eMedicine Specialties > Ophthalmology > Conjunctiva

Conjunctivitis, Viral: Treatment & Medication

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

Treatment

Medical Care

Treatment of adenoviral conjunctivitis is supportive. No evidence exists that demonstrates efficacy of antiviral agents.

  • 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 because they are minimally helpful and may cause rebounding of symptoms, as well as local toxicity and hypersensitivity.
  • For patients who may be susceptible, a topical astringent or antibiotic may be used to prevent bacterial superinfection.
  • Topical steroids may be used for pseudomembranes or when subepithelial infiltrates impair vision, although subepithelial infiltrates may recur after discontinuing the steroids. Extreme caution should be taken when using corticosteroids, as they may worsen an underlying HSV infection.
  • An in vitro study using adenovirus 8 and A549 human epithelial cell cultures demonstrated that povidone-iodine at a concentration of 1:10 (0.8%) is highly effective against free adenovirus, less effective against intracellular adenoviral particles in already infected cells, and not significantly cytotoxic for healthy cells. Thus, povidone-iodine 0.8% may represent a potential option to reduce contagiousness in cases of adenoviral infections.
  • Patients with conjunctivitis caused by HSV usually are treated with topical antiviral agents, including idoxuridine solution and ointment, vidarabine ointment, and trifluridine solution. An ophthalmologist should see any patient with ocular HSV infection. Treatment of HSV keratitis is discussed in Keratitis, Herpes Simplex.
  • Treatment of VZV eye disease includes oral acyclovir, 600-800 mg, 5 times daily for 7-10 days, to terminate viral replication. Topical corticosteroids usually are not indicated for conjunctivitis or keratitis.
  • Treatment of acute hemorrhagic conjunctivitis is supportive as in adenoviral infection and includes bed rest, cold compresses, and analgesics. Antibiotics have no useful role unless bacterial superinfection is present.
  • 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. Occasionally, surgical excision is required.
  • Other viral causes of conjunctivitis generally are self-limited and treated supportively with compresses for comfort and topical antibiotics as necessary to prevent bacterial superinfection.

Consultations

An important aspect of treatment is to know the proper time to refer the patient to a specialist.

  • Patients with hyperacute conjunctivitis or those with corneal involvement, such as ulceration, herpetic keratitis, or suspected orbital cellulitis, should be referred to an ophthalmologist.
  • An ophthalmologist also should evaluate patients who fail to respond to appropriate therapy.

Medication

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 steroids for pseudomembranes and subepithelial infiltrates; topical antibiotic to prevent bacterial superinfection; topical antiviral agents for HSV infection; and oral acyclovir for VZV infection.7

Ocular lubricants

Used for symptomatic relief.


Artificial tears (Refresh, Celluvisc, Murine)

Act to stabilize and thicken precorneal tear film and prolong tear film breakup time, which occurs with dry eye states.

Adult

1-2 gtt 4-8 times/d; may use more frequently if preservative free

Pediatric

Administer as in adults

Pregnancy

A - Fetal risk not revealed in controlled studies in humans

Precautions

Hyperemia, photophobia, stickiness of eyelashes, and ocular discomfort or irritation may occur

Antihistamines

Used to treat severe itching.


Levocabastine (Livostin)

Potent histamine H1-receptor antagonist; for ophthalmic use.

Adult

1 gtt in each affected eye qid

Pediatric

<12 years: Not established
>12 years: Administer as in adults

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Shake well prior to use; not for internal (systemic) use; avoid use of contact lenses while on medication

Corticosteroids

For pseudomembranes and decreased vision and/or glare due to subepithelial infiltrates. Have anti-inflammatory properties and cause profound and varied metabolic effects. In addition, these agents modify the body's immune response to diverse stimuli.


Prednisolone (AK-Pred, Pred Forte)

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.

Adult

1 gtt q1-6h, depending on severity of infection; taper slowly over several d to wk

Pediatric

Administer as in adults

Documented hypersensitivity; HSV keratitis; acute viral keratitis; VZV; suspected fungal keratitis; mycobacterial infection; glaucoma

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in patients with glaucoma; corticosteroids are associated with increased intraocular pressure and cataract in some patients; they may worsen certain infections, such as from herpes simplex, bacteria, and fungi

Antivirals

Used for the treatment of HSV infection.


Trifluridine (Viroptic)

Pyrimidine (thymidine) analogue DOC in the United States for topical antiviral therapy for HSV infection. Inhibits viral replication by incorporating into viral DNA in place of thymidine. If no response in 7-14 d, consider other treatments.

Adult

1 gtt into affected eye q2h while awake; not to exceed 9 gtt/d for 10 d, not to exceed 21 d; taper thereafter

Pediatric

Administer as in adults

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

All topical antiviral medications currently available for clinical use in the United States are toxic; adverse reactions include discomfort upon instillation and palpebral edema, irritation, and superficial punctate or epithelial keratopathy


Acyclovir (Zovirax)

Prodrug activated by phosphorylation by virus-specific thymidine kinase that inhibits viral replication.

Adult

Herpes zoster ophthalmicus: 800 mg PO 5 times/d for 7-10 d
Recurrent episodes: 400-800 mg PO bid for 7-10 d; initiate treatment immediately upon onset of symptoms of recurrent episodes
Prevention of herpes simplex infections: 400 mg PO bid, can be used to prevent recurrent herpes simplex infections and inflammations

Pediatric

20 mg/kg/dose PO q6h up to a maximum of 800 mg

Concomitant use of probenecid or zidovudine prolongs half-life and increases CNS toxicity of acyclovir

Documented hypersensitivity; caution in renal disease

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in renal failure or when using nephrotoxic drugs

More on Conjunctivitis, Viral

Overview: Conjunctivitis, Viral
Differential Diagnoses & Workup: Conjunctivitis, Viral
Treatment & Medication: Conjunctivitis, Viral
Follow-up: Conjunctivitis, Viral
References
Further Reading
[ CLOSE WINDOW ]

References

  1. Ishiko H, Shimada Y, Konno T, Hayashi A, Ohguchi T, Tagawa Y, et al. Novel human adenovirus causing nosocomial epidemic keratoconjunctivitis. J Clin Microbiol. Jun 2008;46(6):2002-8. [Medline].

