Conjunctivitis (viral, non-herpetic)
The CMGs are guidelines on the diagnosis and management of a range of common and rare, but important, eye conditions that present with varying frequency in primary and first contact care.
The CMGs are guidelines on the diagnosis and management of a range of common and rare, but important, eye conditions that present with varying frequency in primary and first contact care.
Adenoviral conjunctivitis is the most common form of acute infective conjunctivitis, accounting for up to 75% of cases
epidemic conjunctivitis and keratoconjunctivitis (EKC) (this Guideline)
o most cases affect adults aged 20 to 40 yearspharyngoconjunctival fever (not dealt with in this Guideline)
Less common causes of non-herpetic viral conjunctivitis
- acute haemorrhagic conjunctivitis (rare epidemics)
- conjunctivitis is a rare manifestation of COVID-19 disease
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.)
Acute onset
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
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:
Other forms of conjunctivitis
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%
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:
Review to monitor for painful or sight-compromising corneal involvement or development of conjunctival pseudomembrane (in either case, refer to ophthalmologist)
(GRADE*: Level of evidence=low, Strength of recommendation=strong)
If COVID-19 disease suspected, refer to current College advice:
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)
B2: alleviation/palliation; normally no referral
A2: first aid measures and emergency referral (same day) if conjunctivitis severe (e.g. presence of pseudomembrane) or if significant keratitis present (e.g. severe pain and/or visual loss)
Conjunctival swabs for virus isolation and strain identification
Currently available anti-viral medication is ineffective
Topical steroid may be indicated in the acute phase where there is conjunctival pseudomembrane formation
Topical steroids are sometimes used during the acute phase, however there is insufficient evidence to support their use in the treatment of sub-epithelial opacities
Topical ciclosporin (off-licence use)
*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
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)
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
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
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
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. 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 13
Date of search 12.04.20
Date of revision 26.05.20
Date of publication 23.06.20
Date for review 11.04.22
© College of Optometrists
View more Clinical Management Guidelines