What is the treatment and management for viral conjunctivitis in a patient of any age?

Viral Conjunctivitis: Treatment and Management

Viral conjunctivitis requires no antimicrobial treatment in the vast majority of cases, as it is self-limited and resolves within 5-14 days with supportive care alone. 1, 2

Immediate Clinical Approach

Do not prescribe antibiotics for viral conjunctivitis. This is a critical point emphasized by the American Academy of Ophthalmology—antibiotics provide no benefit, contribute to antimicrobial resistance, and may cause unnecessary toxicity. 1, 2

Distinguishing Viral from Bacterial Conjunctivitis

The clinical presentation guides your diagnosis:

Viral conjunctivitis characteristics:

• Watery discharge (not purulent) 2, 3
• Follicular reaction on inferior tarsal conjunctiva 2
• Often starts unilateral but becomes sequentially bilateral 2
• Preauricular lymphadenopathy frequently present 2
• Associated upper respiratory infection common 2
• Abrupt onset 2

Bacterial conjunctivitis characteristics:

• Mucopurulent or purulent discharge with matted eyelids 2, 3
• Papillary (not follicular) reaction 2
• Less commonly associated with preauricular lymphadenopathy 2

Supportive Treatment Protocol

For symptomatic relief, offer the following options:

• Artificial tears for lubrication and comfort 1, 2, 3
• Cold compresses to reduce inflammation 1, 3
• Topical antihistamines for symptomatic relief of irritation 1, 2
• Oral analgesics if needed for discomfort 1

These measures address symptoms but do not alter the disease course. 1

When to Consider Topical Corticosteroids

Topical corticosteroids should be reserved for severe cases only and require close ophthalmology follow-up. 1, 2

Indications for corticosteroid use:

• Marked chemosis or lid swelling 1
• Epithelial sloughing 1
• Membranous conjunctivitis 1
• Corneal subepithelial infiltrates causing blurred vision, photophobia, or decreased visual acuity 1

Critical warnings about corticosteroid use:

• May prolong viral shedding (demonstrated in animal models) 1
• Requires monitoring of intraocular pressure and cataract formation 1, 2
• Must be tapered once inflammation is controlled 1
• Should be avoided in herpes simplex virus conjunctivitis as it can worsen the infection 2

Patient Education: Breaking the Chain of Transmission

Counsel patients that viral conjunctivitis is highly contagious and requires strict hygiene measures. 1, 2

Specific instructions to provide:

• Wash hands frequently with soap and water (not just sanitizer) 1
• Use separate towels and pillows from other household members 1
• Avoid close contact with others for 10-14 days from symptom onset in the last affected eye 1
• Do not share personal items 2
• Healthcare workers and childcare providers should avoid work during the contagious period due to high transmission potential 1

The virus can survive on surfaces for up to 28 days in a desiccated state, making environmental disinfection important. 1

Follow-Up Recommendations

For patients NOT on corticosteroids:

• Return if symptoms persist beyond 2-3 weeks 1
• Return immediately for worsening pain, decreased vision, or red eye 1

For patients WITH severe disease (corneal ulceration or membranous conjunctivitis):

• Re-evaluate within 1 week 1
• Include interval history, visual acuity measurement, and slit-lamp biomicroscopy 1

For patients on topical corticosteroids:

• Monitor intraocular pressure periodically 1, 2
• Perform pupillary dilation to evaluate for cataract 1
• Taper steroids once inflammation is controlled 1

Red Flags Requiring Immediate Ophthalmology Referral

Refer urgently if any of the following are present:

• Visual loss or decreased vision 2
• Moderate or severe pain 2
• Severe purulent discharge 2
• Corneal involvement 2
• Conjunctival scarring 2
• History of herpes simplex virus eye disease 2
• Immunocompromised state 2
• Vesicular rash on eyelids or nose 3
• Recent ocular surgery 3
• Lack of response to therapy 2
• Recurrent episodes 2

Special Considerations

Membranous Conjunctivitis

If pseudomembranes or membranes are present, consider debridement to prevent corneal epithelial abrasions or permanent cicatricial changes such as foreshortening of the conjunctival fornix. 1

Subepithelial Infiltrates

These typically occur 1 or more weeks after conjunctivitis onset. 1

• Mild cases: Observation is sufficient 1
• Cases with blurred vision, photophobia, or decreased vision: Topical corticosteroids at minimum effective dose 1

Herpes Simplex Virus Conjunctivitis

This requires different management than adenoviral conjunctivitis. Look for distinctive signs including vesicular rash or ulceration of eyelids and dendritic epithelial keratitis. 2 Antiviral therapy (acyclovir, valacyclovir) is indicated for HSV conjunctivitis. 4

Prevention Strategies

Herpes zoster vaccination: The American Academy of Ophthalmology strongly recommends the recombinant zoster vaccine (Shingrix) for immunocompetent patients 50 years or older and immunocompromised patients 19 years or older. 1 This prevents herpes zoster ophthalmicus, which can cause conjunctivitis along with other ocular complications.

Neonatal prophylaxis: Single-use tubes of 0.5% erythromycin ophthalmic ointment remain the standard prophylactic agent to prevent ophthalmia neonatorum. 1

Common Pitfalls to Avoid

• Do not prescribe antibiotics reflexively—they offer no benefit and cause harm through toxicity and resistance. 1, 2
• Do not use topical corticosteroids indiscriminately—they may prolong viral shedding and can worsen HSV infections. 1, 2
• Do not underestimate contagiousness—inadequate patient education leads to community spread, particularly in healthcare and childcare settings. 2
• Do not miss gonococcal or chlamydial conjunctivitis—these require systemic antibiotic therapy and have serious sequelae if untreated. 2
• Do not ignore chronic or recalcitrant conjunctivitis—this may indicate underlying malignancy such as sebaceous or squamous cell carcinoma. 1, 2