Practice Essentials

Viral conjunctivitis, or pinkeye (see the image below), is a common, self-limiting condition

that is typically caused by adenovirus. Other viruses that can be responsible for conjunctival

infection include herpes simplex virus (HSV), varicella-zoster virus (VZV), picornavirus

(enterovirus 70, Coxsackie A24), poxvirus (molluscum contagiosum, vaccinia), and human

immunodeficiency virus (HIV).

Viral conjunctivitis. Image courtesy of Wikimedia Commons.

Viral conjunctivitis is highly contagious, usually for 10-12 days from onset as long as the

eyes are red. Patients should avoid touching their eyes, shaking hands, and sharing towels,

among other activities. Transmission may occur through accidental inoculation of viral

particles from the patient's hands or by contact with infected upper respiratory droplets,

fomites, or contaminated swimming pools. The infection usually resolves spontaneously

within 2-4 weeks.

Signs and symptoms

Signs and symptoms of viral conjunctivitis may include the following:

Itchy eyes

Tearing

Redness

Discharge

Light sensitivity (with corneal involvement)

See Clinical Presentation for more details.

Diagnosis

Generally, a diagnosis of viral conjunctivitis is made on the clinical features alone. Lab tests

are typically not necessary, but they may be helpful in some cases. Specimens can be

obtained by culture and smear if inflammation is severe, in chronic or recurrent infections,

with atypical conjunctival reactions, and in patients who fail to respond to treatment. Giemsa

staining of conjunctival scrapings may aid in characterizing the inflammatory response.

See Workup for more details.

Management

Treatment of adenoviral conjunctivitis is supportive. Patients should be instructed to use cold

compresses and lubricants, such as artificial tears, for comfort. Topical vasoconstrictors and

antihistamines may be used for severe itching but generally are not indicated. For patients

who may be susceptible, a topical astringent or antibiotic may be used to prevent bacterial

superinfection.

Virus-specific treatments

Patients with conjunctivitis caused by HSV usually are treated with topical antiviral agents,

including idoxuridine solution and ointment, vidarabine ointment, and trifluridine solution.

Treatment of VZV eye disease includes oral acyclovir to terminate viral replication.

For conjunctivitis associated with molluscum contagiosum, disease will persist until the skin

lesion is treated. Removal of the central core of the lesion or inducement of bleeding within

the lesion usually is enough to cure the infection.

Prevention

Preventing transmission of viral conjunctivitis is important. Both patient and provider should

wash hands thoroughly and often, keep hands away from the infected eye, and avoid sharing

towels, linens, and cosmetics. Infected patients should be advised to stay home from school

and work. Those who wear contact lenses should be instructed to discontinue lens wear until

signs and symptoms have resolved.

See Treatment and Medication for more details.

Viruses are a common cause of conjunctivitis in patients of all ages. A variety of viruses can

be responsible for conjunctival infection; however, adenovirus is by far the most common

cause, and herpes simplex virus (HSV) is the most problematic. Less common causes include

varicella-zoster virus (VZV), picornavirus (enterovirus 70, Coxsackie

A24), poxvirus (molluscum contagiosum, vaccinia), and human immunodeficiency virus

(HIV). Rarely, conjunctivitis is seen during systemic infection with influenza virus, Epstein-

Barr virus, paramyxovirus (measles, mumps, Newcastle), or rubella. (See Etiology.)[1]

Viral conjunctivitis, although usually benign and self-limited, tends to follow a longer course

than acute bacterial conjunctivitis, lasting for approximately 2-4 weeks. Viral infection is

characterized commonly by an acute follicular conjunctival reaction and preauricular

adenopathy. (See History and Physical Examination.)

Etiology

Adenoviral conjunctivitis is the most common cause of viral conjunctivitis. Particular

subtypes of adenoviral conjunctivitis include epidemic keratoconjunctivitis (pink eye) and

pharyngoconjunctival fever.

