions through incision and curettage, simple excision, excision and cautery, or cryotherapy 1
• The conjunctivitis may require weeks to resolve after lesion elimination 1

Management of 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

Follow-up Protocol

• Patients with severe disease should be re-evaluated within 1 week 1
• Patients not treated with corticosteroids should return if symptoms persist beyond 2-3 weeks 1
• Follow-up visits should include interval history, visual acuity measurement, and slit-lamp biomicroscopy 1

Red Flags Requiring Immediate Ophthalmology Referral

• Conjunctival scarring 1
• Severe pain or decreased vision 6
• Recent ocular surgery 6
• Vesicular rash on eyelids or nose 6
• History of rheumatologic disease or immunocompromised state 6
• Neonatal conjunctivitis 6

Common Pitfalls to Avoid

• Never use combination antibiotic-corticosteroid preparations unless the conjunctivitis is proven to be nonherpetic 5
• Do not prescribe antibiotics for typical viral conjunctivitis, as this contributes to unnecessary antibiotic use without clinical benefit 1, 2
• Avoid premature use of corticosteroids in adenoviral disease without confirming it is not HSV, as corticosteroids are contraindicated in HSV conjunctivitis 1, 5