  2. Kuo SC, Shen SC, Chang SW, Huang SC, Hsiao CH. Corneal superinfection in acute viral conjunctivitis in young children. J Pediatr Ophthalmol Strabismus. Nov-Dec 2008;45(6):374-6. [Medline].

  3. Park SW, Lee CS, Jang HC, et al. Rapid identification of the coxsackievirus A24 variant by molecular serotyping in an outbreak of acute hemorrhagic conjunctivitis. J Clin Microbiol. Mar 2005;43(3):1069-71. [Medline].

  4. Kimura R, Migita H, Kadonosono K, Uchio E. Is it possible to detect the presence of adenovirus in conjunctiva before the onset of conjunctivitis?. Acta Ophthalmol. Feb 2009;87(1):44-7. [Medline].

  5. Udeh BL, Schneider JE, Ohsfeldt RL. Cost effectiveness of a point-of-care test for adenoviral conjunctivitis. Am J Med Sci. Sep 2008;336(3):254-64. [Medline].

  6. Kaneko H, Maruko I, Iida T, Ohguchi T, Aoki K, Ohno S, et al. The possibility of human adenovirus detection from the conjunctiva in asymptomatic cases during nosocomial infection. Cornea. Jun 2008;27(5):527-30. [Medline].

  7. Monnerat N, Bossart W, Thiel MA. [Povidone-iodine for treatment of adenoviral conjunctivitis: an in vitro study]. Klin Monatsbl Augenheilkd. May 2006;223(5):349-52. [Medline].

  8. Boerner CF, Lee FK, Wickliffe CL, et al. Electron microscopy for the diagnosis of ocular viral infections. Ophthalmology. Dec 1981;88(12):1377-81. [Medline].

  9. Diamante GG, Leibowitz HM. Superficial punctate keratopathy. In: Leibowitz HM, Waring GO, eds. Corneal Disorders: Diagnosis and Management. 2nd ed. 1998:432-79.

  10. Jackson WB. Differentiating conjunctivitis of diverse origins. Surv Ophthalmol. Jul-Aug 1993;38 Suppl:91-104. [Medline].

  11. Lee SY, Pavan-Langston D. Role of acyclovir in the treatment of herpes simplex virus keratitis. Int Ophthalmol Clin. 1994;34(3):9-18. [Medline].

  12. Liesegang TJ. Conjunctiva. In: Wright KW, ed. Textbook of Ophthalmology. 1997:665-90.

  13. MMWR. Microsporidian keratoconjunctivitis in patients with AIDS. MMWR Morb Mortal Wkly Rep. Mar 23 1990;39(11):188-9. [Medline].

  14. Reed DB. Viral and bacterial conjunctivitis. Prevention of disastrous results. Postgrad Med. Sep 15 1989;86(4):103-4, 107-9, 113-4. [Medline].

  15. Syed NA, Hyndiuk RA. Infectious conjunctivitis. Infect Dis Clin North Am. Dec 1992;6(4):789-805. [Medline].

[ CLOSE WINDOW ]

Keywords

viral conjunctivitis, conjunctival infection, adenovirus, adenoviral conjunctivitis, epidemic keratoconjunctivitis, pinkeye, pink eye, pharyngoconjunctival fever, herpes simplex virus, HSV, ocular herpes simplex infection, follicular conjunctivitis, varicella-zoster virus, VZV, picornavirus, enterovirus 70, Coxsackie A24, hemorrhagic conjunctivitis, poxvirus, molluscum contagiosum, vaccinia, human immunodeficiency virus, HIV

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Ingrid U Scott, MD, MPH, Professor, Department of Ophthalmology and Public Health Sciences, Penn State College of Medicine
Ingrid U Scott, MD, MPH is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, American Society of Cataract and Refractive Surgery, American Society of Retina Specialists, Association for Research in Vision and Ophthalmology, Macula Society, Phi Beta Kappa, and Retina Society
Disclosure: Nothing to disclose.

Coauthor(s)

Kevin Luu, MD, Consulting Staff, Pediatric Anesthesia Associates Medical Group Inc; Consulting Staff, Children's Hospital Central California
Kevin Luu, MD is a member of the following medical societies: Phi Beta Kappa
Disclosure: Nothing to disclose.

Medical Editor

Jerre Freeman, MD, Founder, Chairman, Memphis Eye and Cataract Associates; Clinical Professor, Department of Ophthalmology, University of Tennessee Health Science Center
Jerre Freeman, MD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, American Society of Cataract and Refractive Surgery, and Tennessee Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Christopher J Rapuano, MD, Professor, Department of Ophthalmology, Jefferson Medical College of Thomas Jefferson University; Co-Chairman of the Cornea Service, Co-Chairman of Refractive Surgery Department, Wills Eye Institute
Christopher J Rapuano, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, Contact Lens Association of Ophthalmologists, Cornea Society, Eye Bank Association of America, International Society of Refractive Surgery, and Pan-American Association of Ophthalmology
Disclosure: Allergan Honoraria Speaking and teaching; Allergan Consulting fee Consulting; Alcon Honoraria Speaking and teaching; Inspire Honoraria Speaking and teaching; RPS Ownership interest Other; Vistakon Honoraria Speaking and teaching

CME Editor

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.