What is the recommended treatment for a patient with viral conjunctivitis (viral pink eye)?

Treatment of Viral Conjunctivitis

Viral conjunctivitis requires supportive care only—no antibiotics, no antivirals for adenovirus—with artificial tears, cold compresses, and strict infection control for 10-14 days. 1

Immediate Management Algorithm

Confirm the Diagnosis First

• Look for watery (not purulent) discharge, follicular reaction on inferior tarsal conjunctiva, preauricular lymphadenopathy, and often sequential bilateral involvement to distinguish viral from bacterial conjunctivitis 1, 2
• Rule out HSV before any treatment—check for vesicular rash on eyelids, dendritic corneal lesions on fluorescein staining, or unilateral presentation in adults, because corticosteroids will devastate HSV infections 1, 3
• Obtain immediate ophthalmology referral if you see visual loss, moderate-to-severe pain, corneal involvement, or history of HSV eye disease 3, 2

Standard Supportive Care (For Adenoviral Conjunctivitis)

• Prescribe preservative-free artificial tears 4 times daily to dilute viral particles and inflammatory mediators 1, 3
• Recommend cold compresses for symptomatic relief of inflammation 1, 3
• Consider topical antihistamines (second-generation) for itching and discomfort, though dosing is not standardized 1, 3
• Oral analgesics for pain management as needed 1

Critical "Don'ts"

• Never prescribe topical antibiotics—they provide zero benefit for viral infections and cause unnecessary toxicity, allergic reactions, and antibiotic resistance 1, 3
• Avoid corticosteroids in routine cases, as animal models suggest they prolong viral shedding 1

Infection Control Measures (Non-Negotiable)

• Instruct patients to avoid close contact with others for 10-14 days from symptom onset in the last affected eye 1
• Emphasize strict handwashing with soap and water—adenovirus survives for weeks on surfaces 1, 3
• Disinfect surfaces with EPA-registered hospital disinfectants or 1:10 dilution of household bleach (sodium hypochlorite) 1
• Discard multiple-dose eyedrop containers to prevent cross-contamination 3

When to Escalate to Corticosteroids (Severe Cases Only)

Use corticosteroids only for severe adenoviral keratoconjunctivitis with subepithelial infiltrates causing blurred vision, photophobia, or decreased visual acuity—and only with mandatory close ophthalmology follow-up. 1

Corticosteroid Protocol (If Indicated)

• Choose agents with poor ocular penetration: fluorometholone, rimexolone, or loteprednol to minimize intraocular pressure elevation and cataract formation 1
• Monitor intraocular pressure at every visit and perform periodic pupillary dilation to check for cataracts 1, 3
• Taper slowly to minimum effective dose 1
• Never use corticosteroids without confirming the diagnosis is not HSV—this causes corneal scarring and vision loss 1

Additional Severe Case Management

• For membranous conjunctivitis, debride membranes to prevent corneal epithelial abrasions or permanent cicatricial changes 1
• Re-evaluate within 1 week for severe disease 1

Special Viral Etiologies Requiring Different Treatment

Herpes Simplex Virus (HSV) Conjunctivitis

• Prescribe topical ganciclovir 0.15% gel or trifluridine 1% solution as first-line treatment 1, 3
• Alternative: oral antivirals (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
• Absolutely avoid corticosteroids—they potentiate HSV infection and cause devastating outcomes 1, 3
• Caution with oral antivirals in patients with impaired renal clearance 1

Varicella Zoster Virus (VZV) Conjunctivitis

• Prescribe topical antibiotics to prevent secondary bacterial infection as vesicles undergo necrosis 1
• Topical antivirals alone are not helpful, but may be added in unresponsive cases 1, 3
• For persistent or recalcitrant disease, use oral antivirals (same dosing as HSV) 1

Molluscum Contagiosum-Related Conjunctivitis

• Physical removal of eyelid lesions is required—use incision and curettage, simple excision, excision and cautery, or cryotherapy 1
• Conjunctivitis may take weeks to resolve after lesion elimination 1

Follow-Up Strategy

• Re-evaluate within 1 week for severe disease with corneal involvement or membranous conjunctivitis 1
• Patients not on corticosteroids should return if symptoms persist beyond 2-3 weeks 1
• Follow-up visits must include visual acuity measurement and slit-lamp biomicroscopy 1

Common Pitfalls to Avoid

• Misdiagnosing HSV as adenovirus and using corticosteroids—this is the most catastrophic error, leading to corneal perforation and blindness 1, 3
• Prescribing antibiotics "just in case"—this contributes to resistance and causes unnecessary adverse effects without any benefit 1, 3
• Deferring intraocular pressure measurement during acute conjunctivitis unless absolutely necessary, as tonometer tips transmit infection despite disinfection 1
• Missing gonococcal or chlamydial conjunctivitis in adults with severe purulent discharge—these require systemic antibiotics and evaluation for sexually transmitted infections 3
• Immediate ophthalmology referral is mandatory for neonatal conjunctivitis, which requires systemic treatment 1, 3

Emerging Treatments (Not Yet Standard of Care)

• Povidone-iodine may reduce viral titers and shorten clinical course, but requires further validation 1
• Off-label topical ganciclovir 0.15% gel shows potential against specific adenovirus serotypes, but evidence is insufficient for routine use 1