Viral Conjunctivitis

Conjunctivitis may accompany the common cold and other systemic viral infections (especially measles Measles Measles is a highly contagious viral infection that is most common among children. It is characterized by fever, cough, coryza, conjunctivitis, an enanthem (Koplik spots) on the oral mucosa... read more , but also chickenpox Chickenpox Chickenpox is an acute, systemic, usually childhood infection caused by the varicella-zoster virus (human herpesvirus type 3). It usually begins with mild constitutional symptoms that are followed... read more , rubella Rubella (See also Congenital Rubella.) Rubella is a viral infection that may cause adenopathy, rash, and sometimes constitutional symptoms, which are usually mild and brief. Infection during early pregnancy... read more , and mumps Mumps Mumps is an acute, contagious, systemic viral disease, usually causing painful enlargement of the salivary glands, most commonly the parotids. Complications may include orchitis, meningoencephalitis... read more ). Localized viral conjunctivitis without systemic manifestations usually results from adenoviruses Adenovirus Infections Infection with one of the many adenoviruses may be asymptomatic or result in specific syndromes, including mild respiratory infections, keratoconjunctivitis, gastroenteritis, cystitis, and primary... read more (up to 90% of viral conjunctivitis) and sometimes enteroviruses Overview of Enterovirus Infections Enteroviruses, along with rhinoviruses (see Common Cold) and human parechoviruses, are a genus of picornaviruses (pico, or small, RNA viruses). All enteroviruses are antigenically heterogeneous... read more or herpes simplex virus Herpes Simplex Virus (HSV) Infections Herpes simplex viruses (human herpesviruses types 1 and 2) commonly cause recurrent infection affecting the skin, mouth, lips, eyes, and genitals. Common severe infections include encephalitis... read more (1.3 to 4.8% of viral conjunctivitis).

Epidemic keratoconjunctivitis is a severe form of viral conjunctivitis that is usually caused by adenovirus serotypes Ad 5, 8, 11, 13, 19, and 37. Adenoviruses can also be identified by genotypes. Genotype HAdV-D is associated with conjunctivitis and HAdV-D53 and HAdV-D54 have been associated with epidemic keratoconjunctivitis. Pharyngoconjunctival fever usually results from serotypes Ad 3, 4, and 7. Outbreaks of acute hemorrhagic conjunctivitis, a rare conjunctivitis associated with infection by enterovirus type 70, have occurred in Africa and Asia. Ebola virus and SARS-CoV-2 infections (which are associated with the highly contagious and potentially fatal Ebola hemorrhagic fever Marburg and Ebola Virus Infections Marburg and Ebola are filoviruses that cause hemorrhage, multiple organ failure, and high mortality rates. Diagnosis is with enzyme-linked immunosorbent assay, polymerase chain reaction (PCR)... read more and COVID-19 COVID-19 COVID-19 is an acute, sometimes severe, respiratory illness caused by the novel coronavirus SARS-CoV-2. Prevention is by vaccination and infection control precautions (eg, face masks, handwashing... read more , respectively) can manifest with bilateral conjunctival hyperemia, tearing, and systemic symptoms. Caution and appropriate personal protective equipment should be used when examining patients with conjunctivitis, systemic symptoms, and travel from high-risk regions.

After an incubation period of about 5 to 12 days, conjunctival hyperemia, watery discharge, and ocular irritation usually begin in one eye and spread rapidly to the other. Follicles may be present on the palpebral conjunctiva. A preauricular lymph node is often enlarged and painful. Many patients have had contact with someone with conjunctivitis, a recent upper respiratory infection, or both.

In epidemic keratoconjunctivitis, patients may have photophobia and foreign body sensation due to corneal involvement. Chemosis may be present. Pseudomembranes of fibrin and inflammatory cells on the tarsal conjunctiva, focal corneal inflammation, or both may blur vision. Even after conjunctivitis has resolved, residual corneal subepithelial opacities (multiple, coin-shaped, 0.5 to 1.0 mm in diameter) may be visible with a slit lamp Slit-lamp examination The eye can be examined with routine equipment, including a standard ophthalmoscope; thorough examination requires special equipment and evaluation by an ophthalmologist. History includes location... read more for up to 2 years. Corneal opacities occasionally result in decreased vision and significant halos and starbursts.

Diagnosis of conjunctivitis and differentiation between bacterial Acute Bacterial Conjunctivitis Acute conjunctivitis can be caused by numerous bacteria. Symptoms are hyperemia, lacrimation, irritation, and discharge. Diagnosis is clinical. Treatment is with topical antibiotics, augmented... read more , viral Viral Conjunctivitis Viral conjunctivitis is a highly contagious acute conjunctival infection usually caused by an adenovirus. Symptoms include irritation, photophobia, and watery discharge. Diagnosis is clinical... read more , and noninfectious conjunctivitis Allergic Conjunctivitis Allergic conjunctivitis is an acute, intermittent, or chronic conjunctival inflammation usually caused by airborne allergens. Symptoms include itching, lacrimation, discharge, and conjunctival... read more (see table ) are usually clinical; however, differentiation between viral and bacterial conjunctivitis can be imprecise because symptoms may overlap. Special tissue cultures are necessary for growth of the virus but are rarely indicated. Nucleic acid amplification tests (NAAT) and other rapid, office-based immunodiagnostic tests, can be useful especially when the inflammation is severe and other diagnoses (eg, orbital cellulitis Preseptal and Orbital Cellulitis Preseptal cellulitis (periorbital cellulitis) is infection of the eyelid and surrounding skin anterior to the orbital septum. Orbital cellulitis is infection of the orbital tissues posterior... read more ) must be ruled out.

Features that may help differentiate between viral and bacterial conjunctivitis can include purulence of ocular discharge, presence of preauricular lymphadenopathy, and, in epidemic keratoconjunctivitis, chemosis. Patients with photophobia are stained with fluorescein and examined with a slit lamp. Epidemic keratoconjunctivitis may cause punctate corneal staining. Secondary bacterial infection of viral conjunctivitis is very rare. However, if any signs suggest bacterial conjunctivitis (eg, purulent discharge), cultures or other studies may be useful.

Viral conjunctivitis is highly contagious, and transmission precautions must be followed.

Physicians take the following precautions to avoid transmitting infection:

Patients should do the following:

Eyes should be kept free of discharge and should not be patched. Small children with conjunctivitis should be kept home from school to avoid spreading the infection.

Viral conjunctivitis is self-limiting, lasting 1 week in mild cases to up to 3 weeks in severe cases. It requires only cool compresses for symptomatic relief. However, patients who have severe photophobia or whose vision is affected may benefit from topical corticosteroids (eg, 1% prednisolone acetate 4 times a day). Corticosteroids, if prescribed, are usually prescribed by an ophthalmologist. Herpes simplex keratitis Herpes Simplex Keratitis Herpes simplex keratitis is corneal infection with herpes simplex virus. It may involve the iris. Symptoms and signs include foreign body sensation, lacrimation, photophobia, and conjunctival... read more must be ruled out first (by fluorescein staining and slit-lamp examination Slit-lamp examination The eye can be examined with routine equipment, including a standard ophthalmoscope; thorough examination requires special equipment and evaluation by an ophthalmologist. History includes location... read more ) because corticosteroids can exacerbate it. Topical cyclosporin A eye drops are overall less effective but are helpful if corticosteroid drop use is limited by adverse effects. In severe cases, any conjunctival pseudomembranes should be removed at the slit-lamp examination to reduce the chances of conjunctival scarring and symblepharon formation.