Pediatric Viral Conjunctivitis: Symptoms and Management
Viral conjunctivitis in children is primarily managed with supportive care alone, as no proven effective antiviral treatment exists for the most common cause (adenovirus), and topical antibiotics should be avoided to prevent unnecessary adverse effects and resistance. 1, 2
Clinical Presentation
Viral conjunctivitis in children typically presents with:
- Watery discharge (not purulent or mucopurulent) 3, 4
- Burning or gritty sensation in the eyes 4
- Follicular reaction on conjunctival examination 2
- Preauricular lymphadenopathy (swollen lymph node in front of the ear) 2
- Bilateral involvement is common, though may start unilaterally 3
- Absence of matted eyelids on waking (which suggests bacterial cause) 5
Supportive Treatment Approach
For uncomplicated viral conjunctivitis, implement the following symptomatic measures:
- Refrigerated preservative-free artificial tears 4 times daily to dilute viral particles and inflammatory mediators 2
- Cold compresses for comfort and to reduce inflammation 1, 2
- Topical antihistamines (second-generation) may be used to relieve itching and discomfort, though this is not standard first-line therapy 2
- Sunglasses as a barrier and for photophobia relief 2
Avoid topical antibiotics entirely in confirmed viral conjunctivitis, as they provide no benefit, can cause toxicity, and contribute to antibiotic resistance 1, 2
Infection Control Measures
Strict hygiene is critical to prevent transmission:
- Frequent handwashing with soap and water (not just sanitizer) 1, 2
- Separate towels and pillows from other family members 6, 7
- Avoid close contact for 7-14 days from symptom onset 2
- Discard multiple-dose eyedrop containers to avoid cross-contamination 2
- Children may return to school/daycare once symptoms begin improving, though specific exclusion policies vary 8
Special Viral Etiologies Requiring Different Management
Herpes Simplex Virus (HSV) Conjunctivitis
If HSV is suspected (vesicular blepharitis, dendritic lesions), this requires antiviral treatment:
- Topical ganciclovir 0.15% gel OR topical trifluridine 1% solution as first-line therapy 2
- Oral antivirals (acyclovir, valacyclovir, or famciclovir) may also be used 2
- Never use topical corticosteroids in HSV conjunctivitis without antiviral coverage, as steroids potentiate the infection 2
- Neonates with HSV require immediate pediatric consultation due to risk of life-threatening systemic infection 1
Varicella Zoster Virus (VZV) Conjunctivitis
Children with chickenpox-associated conjunctivitis:
- Topical antibiotics to prevent secondary bacterial infection of necrotic vesicles (not for antiviral effect) 1
- Topical antivirals alone are not helpful for VZV conjunctivitis 1
- Oral antivirals (acyclovir 800 mg five times daily for 7 days, or age-appropriate dosing) for persistent or severe disease 1
Molluscum Contagiosum
Conjunctivitis from molluscum requires lesion removal:
- Incision and curettage, excision, or cryotherapy of the eyelid lesion(s) 1
- Conjunctivitis may take weeks to resolve after lesion elimination 1
When to Refer to Ophthalmology
Immediate ophthalmology referral is indicated for: 1, 6, 7
- Visual loss of any degree
- Moderate to severe pain (viral conjunctivitis is typically mild discomfort)
- Severe purulent discharge (suggests bacterial, possibly gonococcal)
- Corneal involvement (infiltrate, opacity, or ulceration)
- Conjunctival scarring or membranes
- Lack of response to therapy after 3-4 days
- History of HSV eye disease
- Immunocompromised state
- Neonatal conjunctivitis (requires systemic treatment coordination with pediatrician) 2
Critical Pitfalls to Avoid
Do not prescribe topical corticosteroids without ophthalmology consultation, as they:
- Prolong adenoviral infections 2
- Potentiate HSV infections and can cause corneal perforation 2
- Require monitoring for increased intraocular pressure and cataracts 2
Do not miss bacterial causes masquerading as viral:
- Severe purulent discharge suggests gonococcal infection requiring systemic ceftriaxone plus azithromycin 2, 7
- Persistent symptoms beyond 7-10 days warrant re-evaluation for bacterial superinfection or alternative diagnosis 6
- In children with sexually transmitted causes (gonorrhea, chlamydia), consider sexual abuse and report as mandated 1, 6, 7
Topical trifluridine should not be used for more than 2 weeks due to epithelial toxicity 2
Expected Clinical Course
- Viral conjunctivitis typically resolves spontaneously in 7-14 days without treatment 3, 4
- Return for evaluation if no improvement after 3-4 days, as this suggests alternative diagnosis or complications 6, 7
- Most cases can be managed effectively in outpatient primary care without ophthalmology involvement 1, 6