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

Management of Viral Conjunctivitis

For most cases of viral conjunctivitis, supportive care with artificial tears, cold compresses, and strict infection control measures for 10-14 days is the recommended approach, with antiviral therapy reserved only for specific viral etiologies like HSV, VZV, or molluscum contagiosum. 1, 2

Supportive Care for Typical Adenoviral Conjunctivitis

The cornerstone of management is symptomatic relief, as most cases are self-limited:

• Artificial tears provide comfort and help dilute viral particles on the ocular surface 1, 2
• Cold compresses reduce inflammation and provide symptomatic relief 1, 2
• Topical antihistamines may alleviate itching and discomfort 1, 2
• Oral analgesics can be used for pain management 1, 2

Critical: What NOT to Do

• Never use topical antibiotics for viral conjunctivitis—they provide no benefit and may cause toxicity or allergic reactions 1, 2
• Avoid topical corticosteroids unless you have confirmed the diagnosis is NOT HSV, as steroids potentiate HSV epithelial infections and can lead to corneal scarring and vision loss 3, 1, 2

Infection Control Measures

Adenovirus is highly contagious and can survive for weeks on surfaces:

• Patients must minimize contact with others for 10-14 days from symptom onset in the last affected eye 1, 2
• Disinfect exposed surfaces with EPA-registered hospital disinfectants or sodium hypochlorite (1:10 dilution of household bleach) 1, 2
• Defer intraocular pressure measurement during acute conjunctivitis unless absolutely necessary, as tonometer tips can transmit infection 1, 2
• In clinical settings, consider abbreviated exams in dedicated rooms with limited physical interaction 1, 2

Management of Severe Adenoviral Keratoconjunctivitis

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

• Topical corticosteroids may be considered ONLY with mandatory close ophthalmology follow-up 1, 2
• Prefer corticosteroids with poor ocular penetration (such as loteprednol, fluorometholone, or rimexolone) to minimize intraocular pressure elevation and cataract formation 1, 2
• Be aware that corticosteroids may prolong viral shedding 1, 2
• Taper slowly to the minimum effective dose 2

Specific Viral Etiologies Requiring Antiviral Treatment

Herpes Simplex Virus (HSV) Conjunctivitis

HSV requires antiviral treatment, NOT corticosteroids:

• Topical options: Ganciclovir 0.15% gel (less toxic to ocular surface) or trifluridine 1% solution 3, 1, 2
• Oral antivirals: Acyclovir, valacyclovir, or famciclovir may be used 1, 2
• Topical corticosteroids potentiate HSV epithelial infections and must be avoided 3, 1
• Trifluridine inevitably causes epithelial toxicity if used for more than 2 weeks 3
• Follow-up within 1 week of treatment initiation with interval history, visual acuity measurement, and slit-lamp biomicroscopy 3, 2
• Neonates require prompt consultation with pediatrician, as systemic HSV infection is life-threatening 3

Varicella Zoster Virus (VZV) Conjunctivitis

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

• Oral antivirals at specific doses: 3, 1, 2, 4
  • Acyclovir 800 mg five times daily for 7 days, OR
  • Valacyclovir 1000 mg every 8 hours for 7 days (preferred due to superior bioavailability), OR
  • Famciclovir 500 mg three times daily for 7 days
• Topical antibiotics should be applied to eyelid vesicles to prevent secondary bacterial infection, as vesicles undergo necrosis before healing and can lead to severe conjunctival scarring or cicatricial ectropion 3, 2, 4
• Topical antivirals alone are not helpful for VZV conjunctivitis but may be used as additive treatment in unresponsive patients 3, 2
• Caution in patients with impaired renal clearance when using oral antivirals 3, 1, 4
• Immunocompromised patients may need more aggressive treatment with dose adjustments and prolonged duration 3, 2, 4

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 3, 1, 2, 4
• Identify and treat nascent lesions to reduce risk of recurrence 3
• The conjunctivitis may require weeks to resolve after elimination of the lesion 3, 2
• In adults, large and multiple molluscum lesions with relatively little conjunctival inflammation may indicate an immunocompromised state 3, 1

Management of Complications

• For membranous conjunctivitis: Debridement of membranes may prevent corneal epithelial abrasions or permanent cicatricial changes 1, 2
• For subepithelial infiltrates: Mild cases require only observation, while cases with blurring, photophobia, and decreased vision may require topical corticosteroids at minimum effective dose 1, 2

Follow-Up Protocol

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

Red Flags Requiring Immediate Ophthalmology Referral

• Neonatal conjunctivitis 2
• Severe pain or decreased vision 5
• Vesicular rash on eyelids or nose (suggests HSV or VZV) 5
• Conjunctival scarring 2
• Recent ocular surgery 5
• Immunocompromised state 5
• History of rheumatologic disease 5