Viral Conjunctivitis

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  • mostly due to adenoviruses (65-90%)


  • non-specific acute follicular conjunctivitis
    • most common
    • usually accompanied by mild systemic symptoms such as a sore throat or rhinitis
  • pharyngoconjunctival fever
    • droplet transmission
    • combined with upper respiratory tract infections
  • epidemic keratoconjunctivitis
    • most severe form, in 80% associated with keratitis
    • contagious for 2-3 weeks


  • Itching, burning, tearing, foreign body sensation, photophobia
  • Initially often unilateral, after a few days bilateral
  • History of close contacts (family, friends, acquaintances) with conjunctivitis and any recent viral infections


  • Conjunctival hyperaemia, haemorrhages, chemosis, eyelid oedema
  • Conjunctival follicles
  • Preauricular lymphadenopathy
  • Membranes and pseudomembranes
  • Epithelial microcysts, epithelial keratitis punctata, subepithelial infiltrates (=nummuli)
  • in HSV: vesicles on eyelids or ulcerations of bulbar conjunctiva

Differential Diagnosis


  • AdenoPlus test (instructional video )
    • If possible, do not use oxybuprocaine or other topical anaesthetics because of the risk of a false-positive test, wait at least 5 minutes after the last drop
    • Swab the tarsal conjunctiva 6-8 times, then place the swab on one spot for at least 5 sec.
    • Hold in buffer solution for 10 sec
    • Read result after 10 min
    • High clinical suspicion and negative AdenoPlus test: consider taking a swab for adenovirus PCR
  • Conjunctival swab for bacteria only indicated if secretion is pronounced or if chronic


  • Inform patient about self-limiting course and high contagiousness during first 2 weeks
    • Hygiene measures, consider issuing certificate of incapacity for work
  • Lacrycon gtt 3-4x daily to hourly
  • In case of severe itching, consider antihistamine eyedrops (e.g. Zaditen SDU (Ketotifen) 2x/d)
    • See allergic conjunctivitis
  • Cooling compresses
  • Consider FML NEO gtt (Fluorometholone, Neomycin) 2-3x/d for 5-7 days or Tobradex gtt (Tobramycin) 3x/d for 5-7 days (Cave: steroids are not evidence-based, may increase viral load)
  • in epidemic keratoconjunctivitis: Consider Povidone Iodine 0.1% gtt 6x daily for 5-7 days (to reduce viral load)
  • If (pseudo)membranes appear: peeling with cotton swabs or tweezers and regular follow-ups
    • Consider steroid therapy: e.g. Pred forte gtt (Prednisolone) 4x/d or Ultracortenol ointment (Prednisolone) 4x/d
  • In case of subepithelial infiltrates (nummuli)
    • good lubrication, usually self-limiting
    • in case of severe glare consider therapy with Ciclosporin-A ggt
      • Ciclosporin-A 0.1% gtt 1x/day (Ikervis) for 3-6 months
      • alternatively Tacrolimus ointment possible
      • alternatively Dexafree gtt (Dexamethason) initially 4x/d
        • CAVE: frequent recurrences after discontinuation, taper very slowly!
      • Chronic infiltrates: Phototherapeutic keratectomy (PTK) for therapy-refractory subepithelial infiltrates with significant visual loss
        • CAVE: 10% recurrences
  • in Herpes simplex Conjunctivitis
    • Virgan eye gel (Gangciclovir) 5x/d
      • alternatively Zovirax ointment 5x/d
    • Follow-up usually after 2 – 3 days to assess response to therapy


  • EyeWiki Conjunctivitis
  • EyeWiki Epidemic Keratoconjunctivitis
  • The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease; Nika Bagheri MD, Brynn Wajda MD, et al; Lippincott Williams&Wilkins; 7. Edition (2016)
  • Kanski’s Clinical Ophthalmology: A Systematic Approach; Jack J. Kanski MD, Brad Bowling MD; Saunders Ltd.; 8. Edition (2015)