What is Madras eye and how is it managed?

Madras Eye (Epidemic Keratoconjunctivitis)

Madras eye is a highly contagious viral conjunctivitis caused by adenovirus, presenting with acute red eye, watery discharge, and follicular reaction, requiring supportive care and strict infection control measures for 10-14 days. 1, 2

What is Madras Eye?

Madras eye, also known as epidemic keratoconjunctivitis (EKC), is a severe form of adenoviral conjunctivitis that earned its colloquial name from major outbreaks. 1 The condition is characterized by:

• Abrupt onset, often starting unilaterally but becoming sequentially bilateral within days 3
• Follicular reaction on the inferior tarsal conjunctiva (distinguishing it from bacterial causes) 3, 4
• Watery discharge with marked lid swelling and chemosis 2, 3
• Preauricular lymphadenopathy (swollen lymph nodes in front of the ear) 2, 3
• Subconjunctival hemorrhages may be present 2

In severe cases, patients develop pseudomembranes, subepithelial corneal infiltrates that can blur vision for weeks to months, and conjunctival scarring. 3 The virus is extraordinarily resilient, surviving for weeks on surfaces like countertops, making transmission highly efficient. 1, 2

Clinical Diagnosis

Diagnosis is primarily clinical when viral conjunctivitis occurs with concurrent upper respiratory infection. 2, 3 Key diagnostic features include:

• Follicular pattern on inferior tarsal conjunctiva (not papillary, which suggests bacterial) 3, 4
• Watery rather than purulent discharge 3, 4
• Absence of matted eyelids on waking (which suggests bacterial conjunctivitis) 4
• Itching is minimal or absent (unlike allergic conjunctivitis where itching dominates) 3, 4

Rapid immunodiagnostic testing has 88-89% sensitivity and 91-94% specificity if confirmation is needed, though testing is not required for typical presentations. 2 PCR provides highly sensitive detection when available. 2

Management Approach

Supportive Care (Mainstay of Treatment)

No antimicrobial treatment is indicated, as the condition is self-limited, typically resolving within 5-14 days. 1, 3 Management focuses on:

• Artificial tears (refrigerated for added comfort) for symptomatic relief 3
• Cold compresses to reduce swelling and discomfort 3
• Topical antihistamines may provide symptomatic relief 3
• Avoid topical antibiotics entirely, as they provide no benefit and may cause toxicity 3

When to Consider Corticosteroids

For severe cases with marked chemosis, lid swelling, or pseudomembranes, a short course of topical corticosteroids may be considered, but only with close ophthalmology follow-up. 3 Critical caveats:

• Corticosteroids may prolong viral shedding 3
• They can worsen herpes simplex virus infections if misdiagnosed 3
• Regular monitoring of intraocular pressure and periodic pupillary dilation is mandatory 3
• This should only be done by or in consultation with an ophthalmologist 3

Infection Control (Critical Component)

Patients remain infectious for 10-14 days from symptom onset in the last affected eye and must minimize contact with others during this period. 1, 2, 3 Specific measures include:

• Frequent handwashing with soap and water 3
• Avoid touching eyes 1
• Use disposable towels and avoid sharing personal items like pillows 3
• Disinfect surfaces with EPA-registered hospital disinfectant, as the virus survives for weeks 1, 2
• Avoid group activities, school, or work while discharge is present 1

Red Flags Requiring Urgent Ophthalmology Referral

Refer immediately if any of the following are present: 3

• Visual loss or decreased vision 3
• Moderate or severe pain (viral conjunctivitis causes discomfort, not severe pain) 3
• Corneal involvement beyond superficial punctate keratitis 3
• Severe purulent discharge (suggests bacterial superinfection or misdiagnosis) 3
• History of herpes simplex virus eye disease 3
• Immunocompromised state 3
• Lack of response to supportive therapy 3

Follow-Up Recommendations

• Patients with severe presentations should be re-evaluated within 1 week 3
• Patients not improving after 2-3 weeks require ophthalmology evaluation to assess for subepithelial infiltrates or other complications 3
• Contact lens wear must be avoided during any infectious conjunctivitis 3

Common Pitfalls to Avoid

Do not prescribe topical antibiotics, as this is viral and antibiotics cause unnecessary toxicity without benefit. 3 The most common error is underestimating contagiousness—inadequate patient education leads to community spread. 2, 3 Never use topical corticosteroids without ophthalmology involvement, as complications include elevated intraocular pressure, cataract formation, and worsening of unrecognized herpes simplex infections. 3