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

General Management Approach

Supportive care is the cornerstone of treatment for uncomplicated viral conjunctivitis:

• 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

Critical: Avoid topical antibiotics—they provide no benefit for viral infections and may cause toxicity or allergic reactions. 1 The majority of cases are self-limited and resolve without specific treatment. 2

Infection Control (Essential to Prevent Transmission)

Patients must minimize contact with others for 10-14 days from symptom onset in the last affected eye, as adenovirus can survive for weeks on surfaces. 1

• Emphasize strict handwashing and personal hygiene 3
• Disinfect exposed surfaces with EPA-registered hospital disinfectants or sodium hypochlorite (1:10 dilution of household bleach) 1
• In clinical settings, consider abbreviated exams in dedicated rooms with limited physical interaction 1
• Defer intraocular pressure measurement during acute conjunctivitis unless absolutely necessary, as tonometer tips can transmit infection 1

Management of Severe Adenoviral Keratoconjunctivitis

For severe cases with significant subepithelial infiltrates causing blurred vision, photophobia, or decreased visual acuity, topical corticosteroids may be considered—but only with mandatory close ophthalmology follow-up. 1

When using corticosteroids:

• Prefer corticosteroids with poor ocular penetration (such as loteprednol) to minimize intraocular pressure elevation and cataract formation 4
• Taper slowly to the minimum effective dose 1
• Monitor regularly for increased intraocular pressure and cataract formation 1
• Critical pitfall: Corticosteroids may prolong viral shedding and can worsen HSV infections if misdiagnosed, potentially leading to corneal scarring and vision loss 1

Never use corticosteroids without confirming the diagnosis is not HSV conjunctivitis. 1

Specific Viral Etiologies Requiring Different Management

Herpes Simplex Virus (HSV) Conjunctivitis

HSV conjunctivitis requires antiviral treatment, not corticosteroids alone:

• Topical options: Ganciclovir 0.15% gel three to five times daily (less toxic to ocular surface) OR trifluridine 1% solution five to eight times daily (causes epithelial toxicity if used >2 weeks) 4
• Oral antivirals: Acyclovir 200-400 mg five times daily, valacyclovir 500 mg two to three times daily, or famciclovir 250 mg twice daily 4
• Oral antivirals alone may not prevent progression of HSV blepharoconjunctivitis; adding topical antiviral treatment is more effective 4
• Topical corticosteroids potentiate HSV epithelial infections and must be avoided 4
• Neonates require prompt consultation with pediatrician, as systemic HSV infection is life-threatening 4

Varicella Zoster Virus (VZV) Conjunctivitis

For persistent or recalcitrant VZV conjunctivitis in immunocompetent patients:

• 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 4, 1
• Topical antibiotics should be used to prevent secondary bacterial infection, as vesicles undergo necrosis before healing 1
• Topical antivirals alone have not been shown helpful but may be used as additive treatment in unresponsive patients 4, 1
• Caution in patients with impaired renal clearance 4, 1
• Immunocompromised patients may need more aggressive treatment 4

Molluscum Contagiosum-Related Conjunctivitis

Treatment requires physical removal of the causative eyelid lesions:

• Options: Incision and curettage (aggressive enough to cause bleeding), simple excision, excision with cautery, or cryotherapy 4, 1
• Identify and treat all nascent lesions simultaneously to reduce recurrence risk 4, 1
• The conjunctivitis may require weeks to resolve after lesion elimination 4, 1
• In adults, large and multiple molluscum lesions with minimal conjunctival inflammation may indicate immunocompromised state 4

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

Follow-Up Recommendations

• 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
• HSV patients require follow-up within 1 week of treatment 4

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