Viral Conjunctivitis (Pink Eye) Treatment & Management

Treatment of adenoviral conjunctivitis is supportive. No evidence exists that demonstrates the efficacy of specific antiviral agents other than topical ganciclovir. A combination topical agent that contains betadine and low-dose dexamethasone is in confirmatory phase III clinical trials as a broad-spectrum agent for the treatment of adenovirus, HSV, VZV, and other forms of infectious conjunctivitis. There are no oral antiviral candidates under consideration as antiadenoviral therapeutics, nor is there any evidence that oral antiherpetic drugs have any effect on ocular adenoviral disease.

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 and may lead to long-term dependence.

A study by Wilkins et al focused on whether topical steroids improve the comfort of patients compared with hypromellose in acute presumed viral conjunctivitis. It found that the use of a short course of topical dexamethasone for patients with acute follicular conjunctivitis presumed to be viral in origin was not harmful. ^[10]

Adenoviral 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. ^[11]

HSV infection

Patients with conjunctivitis caused by HSV usually are treated with topical antiviral agents, including ganciclovir gel, idoxuridine solution and ointment, vidarabine ointment, and trifluridine solution. An ophthalmologist should see any patient with ocular HSV infection.

VZV infection

Treatment of VZV eye disease includes oral acyclovir, 600-800 mg, 5 times daily for 7-10 days, to terminate viral replication. Valacyclovir 1000 mg or famciclovir 500 mg PO TID for 7-10 days also is approved for herpes zoster infection. Topical corticosteroids usually are not indicated for conjunctivitis or keratitis.

Molluscum contagiosum

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.

Considerations for other viral causes

Other viral causes of conjunctivitis generally are self-limited and treated supportively with cool or warm compresses for comfort, topical antihistamines to limit redness and itching, chilled artificial tears for comfort, and topical antibiotics as necessary to prevent bacterial superinfection.

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.

Prevention of transmission, especially in healthcare facilities, is extremely important. Careful hand washing before seeing every patient, proper cleansing of instruments, and frequent changing of multiuse ophthalmic drops are vital. Using a single infective examination room, as well as educating the staff and the patient, is important.

Patients should be instructed to take contagion and isolation precautions for at least 2 weeks or as long as their eyes are red and weeping. In particular, they should avoid contact with infants, elderly persons, individuals taking immunosuppressive or chemotherapeutic agents, and immunocompromised patients.

Physicians have been sued by patients who believe they acquired viral conjunctivitis in the doctor's office. Every attempt to prevent transmission from patient to patient (not to mention to the doctor) should be made. Suggestions include not having patients with a red eye wait in the general waiting room, having a special examination room for patients with red eyes, disinfecting the examination room after seeing any patient with a red eye, not shaking hands with patients with red eye (after explaining the reason to them), touching their eyelids with cotton-tipped applicators and not your fingers, washing the hands immediately after examining the patient (even before writing in the chart or using the computer), and not giving the chart to the patient to bring to the receptionist. These patients should be escorted directly out of the clinic and instructed to make a follow-up appointment by telephone at least 2 weeks thereafter.

Viral conjunctivitis is an occupational hazard of eye care providers. Doctors, technicians, and every staff member must take all precautions possible not to become a victim.

Patients with conjunctivitis, especially those treated with medications, require follow-up care. Patients should return after the contagious period (2-3 weeks) or sooner only if the condition significantly worsens.

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, significant visual loss, concomitant uveitis, conjunctival membrane or pseudomembrane formation, corneal 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.