What is the medical management for a patient with viral conjunctivitis?

Medical Management of Viral Conjunctivitis

Viral conjunctivitis is primarily a self-limited condition requiring supportive care only, with artificial tears, cold compresses, and strict hygiene measures to prevent transmission—antibiotics should be avoided entirely as they provide no benefit and may cause unnecessary toxicity. 1, 2

Immediate Assessment and Red Flags

Before initiating supportive care, rule out conditions requiring urgent ophthalmology referral:

• Visual loss or decreased vision 2
• Moderate to severe pain 1
• Corneal involvement (dendritic ulcers suggest HSV, not simple adenoviral conjunctivitis) 2
• Severe purulent discharge (suggests bacterial or gonococcal infection) 1
• History of herpes simplex virus eye disease 2
• Immunocompromised state 1
• Neonatal presentation (requires immediate referral and possible hospitalization) 1, 2

Standard Supportive Care (First-Line for Uncomplicated Cases)

Symptomatic relief measures:

• Artificial tears to dilute viral particles and provide comfort 1, 3
• Cold compresses to reduce inflammation 1, 3
• Topical antihistamines (e.g., olopatadine, ketotifen) for itching and discomfort 1, 3
• Oral analgesics for pain management 1

Critical: Do NOT prescribe topical antibiotics—they offer no benefit for viral infections and may cause toxicity or allergic reactions 1, 2

Infection Control (Mandatory Patient Education)

• Minimize contact with others for 10-14 days from symptom onset in the last affected eye 1
• Strict hand hygiene with soap and water 2
• Avoid sharing towels, pillows, or personal items 2
• Disinfect surfaces with EPA-registered hospital disinfectants or sodium hypochlorite (1:10 dilution of household bleach), as adenovirus can survive for weeks on surfaces 1

Management of Severe Adenoviral Keratoconjunctivitis

For severe cases with membranous conjunctivitis, marked chemosis, or corneal involvement:

• Consider debridement of membranes to prevent corneal epithelial abrasions or permanent cicatricial changes 4, 1
• Topical corticosteroids may be considered for severe disease, BUT this requires mandatory close ophthalmology follow-up 4, 1

If corticosteroids are used (ophthalmology-supervised only):

• Prefer low-penetration agents (fluorometholone, rimexolone, or loteprednol) to minimize IOP elevation and cataract formation 4, 1
• Monitor IOP and perform pupillary dilation regularly to evaluate for glaucoma and cataract 4, 1
• Taper slowly to minimum effective dose once inflammation is controlled 4, 1
• Be aware: Animal models suggest corticosteroids may prolong viral shedding 1
• Critical pitfall: Corticosteroids can worsen HSV infections if misdiagnosed, leading to corneal scarring and vision loss 1, 2

Management of Subepithelial Infiltrates

These typically occur 1+ weeks after onset of conjunctivitis 4:

• Mild cases: Observation only 4, 1
• Cases with blurred vision, photophobia, or decreased visual acuity: Topical corticosteroids at minimum effective dose may be considered (ophthalmology-supervised) 4, 1
• Monitor for recurrence in patients with history of adenoviral infection who undergo photorefractive keratectomy or LASIK 4

Special Viral Etiologies Requiring Different Management

Herpes Simplex Virus (HSV) Conjunctivitis

If HSV is suspected (vesicular rash on eyelids, dendritic keratitis):

• Topical options: Ganciclovir 0.15% gel 3-5 times daily OR trifluridine 1% solution 5-8 times daily 4, 1
• Oral antivirals: Acyclovir 200-400 mg five times daily, valacyclovir 500 mg 2-3 times daily, OR famciclovir 250 mg twice daily 4, 1
• Important: Topical ganciclovir is less toxic to the ocular surface than trifluridine (which causes epithelial toxicity if used >2 weeks) 4
• AVOID topical corticosteroids—they potentiate HSV infection 4
• Follow-up within 1 week with interval history, visual acuity, and slit-lamp exam 4

Varicella Zoster Virus (VZV) Conjunctivitis

For children with chickenpox-associated conjunctivitis:

• Topical antibiotics to prevent secondary bacterial infection (vesicles undergo necrosis before healing) 4, 1
• Oral antivirals for persistent/recalcitrant disease: Acyclovir 800 mg five times daily for 7 days, valacyclovir 1000 mg every 8 hours for 7 days, OR famciclovir 500 mg three times daily for 7 days 1
• Caution in renal impairment when using oral antivirals 1
• Note: Topical antivirals alone have not been shown to be helpful 4, 1

Molluscum Contagiosum-Related Conjunctivitis

Physical removal of causative eyelid lesions is required:

• Treatment options: Incision and curettage, simple excision, excision and cautery, or cryotherapy 1
• Expect delayed resolution: Conjunctivitis may require weeks to resolve after lesion elimination 1

Follow-Up Recommendations

For severe disease (corneal ulceration or membranous conjunctivitis):

• Re-evaluate within 1 week with interval history, visual acuity measurement, and slit-lamp biomicroscopy 4, 1

For uncomplicated cases not treated with corticosteroids:

• Instruct patients to return if symptoms persist beyond 2-3 weeks 4, 1

For patients on topical corticosteroids:

• Regular monitoring of IOP and periodic pupillary dilation 4, 1

Emerging Treatments (Not Yet Standard of Care)

• Povidone-iodine: Investigated for broad antimicrobial spectrum; may reduce viral titers and shorten clinical course, but not yet established 1
• Off-label topical ganciclovir 0.15% gel: Shows potential benefit against specific adenovirus serotypes, but further research needed before definitive recommendations 4, 1

Common Pitfalls to Avoid

• Never prescribe antibiotics prophylactically—they provide no benefit and may cause toxicity 1, 2
• Never use corticosteroids without confirming diagnosis is not HSV—can cause corneal scarring and vision loss 1, 2
• Never use corticosteroids without ophthalmology follow-up—risk of IOP elevation, cataract formation, and prolonged viral shedding 1, 2
• Defer IOP measurement during acute conjunctivitis unless absolutely necessary, as tonometer tips can transmit infection 1
• Inadequate patient education about contagiousness leads to community spread 2