What is the treatment for viral conjunctivitis?

Treatment of Viral Conjunctivitis

Viral conjunctivitis is primarily managed with supportive care, as it is self-limited and resolves within 5-14 days without specific antiviral treatment in most cases. 1

Core Management Strategy

The mainstay of treatment is symptomatic relief while the infection runs its natural course. 1 The American Academy of Ophthalmology emphasizes that antibiotics should be completely avoided, as they provide no benefit for viral infections and may cause unnecessary toxicity. 2, 1

Symptomatic Treatment Options

• Artificial tears are recommended to provide comfort and help dilute viral particles on the ocular surface. 1, 3
• Cold compresses reduce inflammation and provide symptomatic relief. 1, 3
• Topical antihistamines may help alleviate itching and discomfort. 1, 3
• Oral analgesics can be used for pain management. 1

Infection Control Measures

Patients must minimize contact with others for 10-14 days from symptom onset in the last affected eye to prevent transmission. 1 This is critical because adenovirus can survive for weeks on surfaces without proper disinfection. 1

• Strict hand hygiene with soap and water is essential. 4
• Avoid sharing personal items like towels and pillows. 4
• Disinfect surfaces with EPA-registered hospital disinfectants or sodium hypochlorite (1:10 dilution of household bleach). 2, 4

Management of Severe Cases

For severe adenoviral keratoconjunctivitis with significant symptoms, topical corticosteroids may be considered, but only with mandatory close ophthalmology follow-up. 1, 4 This is a nuanced decision that requires careful consideration:

• Corticosteroids can reduce inflammation and provide symptomatic relief in severe cases. 1
• However, animal models suggest corticosteroids may prolong viral shedding, and they can worsen HSV infections if misdiagnosed. 2, 1
• When used, prefer corticosteroids with poor ocular penetration or site-specific options to minimize systemic side effects. 1
• Monitor closely for increased intraocular pressure and cataract formation. 1, 4
• Taper slowly to the minimum effective dose. 1
• Use only for 1-2 weeks maximum. 2

Management of Complications

For membranous conjunctivitis, debridement of membranes may prevent corneal epithelial abrasions or permanent cicatricial changes. 1

For subepithelial infiltrates:

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

Special Viral Subtypes Requiring Different Management

Herpes Simplex Virus (HSV) Conjunctivitis

HSV conjunctivitis requires antiviral treatment and corticosteroids must be avoided. 1, 4 This is a critical distinction:

• Consider ganciclovir 0.15% gel, trifluridine 1% solution, or oral antivirals. 1
• Look for distinctive signs including vesicular rash or ulceration of eyelids and dendritic epithelial keratitis. 4

Varicella-Zoster Virus (VZV) Conjunctivitis

• Topical antibiotics are recommended to prevent secondary bacterial infection as vesicles undergo necrosis. 1, 4
• For persistent cases, 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. 1
• Use caution in patients with impaired renal clearance. 1

Molluscum Contagiosum-Related Conjunctivitis

• Treatment requires removal of the causative eyelid lesions through incision and curettage, simple excision, excision and cautery, or cryotherapy. 1, 4
• The conjunctivitis may require weeks to resolve after elimination of the lesion. 1

Follow-Up Recommendations

• Patients with severe disease should be re-evaluated within 1 week. 1, 4
• Patients not treated with corticosteroids should return if symptoms persist beyond 2-3 weeks. 1, 4
• Follow-up visits should include interval history, visual acuity measurement, and slit-lamp biomicroscopy. 1

Red Flags Requiring Immediate Ophthalmology Referral

• Visual loss or decreased vision 4
• Moderate or severe pain 4
• Corneal involvement 4
• Conjunctival scarring 1, 4
• Lack of response to therapy 4
• History of HSV eye disease 4
• Immunocompromised state 4

Common Pitfalls to Avoid

Never use topical antibiotics for viral conjunctivitis, as they provide no benefit and may cause toxicity or allergic reactions. 2, 1, 4 This is one of the most common errors in management.

Never use corticosteroids without confirming the diagnosis is not HSV, as corticosteroids can worsen HSV infections and lead to corneal scarring and vision loss. 2, 1

Defer intraocular pressure measurement during acute conjunctivitis unless absolutely necessary, as tonometer tips can transmit infection despite disinfection efforts. 2