What is the recommended treatment for a patient with viral conjunctivitis?

Treatment of Viral Conjunctivitis

Viral conjunctivitis requires no specific antiviral treatment in most cases—management focuses on supportive care with artificial tears, cold compresses, and topical antihistamines, while avoiding antibiotics entirely. 1

Immediate Management and Patient Education

• No proven effective treatment exists for eradicating adenovirus, which causes 80% of viral conjunctivitis cases 1, 2
• Educate patients that the condition is highly contagious for 10-14 days from symptom onset in the last affected eye 1
• The virus survives for weeks on surfaces—strict hand hygiene and surface disinfection are essential to prevent spread 1
• Consider abbreviated clinic exams in dedicated rooms to minimize transmission 1

Supportive Care Options

• Artificial tears for symptomatic relief 1, 3
• Cold compresses to reduce discomfort 1, 3
• Topical antihistamines for itching and irritation 1
• Oral analgesics for pain management 1

When Antibiotics Should Be Avoided

• Avoid topical antibiotics completely in viral conjunctivitis due to potential adverse effects without therapeutic benefit 1
• Antibiotics do not shorten disease course and contribute to unnecessary antimicrobial resistance 1

Indications for Topical Corticosteroids

Use corticosteroids only in severe cases with the following features:

• Marked chemosis or eyelid swelling 1
• Epithelial sloughing 1
• Membranous conjunctivitis 1
• Corneal subepithelial infiltrates causing blurred vision, photophobia, or decreased visual acuity (occurring 1+ weeks after onset) 1

Critical caveat: Animal studies show corticosteroids prolong viral shedding, though human data are lacking 1. Close follow-up is mandatory with periodic IOP monitoring and pupillary dilation to screen for glaucoma and cataracts 1. Use the minimum effective dose and taper slowly once inflammation resolves 1.

Membrane Management

• Debride membranes to prevent corneal epithelial abrasions or permanent cicatricial changes like conjunctival fornix foreshortening 1

Emerging Therapies (Not Yet Standard)

• Povidone-iodine 0.4-0.6% (alone or with dexamethasone 0.1%) shows promise in reducing viral titers and shortening clinical course, with ongoing trials 1
• Off-label topical ganciclovir 0.15% gel demonstrates potential benefit against specific adenovirus serotypes but lacks large-scale efficacy data for definitive recommendations 1

Follow-Up Protocol

For patients NOT on corticosteroids:

• Return if symptoms (red eye, pain, decreased vision) persist beyond 2-3 weeks 1
• Perform visual acuity measurement and slit-lamp biomicroscopy 1

For patients WITH severe disease or on corticosteroids:

• Re-evaluate within 1 week if corneal epithelial ulceration or membranous conjunctivitis present 1
• Monitor IOP and perform pupillary dilation regularly during prolonged steroid use 1
• Evaluate for corneal subepithelial infiltrates at follow-up visits 1

Special Viral Subtypes Requiring Different Management

Herpes Simplex Virus (HSV) Conjunctivitis:

• Topical ganciclovir 0.15% gel 3-5 times daily OR trifluridine 1% solution 5-8 times daily 1
• Oral antivirals: valacyclovir 500 mg 2-3 times daily, acyclovir 200-400 mg 5 times daily, or famciclovir 250 mg twice daily 1, 4
• Avoid topical corticosteroids—they potentiate HSV epithelial infections 1, 4
• Follow-up within 1 week with visual acuity and slit-lamp exam 1, 4

Varicella Zoster Virus (VZV) Conjunctivitis:

• Oral antivirals: valacyclovir 1000 mg three times daily for 7 days, acyclovir 800 mg five times daily for 7 days, or famciclovir 500 mg three times daily for 7 days 1, 5
• Topical antibiotics to prevent secondary bacterial infection of vesicles 1, 5
• Topical antivirals alone are ineffective but may be added in unresponsive cases 1, 5
• Adjust doses in patients with impaired renal clearance 1, 5

Molluscum Contagiosum:

• Incision and curettage (aggressive enough to cause bleeding), simple excision, excision with cautery, or cryotherapy 1
• Conjunctivitis may take weeks to resolve after lesion removal 1
• Multiple/large lesions in adults suggest immunocompromised state 1

Common Pitfalls to Avoid

• Never prescribe antibiotics for uncomplicated viral conjunctivitis—this is the most common error 1, 3
• Never use topical corticosteroids in HSV conjunctivitis or during active epithelial disease 1, 4
• Do not miss HSV diagnosis when considering steroids for presumed adenoviral disease—dendrites on exam indicate HSV 6
• Recurrence of subepithelial infiltrates can occur after photorefractive keratectomy or LASIK in patients with prior adenoviral infection 1