eMedicine Specialties > Ophthalmology > Conjunctiva

Conjunctivitis, Viral

Author: Ingrid U Scott, MD, MPH, Professor, Department of Ophthalmology and Public Health Sciences, Penn State College of Medicine
Coauthor(s): Kevin Luu, MD, Consulting Staff, Pediatric Anesthesia Associates Medical Group Inc; Consulting Staff, Children's Hospital Central California
Contributor Information and Disclosures

Updated: Aug 5, 2009

Introduction

Background

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), and rubella.

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.

Pathophysiology

Adenoviral conjunctivitis is the most common cause of viral conjunctivitis. Particular subtypes of adenoviral conjunctivitis include epidemic keratoconjunctivitis (pink eye) and pharyngoconjunctival fever. Transmission occurs through contact with infected upper respiratory droplets, fomites, and contaminated swimming pools.¹

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.

Frequency

United States

Viral conjunctivitis is a common ocular disease both in the United States and worldwide. Because it is so common, and many cases are not brought to medical attention, accurate statistics on the frequency of disease are unavailable. Viral infection frequently occurs in epidemics within families, schools, offices, and military organizations.

International

Same as in the United States.

Mortality/Morbidity

Most cases of viral conjunctivitis are self-limited and mild, although chronic infections have been reported. Long-term ocular sequelae are uncommon.

Sex

Viral conjunctivitis can occur equally in men and women.

Age

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

Clinical

History

While the manifestations of various types of bacterial conjunctivitis are fairly homogenous, those of viral conjunctivitis can vary from one disease process to another. History should focus on eliciting information that will aid in differentiating the various etiologic agents of viral infection.

• Inquire about timing, onset, and duration of systemic and ocular symptoms; severity and frequency of symptoms; appropriate risk factors; and personal and environmental exposures.
• Patients with adenoviral conjunctivitis may give a history of recent exposure to an individual with red eye at home, school, or work, or they may have a history of recent symptoms of an upper respiratory tract infection. The eye infection may be unilateral or bilateral.
• Patients may complain of ocular itching, foreign body sensation, tearing, redness, and photophobia (with corneal involvement as in epidemic keratoconjunctivitis).
• Systemic manifestations are rare, except in cases of pharyngoconjunctival fever.
• Primary ocular HSV infection predominantly affects young children and infants, but it may occur in individuals of all ages. Patients usually present with a red, irritated, watery eye. Often, concomitant eyelid skin involvement with multiple vesicular lesions is present.
• VZV is characterized by a generalized vesicular eruption, fever, and constitutional symptoms. Ocular infection usually is unilateral and presents as small papular lesions that erupt along the lid margin or at the limbus and may be accompanied by a mild follicular conjunctivitis.
• Herpes zoster ophthalmicus represents reactivation of latent VZV infection of the trigeminal ganglion. It is characterized by a prodrome of fever, malaise, nausea, vomiting, and severe pain and skin lesions along the ophthalmic division of the trigeminal nerve. Conjunctival involvement includes hyperemia, follicular or papillary conjunctivitis, and a serous or mucopurulent discharge.
• Acute hemorrhagic conjunctivitis has been reported in epidemics in association with 2 major picornaviruses, enterovirus 70 and Coxsackie A24. It mostly affects children and young adults in the lower socioeconomic classes. Patients experience a rapid onset of watery discharge, foreign body sensation, burning, and photophobia within 24 hours of exposure.
• Molluscum contagiosum can produce a chronic follicular conjunctivitis in association with an irritative eyelid lesion. The lesion usually is a small, elevated, pearly, umbilicated nodule near the lid margin. Multiple lesions may be present, especially in patients who are HIV positive.
• Other viruses are less frequent causes of conjunctivitis. In these cases, conjunctivitis usually occurs in association with a systemic illness and includes infections caused by influenza virus, Epstein-Barr virus, paramyxovirus (measles, mumps, Newcastle), rubella, and HIV.

Physical

• Typical signs of adenoviral conjunctivitis include preauricular adenopathy, epiphora, hyperemia, chemosis, subconjunctival hemorrhage, follicular conjunctival reaction, and occasionally a pseudomembranous or cicatricial conjunctival reaction. The cornea often demonstrates a punctate epitheliopathy. The eyelids often are edematous and ecchymotic. In severe cases, there can be a corneal epithelial defect. It typically begins in one eye and progresses to the fellow eye over a few days. The second eye is usually less significantly involved.
• With HSV infection, vesicles may be present on the eyelid or face, the eyelids may be swollen, and an ulcerative blepharitis may be present.
• Corneal involvement in HSV manifests as a dendritic keratitis with typical features of linear branching and dendritic figures.
• Small papular lesions that erupt along the lid margin or at the limbus are present with varicella conjunctivitis. These lesions may resolve without sequelae, or they may become pustular and form painful reactive conjunctival ulcers.
• In herpes zoster ophthalmicus, look for skin involvement with the appearance of a dermatomal pattern of vesicles. These vesicles may become necrotic, resulting in pitted scarring of the skin. Conjunctival involvement includes hyperemia, follicular or papillary conjunctivitis, and a serous or mucopurulent discharge. Preauricular adenopathy is common. Very early in the process, there may be multiple fine dendritic corneal lesions, which disappear over a few days without treatment.
• Acute hemorrhagic conjunctivitis starts unilaterally but rapidly involves the fellow eye within 1 or 2 days. Signs on examination include a swollen, edematous eyelid, and pronounced hemorrhage beneath the bulbar conjunctiva.

Causes

A variety of viruses can be responsible for conjunctival infection. Adenovirus is the most common cause, and HSV is the most problematic. Less common causes include VZV, picornavirus (enterovirus 70, Coxsackie A24), poxvirus (molluscum contagiosum, vaccinia), and HIV.

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