- Abnormalities of the Pupil
- Atopic Keratoconjunctivitis (AKC)
- Basal cell carcinoma (BCC) (periocular)
- Blepharitis (Lid Margin Disease)
- CL-associated Papillary Conjunctivitis (CLAPC), Giant Papillary Conjunctivitis (GPC)
- Cellulitis, preseptal and orbital
- Chalazion (Meibomian cyst)
- Concretions
- Conjunctival pigmented lesions
- Conjunctival scarring
- Conjunctivitis (Acute Allergic)
- Conjunctivitis (bacterial)
- Conjunctivitis (viral, non-herpetic)
- Conjunctivitis (seasonal & perennial allergic)
- Conjunctivitis, Chlamydial
- Conjunctivitis medicamentosa (also Dermatoconjunctivitis medicamentosa)
- Corneal (or other superficial ocular) foreign body
- Corneal Transplant Rejection
- Corneal abrasion
- Corneal hydrops
- Dacryocystitis (acute)
- Dacryocystitis (chronic)
- Dry Eye (Keratoconjunctivitis Sicca, KCS)
- Ectropion
- Endophthalmitis (post-operative) (Exogenous endophthalmitis)
- Entropion
- Episcleritis
- Facial palsy (Bell's Palsy)
- Fuchs Endothelial Corneal Dystrophy (FECD)
- Glaucoma (chronic open angle) (COAG)
- Herpes Simplex Keratitis (HSK)
- Herpes Zoster Ophthalmicus (HZO)
- Hordeolum
- Keratitis (marginal)
- Keratitis, CL-associated infiltrative
- Microbial keratitis (Acanthamoeba sp.)
- Microbial keratitis (bacterial, fungal)
- Molluscum contagiosum
- Nasolacrimal duct obstruction (nasolacrimal drainage dysfunction)
- Ocular hypertension (OHT)
- Ocular rosacea
- Ophthalmia neonatorum
- Photokeratitis (Ultraviolet [UV] burn, Arc eye, Snow Blindness)
- Phthiriasis (pediculosis ciliaris)
- Pigmented fundus lesions
- Pinguecula
- Post-operative suture breakage
- Primary Angle Closure / Primary Angle Closure Glaucoma (PAC / PACG)
- Pterygium
- Recurrent corneal epithelial erosion syndrome
- Retinal Vein Occlusion
- Scleritis
- Steroid-related Ocular Hypertension and Glaucoma
- Sub-conjunctival haemorrhage
- Sub-tarsal foreign body (STFB)
- Trauma (blunt)
- Trauma (chemical)
- Trauma (penetrating)
- Trichiasis
- Uveitis (anterior)
- Vernal Keratoconjunctivitis
- Vitreomacular Traction and Macular Hole
- How to use the Clinical Management Guidelines
Conjunctivitis (viral, non-herpetic)
Contents
Aetiology
Adenoviral conjunctivitis is the most common form of acute infective conjunctivitis, accounting for up to 75% of cases
- adenoviruses are highly contagious pathogens (over 50 serotypes)
- spectrum of disease varies from mild to severe
- two syndromes of adenoviral infection:
- epidemic conjunctivitis and keratoconjunctivitis (EKC) (this Guideline)
- most cases affect adults aged 20 to 40 years
- pharyngoconjunctival fever (not dealt with in this Guideline)
- systemic symptoms predominate, with pharyngitis, tender pre-auricular lymphadenopathy, fever and an acute follicular conjunctivitis
- epidemic conjunctivitis and keratoconjunctivitis (EKC) (this Guideline)
Less common causes of non-herpetic viral conjunctivitis
- Enterovirus 70 (EV70) and Coxsackievirus A24 (CA24v)
- acute haemorrhagic conjunctivitis (rare epidemics)
- Molluscum contagiosum (see separate Clinical Management Guideline)
- SARS-CoV-2 coronavirus
- conjunctivitis is a rare manifestation of COVID-19 disease
Predisposing factors
Infection may be preceded by ‘flu-like symptoms
Low standards of hygiene
Outbreaks can occur in the general population, especially in crowded conditions (schools, camps), in hospital environments (especially ophthalmological units, and neonatal intensive care units) and in nursing homes
Eye clinics (transmission by clinicians’ fingers, tonometer prisms, etc.)
