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Epidemic Keratoconjunctivitis Clinical Presentation

  • Author: Ahmed Bawazeer, MBChB, FRCSC; Chief Editor: Hampton Roy, Sr, MD  more...
Updated: Apr 03, 2015


Epidemic keratoconjunctivitis infection may be preceded by flulike symptoms, including fever, malaise, respiratory symptoms, nausea, vomiting, diarrhea, and myalgia.

Often, a recent history of an eye examination or exposure within the family or at work is present.

The incubation period is 2-14 days, and the person may remain infectious for 10-14 days after symptoms develop.

The ocular symptoms are mainly sudden onset of irritation, soreness, red eye, photophobia, foreign body sensation, and excessive tearing.

In more severe cases, patients can present with ocular and periorbital pain and decreased visual acuity.

Symptoms tend to last for 7-21 days. The fellow eye tends to be involved in more than 50% of the cases within 7 days of onset. The signs and symptoms are typically less severe in the fellow eye.


Physical Examination

Ipsilateral preauricular lymphadenopathy is one of the classic findings of epidemic keratoconjunctivitis (EKC).

Decreased visual acuity is rarely present; it is usually present only if there is corneal involvement.

Other clinical signs include the following:

  • Swelling and erythema of the lid
  • Conjunctival hyperemia
  • Chemosis
  • Follicular reaction, mainly in the lower palpebral conjunctiva (the earliest and most common sign)
  • Papillary hypertrophy
  • Subconjunctival and petechial hemorrhage

In severe cases, membranous and pseudomembranous conjunctivitis can be seen in one third of cases, which can lead to conjunctival scarring and symblepharon (seen in the image below).

Symblepharon secondary to epidemic keratoconjuncti Symblepharon secondary to epidemic keratoconjunctivitis.

Corneal involvement

One of the distinguishing features of EKC is corneal involvement, which is usually mild and transient.

Corneal involvement has been well documented 3-4 days after symptom onset in the form of diffuse, fine epithelial keratitis that stains with fluorescein and rose bengal. This keratitis can persist for 2-3 weeks. In rare cases, a frank corneal epithelial defect may occur.

One week after the onset, focal epithelial keratitis may develop. This is characterized by central ulceration and irregular borders with gray-white dots. These epithelial changes are related to active viral infection. These lesions persist for 1-2 weeks.

About 2 weeks after onset, subepithelial infiltrates can appear beneath the focal epithelial lesions, persisting for weeks to years. They resolve spontaneously, usually without scarring. These infiltrates are immunologic in nature.

In rare cases, disciform keratitis or anterior uveitis can occur.

There is no change in corneal sensation.

Contributor Information and Disclosures

Ahmed Bawazeer, MBChB, FRCSC  Professor and Chairman of Ophthalmology, Department of Ophthalmology, Division of Uveitis and Cornea, King Abdulaziz University, Saudi Arabia

Ahmed Bawazeer, MBChB, FRCSC is a member of the following medical societies: American Academy of Ophthalmology

Disclosure: Nothing to disclose.


William G Hodge, MD, PhD, FRCSC Professor and Chair, Ophthalmologist in Chief, Ivey Eye Institute, Schulich School of Medicine and Dentistry, University of Western Ontario

William G Hodge, MD, PhD, FRCSC is a member of the following medical societies: American Academy of Ophthalmology, Canadian Medical Association, Canadian Ophthalmological Society, Ontario Medical Association, Quebec Medical Association, Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Specialty Editor Board

Simon K Law, MD, PharmD Clinical Professor of Health Sciences, Department of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine

Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, Association for Research in Vision and Ophthalmology, American Glaucoma Society

Disclosure: Nothing to disclose.

Christopher J Rapuano, MD Professor, Department of Ophthalmology, Jefferson Medical College of Thomas Jefferson University; Director of the Cornea Service, Co-Director of Refractive Surgery Department, Wills Eye Hospital

Christopher J Rapuano, MD is a member of the following medical societies: American Academy of Ophthalmology, American Ophthalmological Society, American Society of Cataract and Refractive Surgery, Contact Lens Association of Ophthalmologists, International Society of Refractive Surgery, Cornea Society, Eye Bank Association of America

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cornea Society, Allergan, Bausch & Lomb, Bio-Tissue, Shire, TearScience, TearLab<br/>Serve(d) as a speaker or a member of a speakers bureau for: Allergan, Bausch & Lomb, Bio-Tissue, TearScience.

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, Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

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Follicular conjunctivitis and subconjunctival hemorrhage.
Symblepharon secondary to epidemic keratoconjunctivitis.
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