What is the treatment for viral conjunctivitis?

Treatment of Viral Conjunctivitis

Viral conjunctivitis requires supportive care only—artificial tears, cold compresses, and strict infection control—with no role for topical antibiotics unless you have confirmed HSV or VZV infection, which require specific antiviral therapy. 1

Primary Management: Supportive Care

The American Academy of Ophthalmology recommends the following supportive measures for typical adenoviral conjunctivitis 1:

• Artificial tears to provide comfort and dilute viral particles on the ocular surface 1
• Cold compresses to reduce inflammation and provide symptomatic relief 1
• Topical antihistamines (such as olopatadine 1 drop twice daily, 6-8 hours apart) to alleviate itching and discomfort 1, 2
• Oral analgesics for pain management 1

Critical: What NOT to Do

• Never prescribe topical antibiotics for typical viral conjunctivitis—they provide no benefit and may cause toxicity or allergic reactions 1
• Most cases are self-limited and resolve in 1-2 weeks without treatment 3, 4

Infection Control (Mandatory for All Cases)

Adenovirus can survive for weeks on surfaces, making transmission control essential 1:

• Patients must minimize contact with others for 10-14 days from symptom onset in the last affected eye 1
• Disinfect exposed surfaces with EPA-registered hospital disinfectants or sodium hypochlorite (1:10 dilution of household bleach) 1
• Strict handwashing is essential to decrease transmission risk 5
• In clinical settings, defer intraocular pressure measurement during acute conjunctivitis unless absolutely necessary, as tonometer tips can transmit infection 1

When Viral Conjunctivitis Requires Specific Treatment

Herpes Simplex Virus (HSV) Conjunctivitis

HSV requires antiviral treatment, not corticosteroids alone 1:

• Topical antivirals: ganciclovir 0.15% gel or trifluridine 1% solution 1, 6
• Oral antivirals: acyclovir, valacyclovir, or famciclovir 1
• Never use topical corticosteroids alone—they potentiate HSV epithelial infections and can cause corneal scarring and vision loss 1, 7
• Follow-up within 1 week of treatment initiation 1

Varicella Zoster Virus (VZV) Conjunctivitis

VZV requires oral antiviral therapy 1, 7:

• Valacyclovir 1000 mg three times daily for 7 days (preferred due to superior bioavailability) 7, 8
• Alternative: acyclovir 800 mg five times daily for 7 days 7, 8
• Alternative: famciclovir 500 mg three times daily for 7 days 7, 8
• Apply topical antibiotics to vesicular lesions to prevent secondary bacterial infection, which can lead to cicatricial ectropion 7, 8
• Adjust dosing in patients with impaired renal clearance 7, 8

Molluscum Contagiosum-Related Conjunctivitis

Physical removal of eyelid lesions is required 1:

• Options include incision and curettage, simple excision, or cryotherapy 1

Management of Severe Adenoviral Keratoconjunctivitis

For severe cases with significant subepithelial infiltrates causing blurred vision, photophobia, or decreased visual acuity 1:

• Topical corticosteroids may be considered—but only with mandatory close ophthalmology follow-up 1
• Prefer loteprednol (poor ocular penetration) to minimize intraocular pressure elevation and cataract formation 1
• Warning: Corticosteroids may prolong viral shedding and can worsen HSV infections if misdiagnosed 1

Membranous Conjunctivitis Complication

• Debridement of membranes may prevent corneal epithelial abrasions or permanent cicatricial changes 1

Follow-Up Protocol

• Patients with severe disease: re-evaluate within 1 week 1
• Patients not treated with corticosteroids: return if symptoms persist beyond 2-3 weeks 1
• HSV patients: follow-up within 1 week of treatment 1
• Follow-up visits should include interval history, visual acuity measurement, and slit-lamp biomicroscopy 1, 7

Common Pitfalls to Avoid

• Do not diagnose based on discharge alone—there is no single sign or symptom that accurately differentiates viral from bacterial conjunctivitis 5
• Do not miss HSV—if you see dendrites or suspect HSV, corticosteroids alone will worsen the infection 1, 6
• Do not use topical antivirals alone for VZV—they have not been shown to be helpful 7, 8
• The clinical accuracy rate for diagnosing viral conjunctivitis is less than 50%, so consider rapid diagnostic tests to decrease unnecessary antibiotic use 4