Symptoms of conjunctivitis (viral, non-herpetic)
Acute onset
- redness
- discomfort, usually described as burning or grittiness
- watering
Symptoms of EKC usually appear within 14 days of exposure and typically last 7 to 21 days
Often unilateral at first, becoming bilateral, first eye usually more affected
Blurred vision if central cornea involved
Systemic malaise
Signs of conjunctivitis (viral, non-herpetic)
Watery discharge
Conjunctival hyperaemia (may be intense) and chemosis
Follicles on palpebral conjunctiva, especially upper and lower fornix (if abundant, follicles can produce folds)
Petechial (pin-point) subconjunctival haemorrhages
Pseudomembranes on tarsal conjunctival surfaces (severe cases only)
Pre-auricular lymphadenopathy which may be tender (not present in every case)
Corneal involvement in some cases:
- punctate epithelial lesions within first two weeks
- later replaced by sub-epithelial infiltrates which may persist for months
Differential diagnosis
Other forms of conjunctivitis
- bacterial
- chlamydial
- herpetic (simplex or zoster)
- allergic
Other causes of acute red eye
A point of care diagnostic test (AdenoPlus) is available (see NICE Medtech innovation briefing) [MIB46] 2015.
NB Poor sensitivity (<50%) compared to PCR reference standard; specificity >90%
Management by optometrist
Practitioners should recognise their limitations and where necessary seek further advice or refer the patient elsewhere
Non pharmacological
Wash hands carefully before and after examination and clean equipment before next patient
Do not applanate with a re-usable tonometer prism as condition is highly contagious
Advise patient:
- condition is normally self-limiting, resolving within one to two weeks
- condition is highly contagious for family, friends and work colleagues (do not share towels, etc)
- since people with adenoviral conjunctivitis remain infectious for 2 weeks after symptom onset, those working in patient-facing roles in health and social care settings should avoid close contact with others during this period.
- UK Health Security Agency (UKHSA) and National health systems across the UK do not recommend an exclusion period from school, or nursery for children with infectious conjunctivitis unless an outbreak or cluster of cases occur.
- cold compresses may give symptomatic relief
- discontinue contact lens wear in acute phase
Review to monitor for painful or sight-compromising corneal involvement or development of conjunctival pseudomembrane
(GRADE*: Level of evidence=low, Strength of recommendation=strong)
The recommendation to practise scrupulous infection control, which applies to all cases of viral conjunctivitis, is paramount here.
Follow infection control advice provided in the College Guidance for Professional practice
Pharmacological
Antibacterial agents are not effective in viral conditions
Current topical and systemic anti-viral agents also ineffective in adenovirus infection
Artificial tears and lubricating ointments (drops for use during the day, unmedicated ointment for use at bedtime) may relieve symptoms
Topical antihistamines may be used for severe itching
(GRADE*: Level of evidence=low, Strength of recommendation=strong)
The use of steroids in viral conjunctivitis is controversial. Topical steroids are sometimes used for the treatment of subepithelial infiltrates (SEI). Although SEI are typically self-limiting, steroids may be indicated in symptomatic patients with persistent SEI after >6 weeks duration. Low potency (non-penetrating) steroids (e.g. fluorometholone) with a higher frequency initially and then tapered e.g. four times per day (QDS) for 1-month, three times per day (TDS) for 1-month and twice per day (BD) for 4-months).
