What is the treatment for viral conjunctivitis?

Treatment of Viral Conjunctivitis

Most viral conjunctivitis requires only supportive care with artificial tears, cold compresses, and strict hygiene measures, as the condition is self-limited and resolves without specific antiviral treatment in the majority of cases. 1, 2

General Supportive Management

The cornerstone of treatment for typical viral conjunctivitis (primarily adenoviral) is symptomatic relief and infection control, not antiviral medications 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 no benefit and may cause toxicity or allergic reactions 1, 2. This is one of the most common errors in primary care management 3.

Infection Control Measures

Adenovirus is highly contagious and can survive for weeks on surfaces 1:

• Patients must minimize contact with others for 10-14 days from symptom onset in the last affected eye 1, 2
• Emphasize frequent handwashing, avoiding eye touching, and using disposable towels 4
• Disinfect surfaces with EPA-registered hospital disinfectants or sodium hypochlorite (1:10 dilution of household bleach) 1
• In clinical settings, defer intraocular pressure measurement unless absolutely necessary, as tonometer tips can transmit infection despite disinfection 1

When to Consider Corticosteroids (Severe Cases Only)

For severe adenoviral keratoconjunctivitis with subepithelial infiltrates causing blurred vision, photophobia, or decreased visual acuity, topical corticosteroids may be considered—but only with mandatory close ophthalmology follow-up 5, 1, 2:

• Use corticosteroids with poor ocular penetration (fluorometholone, rimexolone, or loteprednol) to minimize intraocular pressure elevation and cataract formation 5
• Taper slowly to the minimum effective dose 5
• Monitor intraocular pressure and evaluate for cataract formation regularly 5
• Critical warning: Corticosteroids may prolong viral shedding and can worsen HSV infections if misdiagnosed, potentially leading to corneal scarring and vision loss 1, 2

Algorithm for Corticosteroid Use:

• Mild subepithelial infiltrates without visual symptoms: Observation only 5
• Infiltrates with blurring, photophobia, or decreased vision: Consider low-penetration topical corticosteroids at minimum effective dose 5
• Before prescribing: Confirm diagnosis is NOT HSV (corticosteroids are contraindicated in HSV) 1, 2

Specific Viral Etiologies Requiring Different Management

Herpes Simplex Virus (HSV) Conjunctivitis

HSV requires antiviral treatment, not corticosteroids alone 5, 2:

• Topical options: Ganciclovir 0.15% gel (3-5 times daily) or trifluridine 1% solution (5-8 times daily) 5
• Oral antivirals: Acyclovir (200-400 mg five times daily), valacyclovir (500 mg 2-3 times daily), or famciclovir (250 mg twice daily) 5
• Critical: Topical corticosteroids potentiate HSV infection and must be avoided 5
• Topical ganciclovir is less toxic to the ocular surface than trifluridine, which causes epithelial toxicity if used beyond 2 weeks 5
• Follow-up within 1 week with visual acuity measurement and slit-lamp biomicroscopy 5
• Neonates require immediate pediatric consultation as systemic HSV infection is life-threatening 5

Varicella Zoster Virus (VZV) Conjunctivitis

• Topical antibiotics are recommended to prevent secondary bacterial infection as vesicles undergo necrosis 5, 1
• Topical antivirals alone have not been shown helpful but may be used as additive treatment in unresponsive patients 5
• For persistent or recalcitrant disease in immunocompetent patients, oral antivirals are beneficial 5:
  • Acyclovir 800 mg five times daily for 7 days
  • Valacyclovir 1000 mg every 8 hours for 7 days
  • Famciclovir 500 mg three times daily for 7 days
• Use caution in patients with impaired renal clearance 5, 1

Molluscum Contagiosum-Related Conjunctivitis

Physical removal of the causative eyelid lesions is required 5, 1, 2:

• Treatment options: incision and curettage (aggressive enough to cause bleeding), simple excision, excision and cautery, or cryotherapy 5
• The conjunctivitis may require weeks to resolve after lesion elimination 5, 1
• In adults, large and multiple lesions with minimal conjunctival inflammation may indicate immunocompromised state 5

Management of Complications

Membranous Conjunctivitis

• Debridement of membranes may prevent corneal epithelial abrasions or permanent cicatricial changes 1, 2
• Re-evaluate within 1 week for severe disease 5, 1

Follow-Up Recommendations

• Severe disease: Re-evaluate within 1 week 5, 1, 2
• Patients not on corticosteroids: Return if symptoms persist beyond 2-3 weeks 5, 1, 2
• All follow-up visits should include interval history, visual acuity measurement, and slit-lamp biomicroscopy 5, 1, 2

Red Flags Requiring Immediate Ophthalmology Referral

• Severe pain or decreased vision 3
• Recent ocular surgery 3
• Vesicular rash on eyelids or nose (suggests HSV or VZV) 3
• Conjunctival scarring 1
• Neonatal conjunctivitis 5
• Immunocompromised state 3
• History of rheumatologic disease 3