How should viral conjunctivitis be managed?

Management of Viral Conjunctivitis

Viral conjunctivitis requires supportive care only—no antibiotics, no antivirals for adenovirus—with strict infection control measures for 10-14 days from symptom onset in the last affected eye. 1, 2

Core Management Principles

The vast majority of viral conjunctivitis cases are caused by adenovirus and are completely self-limited, resolving without any specific treatment. 1, 3, 4 Antibiotics must be avoided because they provide zero benefit for viral infections, cause unnecessary ocular toxicity and allergic reactions, and promote antimicrobial resistance. 1, 2

Symptomatic Relief Measures

• Refrigerated preservative-free artificial tears four times daily to dilute viral particles and inflammatory mediators on the ocular surface 2, 5
• Cold compresses applied to closed eyelids for comfort and reduction of inflammation 1, 5, 6
• Topical antihistamines (second-generation) to alleviate itching and discomfort 1, 2
• Oral analgesics for pain management as needed 1, 5

Critical Infection Control (Non-Negotiable)

Adenovirus is extraordinarily hardy and can survive for weeks on countertops and surfaces without proper disinfection. 1, 5 This makes transmission control the single most important intervention:

• Patients must minimize contact with others for 10-14 days from symptom onset in the last affected eye 1, 2, 5
• Strict handwashing with soap and water after touching the eyes or face 2
• Disinfect all exposed surfaces with EPA-registered hospital disinfectants or sodium hypochlorite (1:10 dilution of household bleach) 5, 7
• Avoid sharing towels, pillowcases, or eye cosmetics 2
• Defer tonometry (intraocular pressure measurement) during acute infection unless absolutely necessary, as tonometer tips transmit infection despite disinfection 7

When to Consider Topical Corticosteroids (Rare Exception)

Topical corticosteroids should be reserved ONLY for severe adenoviral keratoconjunctivitis with specific complications and require mandatory close ophthalmology follow-up. 1, 2, 5

Specific Indications for Steroids

Use corticosteroids only when the patient has:

• Marked chemosis or severe lid swelling 1, 2
• Epithelial sloughing 1, 2
• Membranous conjunctivitis 1, 2
• Corneal subepithelial infiltrates (occurring ≥1 week after onset) causing blurred vision, photophobia, or decreased visual acuity 1, 5

Steroid Selection and Monitoring Protocol

• Prefer low-penetration steroids: loteprednol, fluorometholone, or rimexolone to minimize intraocular pressure elevation and cataract formation 2, 5, 7
• Measure intraocular pressure periodically to detect steroid-induced glaucoma 1, 2
• Perform pupillary dilation to evaluate for cataract development 1, 2
• Taper slowly to minimum effective dose once inflammation is controlled 1, 2
• Re-evaluate within 1 week for severe cases on steroids 1, 5

Critical Steroid Warnings

Never use topical corticosteroids without first definitively excluding herpes simplex virus (HSV) conjunctivitis, as steroids potentiate HSV replication, worsen infection, and can cause corneal scarring and perforation. 2, 5, 7 Animal models suggest corticosteroids may also prolong adenoviral shedding, though human data are unclear. 1, 7

Specific Viral Etiologies Requiring Antiviral Treatment

Herpes Simplex Virus (HSV) Conjunctivitis

HSV requires antiviral therapy—this is the critical exception to the "no treatment" rule for viral conjunctivitis. 2, 5, 7

Topical antiviral options:

• Ganciclovir 0.15% gel three to five times daily 2, 5, 7
• Trifluridine 1% solution five to eight times daily 2, 5

Oral antiviral options (add for severe cases):

• Acyclovir, valacyclovir, or famciclovir 2, 5, 7

Absolute contraindication: Topical corticosteroids without antiviral coverage—this potentiates infection and causes corneal perforation. 2, 5, 7

Varicella Zoster Virus (VZV) Conjunctivitis

• Topical antibiotics applied to eyelid vesicles to prevent secondary bacterial infection as vesicles undergo necrosis 1, 5, 7
• Oral antivirals for persistent or recalcitrant disease in immunocompetent patients: 1, 5, 7
  • Acyclovir 800 mg five times daily for 7 days
  • Valacyclovir 1000 mg every 8 hours for 7 days
  • Famciclovir 500 mg three times daily for 7 days
• Caution in renal impairment: adjust doses accordingly 1, 7
• Topical antivirals alone are not helpful for VZV 1, 7

Molluscum Contagiosum

Physical removal of the causative eyelid lesions is required—the conjunctivitis will not resolve until the lesion is eliminated. 1, 5, 7

Treatment options:

• Incision and curettage (aggressive enough to cause bleeding) 1
• Simple excision 1
• Excision with cautery 1
• Cryotherapy 1

The conjunctivitis may require weeks to resolve after lesion elimination. 1, 7 In adults, multiple large lesions with minimal inflammation suggest immunocompromise. 1

Emerging Treatments (Not Yet Standard of Care)

• Povidone-iodine 0.4-0.6% alone or combined with dexamethasone 0.1% has shown reductions in viral titers and shortened clinical course in studies, with ongoing clinical trials 1
• Off-label topical ganciclovir 0.15% gel has demonstrated potential benefit against specific adenovirus serotypes, but larger efficacy studies are needed before definitive recommendations 1, 7

Management of Specific Complications

Membranous Conjunctivitis

Debridement of membranes should be considered to prevent corneal epithelial abrasions or permanent cicatricial changes (e.g., foreshortening of the conjunctival fornix). 1, 5, 7

Subepithelial Infiltrates

• Mild cases: observation only 5, 7
• Cases with blurring, photophobia, or decreased vision: topical corticosteroids at minimum effective dose with slow taper 1, 5, 7
• Alternative: cyclosporine drops 0.05-1% as a steroid-sparing agent 7

Follow-Up Strategy

• Patients with severe disease (corneal epithelial ulceration, membranous conjunctivitis, or on corticosteroids): re-evaluate within 1 week 1, 5, 7
• Patients not on corticosteroids: return if symptoms persist beyond 2-3 weeks 5, 7
• All follow-up visits should include interval history, visual acuity measurement, and slit-lamp biomicroscopy 5, 7

Red Flags Requiring Immediate Ophthalmology Referral

Do not attempt outpatient management if any of the following are present:

• Visual loss or noticeable change in vision 2, 5
• Moderate to severe eye pain (beyond mild irritation) 2, 5
• Corneal involvement: opacity, infiltrate, or ulcer on examination 2, 5
• Conjunctival scarring 5, 7
• History of HSV eye disease 2, 5
• Immunocompromised state 2, 5
• Lack of improvement after 7 days or worsening symptoms 5
• Neonatal conjunctivitis (requires immediate referral and systemic treatment) 2, 7

Common Pitfalls to Avoid

1. Prescribing antibiotics "just in case"—this causes toxicity, allergic reactions, and resistance without any benefit 1, 2, 7

2. Using combination antibiotic-steroid drops (e.g., Tobradex) empirically—you must definitively rule out HSV before any steroid use, as misdiagnosis leads to corneal perforation 2, 7

3. Underestimating contagiousness—patients working in healthcare, food service, or sales need clear guidance on work restrictions for 10-14 days 1, 2

4. Prolonged steroid use without ophthalmology supervision—steroids beyond 2 weeks require specialist monitoring for glaucoma and cataract 1, 2

5. Missing HSV or VZV in the differential—look for watery discharge, follicular reaction, preauricular lymphadenopathy (adenovirus) versus dendritic lesions or vesicular rash (HSV/VZV) 2, 7