What is the treatment for viral conjunctivitis?

Treatment of Viral Conjunctivitis

Viral conjunctivitis requires supportive care only—artificial tears, cold compresses, and strict hygiene measures—with no role for topical antibiotics or antivirals in typical adenoviral cases. 1, 2

General Management for Typical Viral (Adenoviral) Conjunctivitis

The cornerstone of treatment is symptomatic relief and infection control, as most cases are self-limited and resolve within 2-3 weeks 1, 3:

• 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: What NOT to Do

• Never prescribe topical antibiotics for viral conjunctivitis—they provide no benefit and may cause toxicity or allergic reactions 1, 2
• Avoid topical corticosteroids unless there are severe subepithelial infiltrates causing vision loss, and only with mandatory ophthalmology follow-up 1, 2

Infection Control Measures

Adenovirus is highly contagious and can survive for weeks on surfaces 1, 2:

• Patients must minimize contact with others for 10-14 days from symptom onset in the last affected eye 1, 2
• Disinfect surfaces with EPA-registered hospital disinfectants or sodium hypochlorite (1:10 dilution of household bleach) 1, 2
• Defer intraocular pressure measurement during acute conjunctivitis unless absolutely necessary, as tonometer tips can transmit infection 1, 2
• In clinical settings, consider abbreviated exams in dedicated rooms with limited physical interaction 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 1, 2:

• Use only corticosteroids with poor ocular penetration (such as loteprednol, fluorometholone, or rimexolone) to minimize intraocular pressure elevation and cataract formation 1, 2
• Mandatory close ophthalmology follow-up is required, as corticosteroids may prolong viral shedding 1, 2
• Never use corticosteroids if HSV is suspected, as they can worsen HSV infections and lead to corneal scarring and vision loss 1, 2

Common Pitfall

The most dangerous error is misdiagnosing HSV conjunctivitis as adenoviral and prescribing corticosteroids, which potentiate HSV epithelial infections and can cause permanent vision loss 1, 2. Look for dendritic lesions on fluorescein staining to distinguish HSV from adenovirus.

Specific Viral Etiologies Requiring Different Management

Herpes Simplex Virus (HSV) Conjunctivitis

HSV requires antiviral treatment, not corticosteroids alone 1, 2:

• Topical antivirals: ganciclovir 0.15% gel or trifluridine 1% solution 1, 2
• Oral antivirals: acyclovir, valacyclovir, or famciclovir for severe cases 1, 2
• Never use topical corticosteroids alone, as they potentiate HSV epithelial infections 1, 2
• Follow-up within 1 week of treatment initiation 1

Varicella Zoster Virus (VZV) Conjunctivitis

VZV with eyelid involvement requires more aggressive treatment 4, 2, 5:

• Topical antibiotics should be applied to eyelid vesicles to prevent secondary bacterial infection, as vesicles undergo necrosis before healing and can lead to cicatricial ectropion 4, 2, 5
• Oral antivirals for persistent or recalcitrant disease in immunocompetent patients 4, 2, 5:
  • Acyclovir 800 mg five times daily for 7 days, OR
  • Valacyclovir 1000 mg every 8 hours for 7 days (preferred due to superior bioavailability), OR
  • Famciclovir 500 mg three times daily for 7 days
• Caution in patients with impaired renal clearance—adjust dosing to prevent toxicity 4, 5
• Topical antivirals alone are not helpful for VZV conjunctivitis but may be used as additive treatment in unresponsive patients 4, 2
• Immunocompromised patients may need more aggressive treatment with prolonged duration 4, 5

Molluscum Contagiosum-Related Conjunctivitis

Physical removal of the causative eyelid lesions is required 4, 1, 2:

• Treatment options include incision and curettage (aggressive enough to cause bleeding), simple excision, excision and cautery, or cryotherapy 4, 1, 2
• The conjunctivitis may require weeks to resolve after elimination of the lesion 4, 2
• In adults, large and multiple molluscum lesions with relatively little conjunctival inflammation may indicate an immunocompromised state 4

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 Recommendations

• 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

• Severe pain 6
• Decreased vision 6
• Recent ocular surgery 6
• Vesicular rash on the eyelids or nose (suggests HSV or VZV) 6
• Conjunctival scarring 2
• Neonatal conjunctivitis 2
• Immunocompromised state 6
• History of rheumatologic disease 6