Viral conjunctivitis is highly contagious, usually for 10-12 days from onset as long as the

eyes are red. Patients should avoid touching their eyes, shaking hands, and sharing towels,

among other activities. Transmission may occur through accidental inoculation of viral

particles from the patient's hands or by contact with infected upper respiratory droplets,

fomites, or contaminated swimming pools.

Primary ocular herpes simplex infection is common in children and usually is associated with

a follicular conjunctivitis. Infection usually is caused by HSV type I, although HSV type II

may be a cause, especially in neonates. Recurrent infection, typically seen in adults, usually is

associated with corneal involvement.

VZV can affect the conjunctiva during primary infection (chickenpox) or secondary infection

(zoster). Infection can be caused by direct contact with VZV or zoster skin lesions or by

inhalation of infectious respiratory secretions.

Picornaviruses cause an acute hemorrhagic conjunctivitis that is clinically similar to

adenoviral conjunctivitis but is more severe and hemorrhagic. Infection is highly contagious

and occurs in epidemics.

Molluscum contagiosum may produce a chronic follicular conjunctivitis that occurs

secondary to shedding of viral particles into the conjunctival sac from an irritative eyelid

lesion.

Vaccinia virus has become a rare cause of conjunctivitis because, with the elimination of

smallpox, the vaccination rarely is administered. Infection occurs through accidental

inoculation of viral particles from the patient's hands.

HIV is the etiologic agent of acquired immunodeficiency syndrome (AIDS). Ocular

abnormalities in patients with AIDS primarily affect the posterior segment, but anterior

segment findings have been reported. When conjunctivitis occurs in a patient with AIDS, it

tends to follow a more severe and prolonged course than in patients without AIDS. In

general, patients with AIDS may develop a transient, nonspecific conjunctivitis, characterized

by irritation, hyperemia, and tearing, that requires no specific treatment. Microsporidia has

been isolated from the cornea and conjunctiva of several patients with AIDS

and keratoconjunctivitis. In these patients, symptoms included foreign body sensation,

blurred vision, and photophobia; most cases resolved without antimicrobial therapy.

Epidemiology

US and international occurrence

Viral conjunctivitis is a common ocular disease in the United States and worldwide. Because

it is so common, and because many cases are not brought to medical attention, accurate

statistics on the frequency of the disease are unavailable. Viral infection frequently occurs in

epidemics within families, schools, offices, and military organizations.

Sex predilection

Viral conjunctivitis can occur equally in men and women.

Age predilection

Viral conjunctivitis can affect all age groups, depending on the specific viral etiology.

Usually, adenovirus affects patients aged 20-40 years. HSV and primary VZV infection

usually affect young children and infants. Herpes zoster ophthalmicus results from

reactivation of latent VZV infection and may present in any age group. Typically, the

picornaviruses affect children and young adults in the lower socioeconomic classes.[2]

Prognosis

Most cases of viral conjunctivitis are acute, benign, and self-limited, although chronic

infections have been reported. Long-term ocular sequelae are uncommon. The infection

usually resolves spontaneously within 2-4 weeks. Subepithelial infiltrates may last for several

months, and, if in the visual axis, they may cause decreased vision or glare.

Morbidity

Complications include the following: punctate keratitis with subepithelial infiltrates, bacterial

superinfection, corneal ulceration with keratoconjunctivitis, and chronic infection.

Epithelial keratitis may accompany viral conjunctivitis. Punctate epithelial erosions that stain

with fluorescein are commonly associated with viral keratitis. Rarely, these changes are

sufficiently distinctive morphologically to allow identification of a specific type of virus as

the etiologic agent. If the conjunctivitis persists or is severe, disturbances in the anterior

stroma beneath the epithelial abnormalities may occur. In general, the stromal or subepithelial

abnormalities are transient and resolve despite persistence of epithelial keratitis. However, in

cases of adenoviral infection, the stromal abnormalities may persist for months to years, long

after the epithelial changes have resolved. In such cases, these subepithelial infiltrates are

considered to be immunologic in origin, the result of antigen-antibody reaction. If they are in

the pupillary axis, they may cause decreased vision and/or glare.