(GRADE*: Level of evidence=low, Strength of recommendation=weak)
Management category
B2: alleviation/palliation; normally no referral
Possible management by ophthalmologist
Conjunctival swabs for virus isolation and strain identification
Currently available anti-viral medication is ineffective
Topical ciclosporin (off-licence use)
Evidence base
*GRADE: Grading of Recommendations Assessment, Development and Evaluation (www.gradingworkinggroup.org)
Sources of evidence
Everitt H, Wormald R, Henshaw K, et al. Viral conjunctivitis. In: Wormald R, Smeeth L, Henshaw K, eds. Evidence Based Ophthalmology. London: BMJ books, 2003
Gouider D, Khallouli A, Maalej A, Yousfi MA, Ksiaa I, Bouguerra C, Ajili F, Khairallah M. Corticosteroids Versus Cyclosporine for Subepithelial Infiltrates Secondary to Epidemic Keratoconjunctivitis: A Prospective Randomized Double-Blind Study. Cornea. 2021;40(6):726-732.
Inomata T, Kitazawa K, Kuno T, Sung J, Nakamura M, Iwagami M, Takagi H, Midorikawa-Inomata A, Zhu J, Fujimoto K, Okumura Y, Miura M, Fujio K, Hirosawa K, Akasaki Y, Kuwahara M, Dana R, Murakami A. Clinical and Prodromal Ocular Symptoms in Coronavirus Disease: A Systematic Review and Meta-Analysis. Invest Ophthalmol Vis Sci. 2020;61(10):29.
Jhanji V, Chan TC, Li EY, Agarwal K, Vajpayee RB. Adenoviral keratoconjunctivitis. Surv Ophthalmol. 2015;60(5):435-43 https://pubmed.ncbi.nlm.nih.gov/26077630
Labib BA, Minhas BK, Chigbu DI. Management of Adenoviral Keratoconjunctivitis: Challenges and Solutions. Clin Ophthalmol. 2020;14:837-852 https://www.dovepress.com/management-of-adenoviral-keratoconjunctivitis-challenges-and-solutions-peer-reviewed-article-OPTH
Lawrenson JG, Buckley RJ. COVID-19 and the Eye (Guest Editorial). Ophthal Physiol Opt 2020 (in press)
Liu SH, Hawkins BS, Ng SM, Ren M, Leslie L, Han G, Kuo IC. Topical pharmacologic interventions versus placebo for epidemic keratoconjunctivitis. Cochrane Database Syst Rev.2022;3(3):CD013520.
Meyer-Rüsenberg B, Loderstädt U, Richard G, Kaulfers PM, Gesser C: Epidemic Keratoconjunctivitis—the cur- rent situation and recommendations for prevention and treatment. Dtsch Arztebl Int 2011; 108(27): 475–80 https://www.ncbi.nlm.nih.gov/pubmed/21814523
NICE - AdenoPlus point-of-care test for diagnosing adenoviral conjunctivitis. NICE Medtech innovation briefing [MIB46] 2015 https://www.nice.org.uk/advice/mib46
Pihos AM. Epidemic keratoconjunctivitis: A review of current concepts in management. J Optom. 2013 Apr; 6(2): 69–74 http://www.ncbi.nlm.nih.gov/pubmed/21319870
Skevaki CL, Galani IE, Pararas MV, Giannopoulou KP, Tsakris A. Treatment of viral conjunctivitis with antiviral drugs. Drugs. 2011;71(3):331-47 http://www.ncbi.nlm.nih.gov/pubmed/21319870
Starr MB. How best to treat adenoviral corneal opacities? Cornea. 2004;23(3):217-9.
Varu DM, Rhee MK, Akpek EK, Amescua G, Farid M, Garcia-Ferrer FJ, Lin A, Musch DC, Mah FS, Dunn SP; American Academy of Ophthalmology Preferred Practice Pattern Cornea and External Disease Panel. Conjunctivitis Preferred Practice Pattern. Ophthalmology. 2019;126(1):P94-P169 https://pubmed.ncbi.nlm.nih.gov/30366797
Summary
What is Viral Conjunctivitis?
