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

Treatment 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 treatment, with antiviral therapy reserved only for specific viral etiologies like HSV, VZV, or molluscum contagiosum. 1, 2

Supportive Care for Typical Viral Conjunctivitis

The cornerstone of management is symptomatic relief and preventing transmission, as most viral conjunctivitis is self-limited 1, 3:

• Artificial tears provide comfort and help dilute viral particles on the ocular surface 1, 2, 4
• Cold compresses reduce inflammation and provide symptomatic relief 1, 2, 4
• Topical antihistamines may alleviate itching and discomfort 1, 2, 4
• Oral analgesics can be used for pain management 1, 2, 4

Critical Pitfall to Avoid

Do not prescribe topical antibiotics for viral conjunctivitis—they provide no benefit and may cause toxicity or allergic reactions. 2, 4 This is a common error in primary care that should be avoided 5.

Infection Control Measures

Adenovirus can survive for weeks on surfaces, making transmission control essential 2, 4:

• Patients must minimize contact with others for 10-14 days from symptom onset in the last affected eye 1, 2, 4
• Disinfect exposed surfaces with EPA-registered hospital disinfectants or sodium hypochlorite (1:10 dilution of household bleach) 1, 2, 4
• Defer intraocular pressure measurement during acute conjunctivitis unless absolutely necessary, as tonometer tips can transmit infection 1, 2, 4
• Strict handwashing is essential to decrease transmission risk 5

Management of Severe Adenoviral Keratoconjunctivitis

For severe cases with significant subepithelial infiltrates causing blurred vision, photophobia, or decreased visual acuity, a more aggressive approach may be warranted 6, 1, 2:

• Topical corticosteroids may be considered ONLY with mandatory close ophthalmology follow-up 1, 2, 4
• Prefer corticosteroids with poor ocular penetration (loteprednol, fluorometholone, or rimexolone) to minimize intraocular pressure elevation and cataract formation 6, 1, 4
• Taper slowly to the minimum effective dose 6, 4
• Monitor for increased intraocular pressure and cataract formation during treatment 4

Important Caveat

Corticosteroids may prolong viral shedding and can worsen HSV infections if misdiagnosed, potentially leading to corneal scarring and vision loss 2, 4. Never use corticosteroids without confirming the diagnosis is not HSV 4.

Specific Viral Etiologies Requiring Antiviral Treatment

Herpes Simplex Virus (HSV) Conjunctivitis

HSV conjunctivitis requires antiviral treatment, not supportive care alone 6, 1, 2:

Topical options:

• Ganciclovir 0.15% gel three to five times per day (less toxic to ocular surface) 6, 1, 2, 4
• Trifluridine 1% solution five to eight times per day (causes epithelial toxicity if used >2 weeks) 6, 1, 2, 7

Oral options:

• Acyclovir 200-400 mg five times per day 6, 2, 4
• Valacyclovir 500 mg two or three times per day 6, 2, 4
• Famciclovir 250 mg twice daily 6, 2, 4

Critical warning: Topical corticosteroids potentiate HSV infection and must be avoided. 6, 2, 4, 7

Follow-up within 1 week of treatment is required, including interval history, visual acuity measurement, and slit-lamp biomicroscopy 6, 2.

Varicella Zoster Virus (VZV) Conjunctivitis

For persistent or recalcitrant acute/subacute VZV disease in immunocompetent patients 6, 2, 4:

Oral antivirals at specific doses:

• Acyclovir 800 mg five times daily for 7 days 6, 2, 4
• Valacyclovir 1000 mg every 8 hours for 7 days 6, 2
• Famciclovir 500 mg three times daily for 7 days 6, 2, 4

Additional management:

• Apply topical antibiotics to eyelid vesicles to prevent secondary bacterial infection, as vesicles undergo necrosis before healing 6, 1, 4
• Caution in patients with impaired renal clearance when using oral antivirals 6, 2
• Immunocompromised patients may need more aggressive treatment 6, 2

Topical antivirals alone have not been shown to be helpful in VZV conjunctivitis but may be used as additive treatment in unresponsive patients 6, 4.

Molluscum Contagiosum-Related Conjunctivitis

Physical removal of the causative eyelid lesions is required 2, 4:

Treatment options include:

• Incision and curettage 2, 4
• Simple excision 2, 4
• Excision and cautery 2
• Cryotherapy 2, 4

The conjunctivitis may require weeks to resolve after elimination of the lesion 2, 4. Large and multiple molluscum lesions with relatively little conjunctival inflammation may indicate an immunocompromised state in adults 2.

Management of Complications

Subepithelial Infiltrates

These typically occur 1 or more weeks after onset of conjunctivitis 6:

• Mild cases: Observation is sufficient 6, 1, 4
• Cases with blurring, photophobia, and decreased vision: Topical corticosteroids at minimum effective dose may be considered 6, 1, 4

Membranous Conjunctivitis

Debridement of membranes may prevent corneal epithelial abrasions or permanent cicatricial changes 1, 2, 4.

Follow-Up Protocol

• Patients with severe disease should be re-evaluated within 1 week 1, 2, 4
• Patients not treated with corticosteroids should return if symptoms persist beyond 2-3 weeks 1, 2, 4
• Follow-up visits should include interval history, visual acuity measurement, and slit-lamp biomicroscopy 6, 1, 2, 4

Red Flags Requiring Immediate Ophthalmology Referral

• Conjunctival scarring 1, 4
• Neonatal conjunctivitis (systemic HSV infection is life-threatening) 6, 4
• Severe pain 5
• Decreased vision 5
• Recent ocular surgery 5
• Vesicular rash on eyelids or nose 5
• History of rheumatologic disease 5
• Immunocompromised state 5