What is the treatment for viral conjunctivitis?

Treatment of Viral Conjunctivitis

Viral conjunctivitis requires supportive care only—artificial tears, cold compresses, and strict hygiene education—with antibiotics providing no benefit and potentially causing harm. 1, 2

Supportive Care Measures

The cornerstone of management is symptomatic relief while the infection self-resolves over 10-14 days:

• Artificial tears provide comfort and help dilute viral particles on the ocular surface 2, 3
• Cold compresses reduce inflammation and provide symptomatic relief 2, 4
• Topical antihistamines may alleviate itching and discomfort 2, 4
• Oral analgesics can be used for pain management 2, 4

Critical Infection Control

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, 2:

• Counsel patients to wash hands frequently, use separate towels and pillows, and avoid close contact during the contagious period 1
• Disinfect exposed surfaces with EPA-registered hospital disinfectants or sodium hypochlorite (1:10 dilution of household bleach) 2, 4
• In clinical settings, defer intraocular pressure measurement unless absolutely necessary, as tonometer tips can transmit infection despite disinfection 2, 4
• Use dilute bleach soak (sodium hypochlorite) at 1:10 concentration for tonometer disinfection; 70% isopropyl alcohol and 3% hydrogen peroxide are no longer recommended 1

What NOT to Do

Avoid topical antibiotics entirely—they provide no benefit for viral infections and may cause toxicity or allergic reactions 1, 2, 4. This is a critical pitfall, as indiscriminate antibiotic use is common but harmful 1.

Avoid topical corticosteroids in uncomplicated cases—they may prolong viral shedding and can catastrophically worsen HSV infections if misdiagnosed, leading to corneal scarring and vision loss 2, 4.

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 2, 4
• Prefer corticosteroids with poor ocular penetration (such as loteprednol) to minimize intraocular pressure elevation and cataract formation 2, 4
• Taper slowly to the minimum effective dose 4
• Monitor for increased intraocular pressure and cataract formation 4

For membranous conjunctivitis, debridement of membranes may prevent corneal epithelial abrasions or permanent cicatricial changes 2, 4.

Special Viral Etiologies Requiring Different Treatment

Herpes Simplex Virus (HSV) Conjunctivitis

HSV requires antiviral treatment, NOT corticosteroids alone:

• Topical options include ganciclovir 0.15% gel or trifluridine 1% solution 2, 5
• Oral antivirals such as acyclovir, valacyclovir, or famciclovir may be used 2
• Topical corticosteroids potentiate HSV epithelial infections and must be avoided 2, 4
• Follow-up within 1 week of treatment initiation is required 2

Varicella Zoster Virus (VZV) Conjunctivitis

• Oral antivirals such as acyclovir 800 mg five times daily for 7 days, valacyclovir 1000 mg three times daily for 7 days, or famciclovir 500 mg three times daily for 7 days 2, 6, 4
• Apply topical antibiotics to eyelid vesicles to prevent secondary bacterial infection, which can lead to necrosis, scarring, and cicatricial ectropion 6, 4
• Topical antivirals alone are not helpful for VZV conjunctivitis but may be used as additive treatment in unresponsive patients 6, 4

Molluscum Contagiosum-Related Conjunctivitis

• Physical removal of the causative eyelid lesions through incision and curettage, simple excision, or cryotherapy 2, 4
• The conjunctivitis may require weeks to resolve after elimination of the lesion 4

Follow-Up Protocol

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

Red Flags Requiring Immediate Ophthalmology Referral

Refer immediately for:

• Severe pain or decreased vision 3
• Conjunctival scarring 4
• Recent ocular surgery 3
• Vesicular rash on the eyelids or nose (suggesting HSV or VZV) 3
• History of rheumatologic disease or immunocompromised state 3
• Neonatal conjunctivitis 3
• Signs of corneal involvement, uveitis, or intraocular inflammation 6