Viral conjunctivitis is an infection of the eye in which one or both eyes become red and uncomfortable. The condition is not normally serious and in most cases clears up without treatment. It is highly infectious and care needs to be taken to prevent others from becoming infected, for example by not sharing towels.
How is Viral Conjunctivitis managed?
In terms of treatment, antibiotics are ineffective against viruses and there is no effective anti-viral drug. Usual care involves the control of symptoms using cool compresses applied to the closed eyes, coupled with the use of lubricating eye drops and ointment. In a small number of cases viral conjunctivitis can lead to the development of small opaque areas within the cornea (the clear window at the front of the eye), which can cause blurred vision. In such cases, and where there is severe inflammation, emergency referral to an ophthalmologist should be arranged.
Conjunctivitis is seen, rarely, in people with COVID-19 disease.
Conjunctivitis (viral, non-herpetic)
Version 14
Date of search 06.05.22
Date of revision 11.09.23
Date of publication 19.12.22
Date for review 05.05.24
© College of Optometrists
- Abnormalities of the Pupil
- Atopic Keratoconjunctivitis (AKC)
- Basal cell carcinoma (BCC) (periocular)
- Blepharitis (Lid Margin Disease)
- CL-associated Papillary Conjunctivitis (CLAPC), Giant Papillary Conjunctivitis (GPC)
- Cellulitis, preseptal and orbital
- Chalazion (Meibomian cyst)
- Concretions
- Conjunctival pigmented lesions
- Conjunctival scarring
- Conjunctivitis (Acute Allergic)
- Conjunctivitis (bacterial)
- Conjunctivitis (viral, non-herpetic)
- Conjunctivitis (seasonal & perennial allergic)
- Conjunctivitis, Chlamydial
- Conjunctivitis medicamentosa (also Dermatoconjunctivitis medicamentosa)
- Corneal (or other superficial ocular) foreign body
- Corneal Transplant Rejection
- Corneal abrasion
- Corneal hydrops
- Dacryocystitis (acute)
- Dacryocystitis (chronic)
- Dry Eye (Keratoconjunctivitis Sicca, KCS)
- Ectropion
- Endophthalmitis (post-operative) (Exogenous endophthalmitis)
- Entropion
- Episcleritis
- Facial palsy (Bell's Palsy)
- Fuchs Endothelial Corneal Dystrophy (FECD)
- Glaucoma (chronic open angle) (COAG)
- Herpes Simplex Keratitis (HSK)
- Herpes Zoster Ophthalmicus (HZO)
- Hordeolum
- Keratitis (marginal)
- Keratitis, CL-associated infiltrative
- Microbial keratitis (Acanthamoeba sp.)
- Microbial keratitis (bacterial, fungal)
- Molluscum contagiosum
- Nasolacrimal duct obstruction (nasolacrimal drainage dysfunction)
- Ocular hypertension (OHT)
- Ocular rosacea
- Ophthalmia neonatorum
- Photokeratitis (Ultraviolet [UV] burn, Arc eye, Snow Blindness)
- Phthiriasis (pediculosis ciliaris)
- Pigmented fundus lesions
- Pinguecula
- Post-operative suture breakage
- Primary Angle Closure / Primary Angle Closure Glaucoma (PAC / PACG)
- Pterygium
- Recurrent corneal epithelial erosion syndrome
- Retinal Vein Occlusion
- Scleritis
- Steroid-related Ocular Hypertension and Glaucoma
- Sub-conjunctival haemorrhage
- Sub-tarsal foreign body (STFB)
- Trauma (blunt)
- Trauma (chemical)
- Trauma (penetrating)
- Trichiasis
- Uveitis (anterior)
- Vernal Keratoconjunctivitis
- Vitreomacular Traction and Macular Hole
- How to use the Clinical Management Guidelines
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