Viral Conjunctivitis (Pink Eye) Clinical Presentation

Updated: Feb 15, 2023
  • Author: Ingrid U Scott, MD, MPH; Chief Editor: Andrew A Dahl, MD, FACS  more...
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While the manifestations of various types of bacterial conjunctivitis are fairly homogeneous, those of viral conjunctivitis can vary from 1 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 a 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 report ocular itching, foreign body sensation, tearing, redness, discharge, eyelids sticking (worse in the morning), 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 oculofacial 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 Coxsackievirus 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, or HIV.


Physical Examination

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, sometimes followed by diffuse subepithelial infiltrates, which generally occur 7-14 days after the onset of symptoms. The eyelids often are edematous and ecchymotic. In severe cases, there can be a corneal epithelial defect. The entire process typically begins in one eye and progresses to the fellow eye over a few days, albeit with less severity in the non-index eye.

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 an epithelial dendritic keratitis with typical features of linear branching and dendritic figures, as well as deeper stromal inflammation. Endothelialitis, trabeculitis with elevated intraocular pressure, and/or uveitis also may occur.

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 with permanent cicatrization and conjunctival pigmentation. Lid lesions may resolve or may lead to notching, distichiasis, alopecia, hypopigmentation, or scarring.

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.