What is the best treatment approach for a patient with common cold conjunctivitis?

Treatment of Common Cold Conjunctivitis

For viral conjunctivitis associated with upper respiratory infection (common cold), supportive care without antibiotics is the recommended approach, as the condition is self-limited and resolves within 5-14 days. 1

Immediate Management Strategy

Confirm Viral Etiology

Look for these specific features that distinguish viral from bacterial conjunctivitis:

• Watery discharge (not purulent or mucopurulent) 1, 2
• Follicular reaction on the inferior tarsal conjunctiva 1
• Preauricular lymphadenopathy (swollen lymph node in front of the ear) 1
• Sequential bilateral involvement (starts in one eye, spreads to the other) 1
• Concurrent upper respiratory symptoms (runny nose, sore throat, cough) 1

First-Line Supportive Treatment

Provide symptomatic relief with the following measures:

• Artificial tears (preservative-free preferred) 4 times daily to dilute viral particles and provide comfort 1, 3
• Cold compresses to reduce inflammation and swelling 3
• Topical antihistamines (such as ketotifen) for itching and discomfort 1, 3
• Oral analgesics for pain management if needed 3

Critical: What NOT to Do

• Do NOT prescribe topical antibiotics - they provide zero benefit for viral infections and may cause toxicity or allergic reactions 1, 3
• Avoid topical corticosteroids in routine cases, as they may prolong viral shedding and can worsen herpes simplex virus if misdiagnosed 3

Infection Control Measures

Educate patients on the highly contagious nature:

• Minimize contact with others for 10-14 days from symptom onset in the last affected eye 3
• Frequent handwashing with soap and water 1
• Avoid touching or rubbing eyes 3
• Use disposable towels and avoid sharing personal items 1
• Disinfect surfaces with EPA-registered disinfectants or 1:10 dilution of household bleach, as adenovirus survives for weeks on surfaces 3
• Avoid group activities while discharge is present 4

When to Consider Escalation

Severe Cases Requiring Ophthalmology Referral

Refer immediately if any of these red flags are present:

• Visual loss or decreased vision 1
• Moderate to severe pain (not just irritation) 1
• Corneal involvement (subepithelial infiltrates causing blurred vision) 1
• Pseudomembrane formation 1
• Vesicular rash on eyelids (suggests herpes simplex virus) 1
• History of herpes simplex virus eye disease 1
• Immunocompromised state 1
• No improvement after 2-3 weeks 3

Corticosteroid Use (Only in Severe Cases with Ophthalmology Follow-up)

For severe adenoviral keratoconjunctivitis with subepithelial infiltrates causing vision problems:

• Use low-penetration corticosteroids (loteprednol, fluorometholone, or rimexolone) 3
• Requires mandatory close ophthalmology follow-up with regular IOP monitoring 3
• Never use without confirming it is NOT herpes simplex virus, as corticosteroids worsen HSV and cause corneal scarring 3

Follow-Up Recommendations

• Routine cases: Patients should return if symptoms persist beyond 2-3 weeks 3
• Severe cases: Re-evaluate within 1 week with visual acuity measurement and slit-lamp examination 3
• Expected timeline: Most cases resolve within 5-14 days without intervention 1

Common Pitfalls to Avoid

• Misdiagnosing bacterial conjunctivitis and prescribing unnecessary antibiotics - look for purulent discharge with matted eyelids, which is absent in viral cases 1
• Missing gonococcal conjunctivitis in sexually active patients - this presents with marked lid edema and copious purulent discharge, requires systemic antibiotics, and can cause corneal perforation 1
• Using antibiotics "just in case" - this contributes to resistance and causes unnecessary side effects 1
• Deferring IOP measurement during acute phase unless absolutely necessary, as tonometer tips can transmit infection 3