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

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

• angle closure glaucoma
• keratitis
• anterior uveitis

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

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)
• infection with adenovirus necessitates 2 weeks off work or school
• 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

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

Conjunctivitis (viral, non-herpetic)
Version 14
Date of search 06.05.22
Date of revision 10.10.22
Date of publication 19.12.22
Date for review 05.05.24
© College of Optometrists