What is the treatment for adenoviral conjunctivitis?

Treatment of Adenoviral Conjunctivitis

Most cases of adenoviral conjunctivitis are self-limited and require only supportive care with artificial tears, cold compresses, and patient education about contagion—antibiotics should be avoided and topical corticosteroids reserved only for severe presentations with marked chemosis, epithelial sloughing, or membranous conjunctivitis. 1

Primary Management: Supportive Care

The cornerstone of treatment is symptomatic relief, as there is no FDA-approved antiviral for adenoviral conjunctivitis 2:

• Preservative-free artificial tears applied frequently to lubricate the ocular surface and dilute inflammatory mediators 3
• Cold compresses to reduce inflammation and provide symptomatic relief 1, 3
• Topical antihistamines may help alleviate itching and discomfort 1
• Oral analgesics (acetaminophen or NSAIDs) for pain management 1, 3

Critical: Avoid Unnecessary Antibiotics

Antibiotics provide no benefit for viral infections and should be avoided due to potential adverse effects including toxicity and allergic reactions 1, 4, 5. The majority of acute infectious conjunctivitis cases in adults are viral and self-limited, not requiring antimicrobial treatment 1.

Infection Control Education

Patients must understand this is a highly contagious infection requiring strict precautions 1:

• Minimize contact with others for 10-14 days from symptom onset in the last affected eye 1, 4
• Adenovirus can survive for weeks on surfaces without proper disinfection 1, 4
• Use EPA-registered hospital disinfectants or sodium hypochlorite (1:10 dilution of household bleach) for surface disinfection 4
• Practice strict hand hygiene, use separate towels and pillows, and avoid sharing personal items 3

When to Use Topical Corticosteroids

Corticosteroids are reserved for severe cases only and require mandatory close follow-up 1, 5:

Indications for corticosteroid use:

• Marked chemosis or severe eyelid swelling 1, 5
• Epithelial sloughing 1, 5
• Membranous or pseudomembranous conjunctivitis 1, 5
• Corneal epithelial ulceration 5

Critical monitoring requirements:

• Re-evaluate within 1 week of initiating corticosteroids 1, 5, 3
• Monitor intraocular pressure and pupillary dilation periodically to detect glaucoma and cataract formation 1, 5
• Use corticosteroids with poor ocular penetration (fluorometholone, loteprednol, or rimexolone) to minimize IOP elevation and cataract risk 1, 3
• Taper slowly to minimum effective dose once inflammation is controlled 1, 5

Important caveat:

Animal models suggest corticosteroids may prolong viral shedding 1, 4. More critically, never use corticosteroids without confirming the diagnosis is not HSV, as they potentiate HSV epithelial infections and can cause corneal scarring and vision loss 4, 5.

Management of Subepithelial Infiltrates

These typically appear 1 or more weeks after conjunctivitis onset 1, 5:

• Mild cases: Observation only 1, 5
• Symptomatic cases (blurring, photophobia, decreased vision): Topical corticosteroids at minimum effective dose 1, 5
• Alternative option: Cyclosporine drops (0.05% to 1% compounded) can reduce subepithelial infiltrates 1, 5

Follow-Up Strategy

For patients with severe disease:

• Re-evaluate within 1 week if they have corneal epithelial ulceration or membranous conjunctivitis 1, 3
• Follow-up visits should include interval history, visual acuity measurement, IOP measurement, and slit-lamp biomicroscopy 1, 3

For patients not on corticosteroids:

• Return if symptoms persist beyond 2-3 weeks 1
• Evaluate for presence of subepithelial infiltrates at follow-up 1

Clinical Examination Modifications

To minimize spread within the clinic 1:

• Consider an abbreviated exam in a dedicated exam room with limited physical interaction 1, 4
• Focus slit-lamp exam on identifying membranes/pseudomembranes, corneal epithelial defects, dendrites, filaments, or infiltrates 1
• Defer tonometry unless absolutely necessary, as tonometer tips can transmit infection despite disinfection 4

Emerging Treatments (Not Yet Standard)

While not FDA-approved, some evidence suggests potential benefit 4, 2:

• Povidone-iodine may reduce viral titers and shorten clinical course, though optimal concentration and regimen remain unclear 4, 6
• Off-label topical ganciclovir 0.15% gel has shown potential against specific adenovirus serotypes but requires further research 4

Common Pitfalls to Avoid

• Do not prescribe antibiotics for uncomplicated viral conjunctivitis—this increases costs, adverse effects, and antibiotic resistance without benefit 1, 4
• Do not use corticosteroids routinely—reserve for severe cases only with mandatory close follow-up 1, 5
• Do not miss HSV conjunctivitis—corticosteroids will worsen HSV infections, causing corneal scarring and vision loss 4, 5
• Do not underestimate contagion—counsel patients about work/school restrictions, particularly for healthcare workers, food service, or sales positions 1