What treatment is recommended for a patient with adenoviral conjunctivitis who develops subepithelial infiltrates after 1 week?

Management of Subepithelial Infiltrates Following Adenoviral Conjunctivitis

For subepithelial infiltrates causing visual symptoms (blurring, photophobia, decreased vision) after adenoviral conjunctivitis, initiate topical corticosteroids at the minimum effective dose, preferably using low-penetration agents like loteprednol or fluorometholone to minimize IOP elevation and cataract risk. 1

Treatment Algorithm Based on Symptom Severity

Mild Cases (No Visual Symptoms)

• Observation alone is sufficient for patients without blurring, photophobia, or decreased vision 1
• Continue artificial tears for symptomatic relief 1

Symptomatic Cases (Blurring, Photophobia, Decreased Vision)

• Initiate topical corticosteroids at minimum effective dose 1
• Preferred agents: Loteprednol, fluorometholone, or rimexolone due to reduced risk of IOP elevation and cataract formation compared to stronger corticosteroids 1
• Dosing: Apply 1-2 drops four times daily initially 2
• Taper slowly to the minimum effective dose once inflammation is controlled 1

Critical Monitoring Requirements

All patients on topical corticosteroids require regular follow-up that includes: 1

• Interval history
• Visual acuity measurement
• Intraocular pressure monitoring (to detect steroid-induced glaucoma)
• Slit-lamp biomicroscopy
• Pupillary dilation periodically to evaluate for cataract formation

Corticosteroid-Sparing Alternatives for Resistant Cases

If subepithelial infiltrates persist despite corticosteroid tapering or if steroid-related complications develop:

• Topical cyclosporine A 1% has demonstrated effectiveness as a corticosteroid-sparing agent, allowing successful tapering of steroids while maintaining control of infiltrates 3
• Topical tacrolimus 0.03% showed significant reduction in SEI scores (from 2.20 to 0.25) and improvement in visual acuity in steroid-resistant cases, with mean treatment duration of 8.8 months 4
• These immunomodulators can be maintained at once daily or less frequently for long-term control 3

Important Caveats and Pitfalls

Do NOT confuse this with HSV epithelial keratitis, where corticosteroids are absolutely contraindicated 5. The key distinction is timing: subepithelial infiltrates occur 1+ weeks after adenoviral conjunctivitis onset, whereas HSV presents with dendritic ulcers 1

Avoid premature discontinuation of corticosteroids, as this commonly leads to recurrence of infiltrates 1. The tapering process may take weeks to months 4, 3

Animal studies suggest prolonged viral shedding with corticosteroid use, though human data is lacking 1. This theoretical concern is outweighed by the benefit of preventing permanent visual impairment in symptomatic cases.

Recurrence risk exists after photorefractive keratectomy or LASIK in patients with prior adenoviral infection history 1

Re-evaluation Timing

• If symptoms persist beyond 2-3 weeks without corticosteroid treatment, patients should return for evaluation 1
• Patients on corticosteroids require more frequent monitoring based on treatment response and IOP measurements 1