Viral conjunctivitis is most often caused by an adenovirus, a DNA virus that can cause a range of human diseases, including upper respiratory tract infection and gastroenteritis. The following adenoviral diseases are listed with their associated serotypes: epidemic keratoconjunctivitis (serotypes 8, 19, and 37, subgroup D), pharyngoconjunctival fever (serotypes 3 and 7), acute hemorrhagic conjunctivitis (serotypes 11 and 21), and acute follicular conjunctivitis (serotypes 1, 2, 3, 4, 7, and 10). Contact precautions are especially important during the examination of infants. Outbreaks of adenoviral conjunctivitis have been associated with retinopathy of prematurity examinations in neonatal intensive care units. In neonates, adenoviral pneumonia can be fatal or lead to serious morbidity.
Haas J, Larson E, Ross B, See B, Saiman L. Epidemiology and diagnosis of hospital-acquired conjunctivitis among neonatal intensive care unit patients. Pediatr Infect Dis J. 2005;24(7):586–589.
Epidemic keratoconjunctivitis (EKC) is a highly contagious conjunctivitis that tends to occur in epidemic outbreaks. This infection is an acute bilateral follicular conjunctivitis that is usually unilateral at onset and associated with preauricular lymphadenopathy. Initial symptoms are foreign-body sensation and periorbital pain. A diffuse superficial keratitis is followed by focal epithelial lesions that stain. After 11–15 days, subepithelial opacities begin to form beneath the focal epithelial infiltrates. The epithelial component fades by day 30, but the subepithelial opacities may remain for up to 2 years. In severe infections, particularly in infants, a conjunctival membrane forms and marked swelling of the eyelids occurs; these signs must be differentiated from those of orbital or preseptal cellulitis. In severe cases, complications include persistent subepithelial opacities and conjunctival scar formation.
Because EKC is easily transmitted, contact precautions must be maintained for up to 2 weeks. Isolation areas should be designated for examination of patients known or suspected to have adenoviral infections.
Diagnosis is usually based on clinical presentation but can be confirmed in the office by a rapid immunodetection assay. The organism can be recovered from the eyes and throat for 2 weeks after onset, demonstrating that patients are infectious during this period. Treatment is supportive in most cases. Artificial tears and cold compresses can provide symptomatic relief. Topical corticosteroids may be used judiciously to decrease symptoms in severe cases and in cases of decreased vision secondary to subepithelial opacities; such agents may prolong the time to full recovery. Corticosteroid use in adenoviral infection is seldom indicated in children.
Pharyngoconjunctival fever presents with conjunctival hyperemia, subconjunctival hemorrhage, conjunctival edema, epiphora, and eyelid swelling, accompanied by sore throat and fever. Within a few days, a follicular conjunctival reaction and preauricular lymphadenopathy develop. Symptoms may last for 2 weeks or more. Treatment is supportive because no topical or systemic treatment alters the course of the disease.
Varicella-zoster virus (VZV) is a herpesvirus that can cause varicella and herpes zoster.
Varicella (chickenpox) is a contagious viral exanthem of childhood caused by primary infection with VZV. Varicella vaccine is very effective in preventing severe disease, but immunized children exposed to VZV may have mild symptoms. Clinical manifestations of primary VZV infection include fever and characteristic vesicular lesions of the skin and mucous membranes. Except for eyelid vesicles and follicular conjunctivitis, ocular involvement is uncommon. Treatment of conjunctival disease is usually not necessary. Intravenous or oral acyclovir is recommended by the American Academy of Pediatrics in the treatment of immunocompromised children with varicella.
Figure 20-4 Herpes zoster.
Reactivation of latent VZV in dorsal root and cranial nerve ganglia results in herpes zoster. Vesicular lesions may erupt on the periorbital skin and are localized to a single dermatome, with subsequent ocular involvement (Fig 20-4). Keratitis and anterior uveitis are most likely to occur if the nasociliary branch of cranial nerve V is affected.
Oral acyclovir is indicated in healthy children to shorten the course of the illness and decrease the risk of bacterial superinfection. Intravenous antiviral agents (famciclovir, valacyclovir, acyclovir) are indicated in immunocompromised patients or individuals with severe disseminated disease. Antiviral medications should be started within 72 hours of onset of symptoms.
Epstein-Barr virus is a herpesvirus that can cause infectious mononucleosis, a benign and self-limited disease that occurs most commonly between ages 15 and 30 years. Findings include fever, widespread lymphadenopathy, pharyngitis, hepatic involvement, and the presence of atypical lymphocytes in the circulating blood. Conjunctivitis is the most common ocular finding. Nummular keratitis may also occur. The diagnosis is confirmed with detection of immunoglobulin M antibodies to viral capsid antigens or with a positive result on the heterophile antibody test. Ocular treatment is cool compresses to the eyes.
Molluscum contagiosum is caused by a DNA poxvirus and usually presents as numerous umbilicated skin lesions (Fig 20-5A). Lesions on or near the eyelid margin can release viral particles onto the conjunctival surface, resulting in a follicular conjunctivitis (Fig 20-5B). Most lesions do not require treatment because they tend to resolve spontaneously; however, resolution can take months or years. Lesions causing conjunctivitis can be treated by incising each lesion and debriding the central core; in young children, such treatment usually requires general anesthesia.
Figure 20-5 Molluscum contagiosum. A, Eyelid lesions. B, Secondary follicular conjunctivitis.
(Part A courtesy of Edward L. Raab, MD; part B courtesy of Gregg T. Lueder, MD.)
Excerpted from BCSC 2020-2021 series: Section 10 - Glaucoma. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.