Guideline for Management of Viral Conjunctivitis

General Management

Supportive care alone is sufficient for the majority of viral conjunctivitis cases, which are self‑limited and typically resolve within 5–14 days without antiviral therapy. 1
Topical antihistamine drops can be employed to relieve ocular irritation. 1
Topical antibiotics should be avoided because they confer no therapeutic benefit and increase unnecessary antibiotic exposure. 3
Topical corticosteroids are not recommended in the acute phase of viral conjunctivitis unless specific indications (e.g., symptomatic subepithelial infiltrates) arise. 1

Routine surface disinfection in clinical settings is advised to limit transmission of viral conjunctivitis. 3

Patients not receiving corticosteroids should be scheduled for a return visit at 2–3 weeks if redness, pain, or visual decline persists. 1
Follow‑up examinations must include visual‑acuity testing and slit‑lamp biomicroscopy to assess resolution or complications. 1

Onset: Subepithelial infiltrates typically appear ≥ 1 week after disease onset. 1
Mild infiltrates: Observation without pharmacologic intervention is appropriate. 1
Symptomatic infiltrates (e.g., blurred vision, photophobia): Initiate low‑dose topical corticosteroids at the minimum effective concentration. 1
Steroid‑sparing option: Cyclosporine eye drops (0.05 %–1 %) have demonstrated benefit in reducing infiltrate severity. 1
When steroids are used, prefer low‑penetration agents such as fluorometholone or loteprednol to lessen risks of intra‑ocular pressure rise and cataract formation. 1
Patients on corticosteroids require regular monitoring (history, visual acuity, intra‑ocular pressure, slit‑lamp exam) and slow tapering to the lowest effective dose once inflammation is controlled. 1

Initiate treatment promptly when HSV is strongly suspected or when corneal involvement is present. 1
Topical therapy:
- Ganciclovir 0.15 % gel 3–5 times daily (preferred for lower ocular surface toxicity). 1
- Trifluridine 1 % solution 5–8 times daily (use limited to ≤ 2 weeks due to epithelial toxicity). 1
Systemic antivirals are more effective than topical agents alone for HSV blepharoconjunctivitis:
- Acyclovir 200–400 mg five times daily.
- Valacyclovir 500 mg 2–3 times daily.
- Famciclovir 250 mg twice daily. 1
Contraindication: Topical corticosteroids must be avoided in HSV infection as they exacerbate epithelial disease. 1
Follow‑up: Re‑evaluate within 1 week with visual acuity and slit‑lamp assessment. 1
Neonates with suspected HSV require immediate pediatric consultation because systemic infection can be life‑threatening. 1

For persistent or refractory disease in immunocompetent individuals, systemic antiviral therapy is beneficial. 1
Recommended oral regimens (7‑day courses):
- Acyclovir 800 mg five times daily.
- Valacyclovir 1000 mg every 8 hours.
- Famciclovir 500 mg three times daily. 1
Topical antibiotics may be employed when eyelid vesicles are present to prevent secondary bacterial infection and subsequent scarring or cicatricial ectropion. 1
Topical antivirals alone have not shown efficacy but can be added if the disease remains unresponsive to systemic therapy. 1

Antibiotics should not be prescribed routinely; viral conjunctivitis accounts for ≈ 80 % of acute conjunctivitis cases, and antibiotics offer no clinical benefit. 3
Corticosteroids are contraindicated in the acute phase of viral conjunctivitis unless symptomatic subepithelial infiltrates develop. 1
Corticosteroids must never be used when HSV infection is suspected, as they worsen epithelial pathology. 1
Adenoviral conjunctivitis often begins in one eye and later involves the fellow eye; clinicians should recognize this bilateral sequential pattern. 2
Patients with a prior adenoviral infection who undergo refractive surgery (LASIK/PRK) may experience recurrence of subepithelial infiltrates. 1