What is the appropriate management of hemorrhagic conjunctivitis?

Management of Hemorrhagic Conjunctivitis

Hemorrhagic conjunctivitis is a highly contagious viral infection requiring supportive care only—no antibiotics or antiviral therapy is effective, and management focuses on symptom relief, infection control, and patient education to prevent epidemic spread. 1, 2, 3

Immediate Diagnostic Confirmation

• Hemorrhagic conjunctivitis presents with sudden onset of severely painful, swollen, red eyes with characteristic subconjunctival hemorrhages and excessive tearing. 4, 5
• The condition is caused by Enterovirus 70 or Coxsackievirus A24 variant, not by bacteria or other treatable pathogens. 3, 4, 5
• Distinguish this from bacterial conjunctivitis (purulent discharge, papillary reaction) and adenoviral conjunctivitis (follicular reaction, less hemorrhage). 1

Treatment Algorithm

Primary Management: Supportive Care Only

• Prescribe refrigerated preservative-free artificial tears four times daily to dilute viral particles and inflammatory mediators. 1, 2
• Recommend cold compresses for comfort and to reduce inflammation. 1, 2
• Consider topical antihistamines (second-generation) for symptomatic relief of itching and discomfort. 1, 2
• The disease is self-limited and resolves in 5-7 days without specific treatment. 5

What NOT to Do

• Do not prescribe topical antibiotics—they provide no benefit for viral infections, cause unnecessary toxicity, and contribute to antibiotic resistance. 1, 2
• Do not prescribe topical corticosteroids for uncomplicated hemorrhagic conjunctivitis—they may prolong viral shedding and are reserved only for severe adenoviral cases with membranous conjunctivitis, which is a different entity. 1, 2
• Avoid topical vasoconstrictors as chronic use causes rebound vasodilation. 1

Critical Infection Control Measures

• Educate patients that hemorrhagic conjunctivitis is extremely contagious and they must minimize contact with others for 10-14 days from symptom onset. 1, 2
• Mandate strict hand hygiene with soap and water after touching eyes or face. 1, 2, 4
• Instruct patients to avoid sharing towels, pillows, bedding, and personal items. 1, 4
• Advise disinfecting surfaces with EPA-registered hospital disinfectant. 1
• School-aged children (5-18 years) and those in crowded urban areas are at highest risk for transmission. 4

Follow-Up Strategy

• Instruct patients to return if symptoms persist beyond 2-3 weeks or if they develop visual loss, severe pain, or corneal involvement. 1, 2
• Most cases resolve spontaneously without complications. 5
• Monitor for the rare complication of polio-like paralysis (radiculomyelitis), which occurs in approximately 1 in 10,000 patients infected with Enterovirus 70. 5

Red Flags Requiring Immediate Ophthalmology Referral

• Visual loss or decreased vision 1, 2
• Moderate to severe pain (beyond typical discomfort) 1, 2
• Corneal involvement (opacity, infiltrate, or ulcer) 1, 2
• Lack of improvement after 2-3 weeks 1, 2
• History of herpes simplex virus eye disease 1, 2
• Immunocompromised state 1, 2

Common Pitfalls to Avoid

• Misdiagnosing hemorrhagic conjunctivitis as bacterial conjunctivitis and prescribing unnecessary antibiotics. The key distinguishing feature is the prominent subconjunctival hemorrhage with watery (not purulent) discharge. 1, 3, 5
• Failing to implement aggressive infection control measures early in the outbreak. Hemorrhagic conjunctivitis spreads rapidly through communities—estimated 490,000 cases occurred in Puerto Rico's 2003 outbreak. 4
• Not warning patients about the highly contagious nature of the disease. This leads to community spread and epidemic proportions. 1, 4
• Using home remedies or unproven treatments. Patients should be counseled against these practices. 5

Public Health Considerations

• Report suspected outbreaks to local health authorities immediately. Multiple large-scale epidemics have occurred, affecting hundreds of thousands. 4, 6
• Target prevention education to school-aged children and crowded urban populations. 4
• Disseminate information after the first report of hemorrhagic conjunctivitis in the area to prevent undue alarm and control spread. 4, 5