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 strict infection control measures—antibiotics should be avoided entirely as they provide no benefit and may cause harm. 1, 2

General Supportive Management

The cornerstone of treatment for typical adenoviral conjunctivitis is symptomatic relief, as most cases resolve spontaneously within 2-3 weeks 1, 2:

• Artificial tears provide comfort and help dilute viral particles on the ocular surface 1, 2
• Cold compresses reduce inflammation and provide symptomatic relief 1, 2
• Topical antihistamines may alleviate itching and discomfort 1, 2
• Oral analgesics can be used for pain management 1, 2

Critical Pitfall to Avoid

Never prescribe topical antibiotics for viral conjunctivitis—they provide zero benefit for viral infections and may cause toxicity, allergic reactions, or contribute to antibiotic resistance 1, 2. This is one of the most common errors in managing viral conjunctivitis.

Infection Control (Essential Component)

Adenovirus can survive for weeks on surfaces, making transmission prevention critical 1:

• Patients must minimize contact with others for 10-14 days from symptom onset in the last affected eye 1, 2
• Strict handwashing and avoiding touching the eyes are essential 1
• Disinfect surfaces with EPA-registered hospital disinfectants or sodium hypochlorite (1:10 dilution of household bleach) 1
• In clinical settings, consider abbreviated exams in dedicated "red-eye rooms" with limited physical interaction 1
• Defer tonometry during acute conjunctivitis unless absolutely necessary, as tonometer tips can transmit infection despite disinfection 1

Management of Severe Adenoviral Keratoconjunctivitis

For patients with severe disease causing blurred vision, photophobia, or decreased visual acuity from subepithelial infiltrates 3, 1:

• Topical corticosteroids at minimum effective dose may be considered, but only with mandatory close ophthalmology follow-up 3, 1
• Prefer corticosteroids with poor ocular penetration (fluorometholone, rimexolone, or loteprednol) to minimize intraocular pressure elevation and cataract formation 3, 1
• Monitor IOP and for cataract formation regularly during corticosteroid use 3
• Taper slowly to the minimum effective dose once inflammation is controlled 3

Important Caveat About Corticosteroids

Corticosteroids may prolong viral shedding and can catastrophically worsen HSV infections if misdiagnosed, leading to corneal scarring and permanent vision loss 1, 2. Never use corticosteroids without confirming the diagnosis is not HSV.

Specific Viral Etiologies Requiring Different Management

Herpes Simplex Virus (HSV) Conjunctivitis

HSV conjunctivitis is self-limited but treatment is usually initiated upon high suspicion or with corneal involvement 3:

Topical antiviral options:

• Ganciclovir 0.15% gel three to five times daily (less toxic to ocular surface) 3
• Trifluridine 1% solution five to eight times daily (inevitably causes epithelial toxicity if used >2 weeks) 3

Oral antiviral options:

• Acyclovir 200-400 mg five times daily 3
• Valacyclovir 500 mg two to three times daily 3
• Famciclovir 250 mg twice daily 3

Critical: Topical corticosteroids potentiate HSV infection and must be avoided 3. Follow-up within 1 week is mandatory, and neonates require immediate pediatric consultation as systemic HSV is life-threatening 3.

Varicella Zoster Virus (VZV) Conjunctivitis

For persistent or recalcitrant acute/subacute VZV disease in immunocompetent patients 3:

• Acyclovir 800 mg five times daily for 7 days 3
• Valacyclovir 1000 mg every 8 hours for 7 days 3
• Famciclovir 500 mg three times daily for 7 days 3
• Topical antibiotics may be used to prevent secondary bacterial infection as vesicles undergo necrosis 3
• Topical antivirals alone are not helpful for VZV conjunctivitis but may be used as additive treatment in unresponsive patients 3
• Caution in patients with impaired renal clearance 3

Molluscum Contagiosum

Treatment requires physical removal of the causative eyelid lesions 3, 1:

• Incision and curettage (aggressive enough to cause bleeding) 3
• Simple excision 3
• Excision and cautery 3
• Cryotherapy 3

The conjunctivitis may require weeks to resolve after lesion elimination 3, 1. Multiple or large lesions in adults may indicate immunocompromised state 3.

Management of Complications

Membranous Conjunctivitis

Debridement of membranes may prevent corneal epithelial abrasions or permanent cicatricial changes (e.g., foreshortening of the conjunctival fornix) 3, 1, 2.

Subepithelial Infiltrates

These typically occur 1 or more weeks after onset of conjunctivitis 3:

• Mild cases: Observation only 3, 1
• Cases with blurring, photophobia, and decreased vision: Topical corticosteroids at minimum effective dose 3, 1

Follow-Up Recommendations

• Severe disease: Re-evaluate within 1 week 1, 2
• Patients not on corticosteroids: Return if symptoms persist beyond 2-3 weeks 3, 1
• All follow-up visits should include: Interval history, visual acuity measurement, and slit-lamp biomicroscopy 3, 1
• Patients on corticosteroids: Regular monitoring of IOP and pupillary dilation 3

Emerging Treatments (Not Yet Standard of Care)

• Povidone-iodine has been investigated and may reduce viral titers and shorten clinical course, but is not yet established 1
• Off-label topical ganciclovir 0.15% gel has shown potential benefit against specific adenovirus serotypes, but further research is needed before definitive recommendations 3, 1