Topical Steroids in Acute Viral Conjunctivitis
Reserve topical corticosteroids for severe cases of adenoviral conjunctivitis with marked chemosis, eyelid swelling, epithelial sloughing, or membranous conjunctivitis, where they reduce symptoms and may prevent scarring; avoid steroids entirely in herpes simplex virus (HSV) conjunctivitis as they potentiate viral replication and worsen infection. 1
Adenoviral Conjunctivitis: When to Use Steroids
Mild to Moderate Disease
- Most cases are self-limited and do not require corticosteroids 1
- Symptomatic management with artificial tears, cold compresses, topical antihistamines, and oral analgesics is sufficient 1
- Antibiotics should be avoided as they provide no benefit and risk adverse effects 1
Severe Disease Requiring Steroids
Use topical corticosteroids when patients present with: 1
- Marked chemosis or severe eyelid swelling
- Epithelial sloughing
- Membranous or pseudomembranous conjunctivitis
- Corneal epithelial ulceration
These severe presentations benefit from steroids to reduce symptoms and potentially prevent permanent scarring 1
Critical Monitoring Requirements
When prescribing topical corticosteroids for adenoviral conjunctivitis: 1
- Re-evaluate patients with severe disease within 1 week
- Monitor intraocular pressure (IOP) periodically with pupillary dilation to detect glaucoma and cataract formation
- Taper steroids slowly to the minimum effective dose once inflammation is controlled
- Consider safer steroid options with poor ocular penetration (fluorometholone, loteprednol) to minimize IOP elevation and cataract risk 1
Important Caveat About Viral Shedding
Animal studies demonstrate that topical corticosteroids prolong viral shedding in adenoviral conjunctivitis, though this has not been definitively proven in humans 1. This theoretical concern reinforces the need for close follow-up and infection control measures.
Management of Subepithelial Infiltrates
Corneal subepithelial infiltrates typically appear 1+ weeks after conjunctivitis onset: 1
- Mild cases with no visual symptoms: Observation only 1
- Symptomatic cases with blurring, photophobia, or decreased vision: Use topical corticosteroids at minimum effective dose 1
- Alternative option: Cyclosporine drops (0.05% to 1% compounded) can reduce subepithelial infiltrates 1
Recent evidence supports short-term steroid use for symptom relief, with one randomized trial showing 87% of patients receiving dexamethasone felt treatment helped versus 70% with lubricants alone (p=0.0248), without serious complications 2. A 2025 meta-analysis confirmed corticosteroids improve clinical resolution (OR 1.51; 95% CI 1.19-1.92) without increased ocular adverse effects compared to non-steroid therapy 3.
Herpes Simplex Virus Conjunctivitis: Absolute Contraindication
Never use topical corticosteroids in HSV conjunctivitis—they potentiate HSV epithelial infections and worsen disease 1
Correct HSV Management
- Topical ganciclovir 0.15% gel three to five times daily OR trifluridine 1% solution five to eight times daily 1
- Oral antivirals: acyclovir (200-400 mg five times daily), valacyclovir (500 mg two to three times daily), or famciclovir (250 mg twice daily) 1
- Topical ganciclovir is less toxic to the ocular surface than trifluridine, which causes epithelial toxicity after 2 weeks 1
Exception: HSV stromal keratitis may benefit from topical steroids, but ONLY when combined with oral antiviral therapy 1
Follow-Up Algorithm
For patients NOT receiving steroids: 1
- Return if symptoms (red eye, pain, decreased vision) persist beyond 2-3 weeks
- Evaluate for subepithelial infiltrates at follow-up
For patients ON steroids: 1
- Regular follow-up visits with interval history, visual acuity, IOP measurement, and slit-lamp examination
- Monitor for glaucoma and cataract development
- Slowly taper to minimum effective dose