What is the treatment for viral conjunctivitis?

Treatment of Viral Conjunctivitis

The American Academy of Ophthalmology recommends supportive care with artificial tears, cold compresses, and strict infection control measures for 10-14 days, avoiding topical antibiotics entirely as they provide no benefit and may cause harm. 1

Supportive Care Measures

• 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 Infection Control (Mandatory)

• 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
• Disinfect exposed surfaces with EPA-registered hospital disinfectants or sodium hypochlorite (1:10 dilution of household bleach) 1, 2
• Strict handwashing and personal hygiene are essential to prevent transmission 3
• Defer intraocular pressure measurement during acute conjunctivitis unless absolutely necessary, as tonometer tips can transmit infection 1, 2

What NOT to Do

• Never use topical antibiotics for viral conjunctivitis—they provide no benefit and may cause toxicity or allergic reactions 1, 2
• Never use topical corticosteroids alone without confirming the diagnosis is not HSV, as they potentiate HSV epithelial infections and can lead to corneal scarring and vision loss 1, 2

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. 1, 2

• Prefer corticosteroids with poor ocular penetration (such as loteprednol, fluorometholone, or rimexolone) to minimize intraocular pressure elevation and cataract formation 1, 2
• Monitor for increased intraocular pressure and cataract formation during treatment 2
• Taper slowly to the minimum effective dose 2
• Be aware that corticosteroids may prolong viral shedding 1, 2

Specific Viral Etiologies Requiring Different Treatment

Herpes Simplex Virus (HSV) Conjunctivitis

• Requires antiviral treatment, not corticosteroids alone 1, 2
• Topical options include ganciclovir 0.15% gel or trifluridine 1% solution 1, 2
• Oral antivirals such as acyclovir, valacyclovir, or famciclovir may be used 1, 2
• Topical corticosteroids potentiate HSV epithelial infections and must be avoided 1, 2
• Follow-up within 1 week of treatment initiation is required 1

Varicella Zoster Virus (VZV) Conjunctivitis

• Oral antivirals are recommended: valacyclovir 1000 mg three times daily for 7 days (preferred due to superior bioavailability), acyclovir 800 mg five times daily for 7 days, or famciclovir 500 mg three times daily for 7 days 4, 2
• Apply topical antibiotics to eyelid vesicles to prevent secondary bacterial infection, which can lead to necrosis, scarring, and cicatricial ectropion 4, 2
• Topical antivirals alone are not helpful for VZV conjunctivitis but may be used as additive treatment in unresponsive patients 4, 2
• Adjust antiviral dosing in patients with impaired renal clearance 4, 2

Molluscum Contagiosum-Related Conjunctivitis

• Physical removal of the causative eyelid lesions is required through incision and curettage, simple excision, excision and cautery, or cryotherapy 1, 2
• The conjunctivitis may require weeks to resolve after elimination of the lesion 2

Management of Complications

• For membranous conjunctivitis, debridement of membranes may prevent corneal epithelial abrasions or permanent cicatricial changes 1, 2
• For subepithelial infiltrates, mild cases require only observation, while cases with blurring, photophobia, and decreased vision may require topical corticosteroids at minimum effective dose 1, 2

Follow-Up Protocol

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

Red Flags Requiring Immediate Ophthalmology Referral

• Neonatal conjunctivitis 2
• Severe pain or decreased vision 3
• Recent ocular surgery 3
• Vesicular rash on the eyelids or nose 3
• Conjunctival scarring 2
• Any signs of ocular involvement beyond simple conjunctivitis (corneal symptoms, uveitis) 4
• History of rheumatologic disease or immunocompromised state 3

Common Pitfalls to Avoid

• Misdiagnosing HSV as adenoviral conjunctivitis and prescribing corticosteroids, which can cause corneal scarring and vision loss 1, 2
• Using topical antibiotics unnecessarily, which provide no benefit for viral infections and may cause adverse effects 1, 2, 3
• Failing to educate patients about the highly contagious nature and need for strict infection control measures 1, 2
• Using combination antibiotic-corticosteroid preparations without confirming non-herpetic etiology 5