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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).
Itchy eyes
Tearing
Redness
Discharge
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
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.
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
Class Summary
These agents are used to treat severe itching.
Levocabastine
Antivirals
Class Summary
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
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.
VKC
AKC
Age at onset
Sex
No sex predilection
Seasonal variation
Generally perennial
Discharge
Conjunctival scarring
Horner-Trantas dots
Horner-Trantas dots and shield ulcers are commonly Presence of Horner-Trantas dots is
seen.
rare.
Corneal neovascularization
Not present
Presence of eosinophils in
conjunctival scraping
Differential Diagnoses
Conjunctivitis, Bacterial
Conjunctivitis, Giant Papillary
Conjunctivitis, Viral
Keratoconjunctivitis, Atopic
Keratoconjunctivitis, Superior Limbic
Keratoconus