What is the treatment for viral conjunctivitis?

Treatment of Viral Conjunctivitis

For most cases of viral conjunctivitis, supportive care alone with artificial tears, cold compresses, and strict hygiene measures for 10-14 days is the recommended treatment, with topical antibiotics providing no benefit and potentially causing harm. 1

Supportive Care (First-Line for Most Cases)

The cornerstone of management is symptomatic relief and infection control:

• Artificial tears provide comfort and help dilute viral particles on the ocular surface 1
• Cold compresses reduce inflammation and provide symptomatic relief 1
• Topical antihistamines may alleviate itching and discomfort 1
• Oral analgesics can be used for pain management 1

Critical: What NOT to Do

• Never use topical antibiotics for viral conjunctivitis—they provide no benefit and may cause toxicity or allergic reactions 1
• Avoid corticosteroids unless you have definitively ruled out HSV, as they potentiate HSV epithelial infections and can lead to corneal scarring and vision loss 1

Infection Control (Mandatory for All Cases)

Patients are highly contagious and must take strict precautions:

• Minimize contact with others for 10-14 days from symptom onset in the last affected eye, as adenovirus can survive for weeks on surfaces 1
• Disinfect exposed surfaces with EPA-registered hospital disinfectants or sodium hypochlorite (1:10 dilution of household bleach) 1
• Defer intraocular pressure measurement during acute conjunctivitis unless absolutely necessary, as tonometer tips can transmit infection 1

When to Escalate Treatment: Severe Adenoviral Keratoconjunctivitis

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

• Topical corticosteroids may be considered but ONLY with mandatory close ophthalmology follow-up 1
• Prefer corticosteroids with poor ocular penetration (such as loteprednol) to minimize intraocular pressure elevation and cataract formation 1
• Be aware that corticosteroids may prolong viral shedding and can worsen HSV infections if misdiagnosed 1

Specific Viral Etiologies Requiring Different Management

Herpes Simplex Virus (HSV) Conjunctivitis

HSV requires antiviral treatment, not corticosteroids alone:

• Topical antivirals: ganciclovir 0.15% gel or trifluridine 1% solution 1
• Oral antivirals: acyclovir, valacyclovir, or famciclovir may be used 1
• Topical corticosteroids must be avoided as they potentiate HSV epithelial infections 1
• Follow-up within 1 week of treatment initiation is required 1

Varicella Zoster Virus (VZV) Conjunctivitis

For persistent or recalcitrant acute/subacute disease in immunocompetent patients:

• Oral antivirals at specific doses: 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 2
• Topical antibiotics should be applied to eyelid vesicles to prevent secondary bacterial infection 1
• Caution in patients with impaired renal clearance when using oral antivirals 2
• Immunocompromised patients may need more aggressive treatment 2

Molluscum Contagiosum-Related Conjunctivitis

Physical removal of the causative eyelid lesions is required:

• Treatment options include incision and curettage (aggressive enough to cause bleeding), simple excision, excision and cautery, or cryotherapy 2
• The conjunctivitis may require weeks to resolve after elimination of the lesion 2
• In adults, large and multiple molluscum lesions with relatively little conjunctival inflammation may indicate an immunocompromised state 2

Management of Complications

Membranous Conjunctivitis

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

Subepithelial Infiltrates

• Mild cases require only observation 1
• Cases with blurring, photophobia, and decreased vision may require topical corticosteroids at minimum effective dose 1

Follow-Up Protocol

The timing depends on severity and treatment:

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

Common Pitfalls to Avoid

• Misdiagnosing HSV as adenoviral conjunctivitis and using corticosteroids, which can cause corneal scarring and vision loss 1
• Using topical antibiotics unnecessarily, which provides no benefit and may cause toxicity 1
• Failing to educate patients about transmission, leading to spread within households and workplaces 1
• Not adjusting antiviral dosing in patients with renal impairment, risking toxicity 2