Medication Summary

Medications used in the treatment of viral conjunctivitis include the following:

Topical artificial tears - 4-8 times per day, for 1-3 weeks

Topical vasoconstrictor/antihistamine - 4 times per day, for severe itching

Topical steroiAntihistamines

Class Summary

These agents are used to treat severe itching.

Levocabastine

 

Levocabastine is a potent histamine H1-receptor antagonist; it is for

ophthalmic use.

ds - For pseudomembranes and subepithelial infiltrates

Topical antibiotic - To prevent bacterial superinfection

Topical antiviral agents - For HSV infection

Antivirals

Class Summary

These agents are used for the treatment of HSV infection.

View full drug information

Trifluridine (Viroptic)

 

Trifluridine is a pyrimidine (thymidine) analogue drug of choice in the United States

for topical antiviral therapy for HSV infection. It inhibits viral replication by

incorporating into viral deoxyribonucleic acid (DNA) in place of thymidine. If the

patient has no response in 7-14 days, consider other treatments.

View full drug information

Acyclovir (Zovirax)

 

This is a prodrug that inhibits viral replication; it is activated by phosphorylation by

virus-specific thymidine kinase.

Oral acyclovir - For VZV infection

Corticosteroids

Class Summary

Corticosteroids may be used for pseudomembranes and decreased vision

and/or glare due to subepithelial infiltrates. They have anti-inflammatory

properties and cause profound and varied metabolic effects. In addition, these

agents modify the body's immune response to diverse stimuli. Extreme caution

should be taken when using corticosteroids, as they may worsen an underlying

HSV infection.

View full drug information

Prednisolone ophthalmic (AK-Pred, Pred Mild, Omnipred)

 

This agent decreases inflammation by suppressing migration of

polymorphonuclear leukocytes and reversing increased capillary permeability.

Less potent (eg, prednisolone 0.125%, fluorometholone 0.1%) are usually

sufficient to treat subepithelial infiltrates. The steroid must be tapered very

slowly, over months.

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Patient Education

To allay patient anxiety, it is helpful to inform patients that their symptoms

may worsen during the first 4-7 days after onset before they begin to improve

and may not resolve for 2-4 weeks. The contagiousness of the infection also

should be emphasized. Proper isolation from the workplace or school is

advisable to prevent epidemics.

Patients with conjunctivitis who wear contact lenses should be instructed to

discontinue lens wear until signs and symptoms have resolved.

For patient education information, see the Eye and Vision Center and the Skin,

Hair, and Nails Center, as well as Pinkeye, How to Instill Your Eyedrops,

andMolluscum Contagiosum.

Diagnostic Considerations

Allergic conjunctivitis must be differentiated from viral and bacterial conjunctivitis. Clinical features (eg, recent exposure to an individual with infective conjunctivitis) may be helpful in this regard.

The main distinction between seasonal and perennial allergic conjunctivitis, as implied by the names, is the timing of symptoms (see Pathophysiology). Major differentiating factors between vernal keratoconjunctivitis (VKC) and atopic keratoconjunctivitis (AKC) are shown in the table below.

Table. Major Differentiating Factors Between VKC and AKC  (Open Table in a new window)

Characteristics VKC AKC

Age at onset Generally presents at a younger age than AKC -

Sex Males are affected preferentially. No sex predilection

Seasonal variation Typically occurs during spring months Generally perennial

Discharge Thick mucoid discharge Watery and clear discharge

Conjunctival scarring - Higher incidence of conjunctival scarring

Horner-Trantas dots Horner-Trantas dots and shield ulcers are commonly seen.

Presence of Horner-Trantas dots is rare.

Corneal neovascularization Not present Deep corneal neovascularization tends to develop

Presence of eosinophils in conjunctival scraping

Conjunctival scraping reveals eosinophils to a greater degree in VKC than in AKC

Presence of eosinophils is less likely

Differential Diagnoses Conjunctivitis, Bacterial Conjunctivitis, Giant Papillary Conjunctivitis, Viral Keratoconjunctivitis, Atopic Keratoconjunctivitis, Superior Limbic Keratoconus