Viral conjunctivitis

Last updated: January 3, 2023

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Viral conjunctivitis is the most common form of infectious conjunctivitis and is usually caused by adenoviruses. Patients present with clinical features of conjunctivitis, including conjunctival injection, watery discharge, and preauricular lymphadenopathy. Associated clinical features (e.g., vesicular rash, history of upper respiratory tract infection) may help determine the etiology. Diagnostic studies are typically not needed to start management. Treatment is usually supportive, but patients with varicella-zoster conjunctivitis or herpes simplex conjunctivitis (HSV conjunctivitis) are at increased risk of keratitis and should be referred to ophthalmology for management, including antivirals. Prevention measures are advised to limit the spread of infection.

Epidemiological data refers to the US, unless otherwise specified.

Viral conjunctivitis is usually self-limited and only requires supportive therapy. [7]

The most common cause of viral conjunctivitis; clinical presentations vary depending on the subtype. Management for all presentations is supportive.


  • Caused by Adenoviridae spp.
  • Multiple subtypes affect humans and can cause different clinical presentations. [2][8]

Transmission [2][8]

Clinical features [5]

There are four presentations of adenovirus conjunctivitis. In addition to conjunctivitis symptoms, patients may have had a preceding URTI.

Epidemic keratoconjunctivitis [1][3][5]

Pharyngoconjunctivitis [1][3]

Acute nonspecific follicular conjunctivitis [5]

Chronic adenovirus conjunctivitis [5]


Treatment [1][3][6]

Adenovirus conjunctivitis and HSV conjunctivitis can manifest very similarly; use topical steroids with extreme caution as steroids worsen HSV disease. [9]

HSV conjunctivitis is usually caused by subtype HSV-1; it is transmitted through close contact and inoculates the conjunctiva. In neonates, HSV can cause severe symptoms; for diagnosis and management see “Neonatal HSV conjunctivitis.” [10]

Clinical features [3]

HSV conjunctivitis may manifest without a periocular rash; in these cases, it may be hard to distinguish from other forms of viral conjunctivitis, e.g., adenovirus conjunctivitis. [9]


Treatment [3]

Topical steroids can worsen HSV infection and should be avoided. [3]

Long-term suppressive antiviral therapy may decrease the risk of recurrent HSV keratitis. [3]

Conjunctivitis is one of the ocular manifestations of varicella-zoster infection; other manifestations include keratitis and retinitis.

Etiology [3]

Clinical features [3]

A delay in treatment may lead to vision loss in patients with concomitant herpes zoster keratitis. [11]

Diagnostics [12]

  • Typically a clinical diagnosis
  • Confirmatory diagnostic tests (e.g., PCR, culture) are usually not required.
  • For further information, see “Diagnostics” in “Chickenpox” and “Shingles.”

Treatment [3]

Isolated varicella-zoster conjunctivitis is usually self-limited. [3]

Prevention [3]

Molluscum contagiosum conjunctivitis can occur when lesions on the eyelid shed virus onto the conjunctiva.

Etiology [3]

Clinical features [3]

Multiple lesions or large lesions suggest underlying immunodeficiency. [3]


Treatment [3]

Epidemiology [14]

  • Affects both adults and children [15]
  • Prevalence rates are unclear but vary between 1% and 32% in studies. [14]

Clinical features [14]

Diagnosis [14]

Treatment [17]

Prevention [18]

  1. Varu DM, Rhee MK, Akpek EK, et al. Conjunctivitis Preferred Practice Pattern®. Ophthalmology. 2019; 126 (1): p.P94-P169. doi: 10.1016/j.ophtha.2018.10.020 . | Open in Read by QxMD
  2. Hoffman J. Adenovirus: ocular manifestations. Community eye health. 2020; 33 (108): p.73-75.
  3. Li JY. Herpes zoster ophthalmicus. Curr Opin Ophthalmol. 2018; 29 (4): p.328-333. doi: 10.1097/icu.0000000000000491 . | Open in Read by QxMD
  4. Yeu E, Hauswirth S. A Review of the Differential Diagnosis of Acute Infectious Conjunctivitis: Implications for Treatment and Management. Clin Ophthalmol. 2020; Volume 14 : p.805-813. doi: 10.2147/opth.s236571 . | Open in Read by QxMD
  5. Yi JS, Satterfield KR, Choi CS, Boos MD, Cabrera MT. Topical adapalene for the treatment of follicular conjunctivitis due to periocular molluscum contagiosum in children. Am J Ophthalmol Case Rep. 2022; 25 : p.101335. doi: 10.1016/j.ajoc.2022.101335 . | Open in Read by QxMD
  6. Al-Namaeh M. COVID-19 and conjunctivitis: a meta-analysis. Ther Adv Ophthalmol. 2021; 13 : p.251584142110033. doi: 10.1177/25158414211003368 . | Open in Read by QxMD
  7. Alnahdi MA, Alkharashi M. Ocular manifestations of COVID-19 in the pediatric age group. Eur J Ophthalmol. 2022 : p.112067212211162. doi: 10.1177/11206721221116210 . | Open in Read by QxMD
  8. Matic KM. SARS-CoV-2 and Multisystem Inflammatory Syndrome In Children (MIS-C). Curr Probl Pediatr Adolesc Health Care. 2021 : p.101000. doi: 10.1016/j.cppeds.2021.101000 . | Open in Read by QxMD
  9. Binotti W, Hamrah P. COVID-19-related Conjunctivitis Review: Clinical Features and Management. Ocul Immunol Inflamm. 2022 : p.1-7. doi: 10.1080/09273948.2022.2054432 . | Open in Read by QxMD
  10. Dockery DM, Rowe SG, Murphy MA, Krzystolik MG. The Ocular Manifestations and Transmission of COVID-19: Recommendations for Prevention. J Emerg Med. 2020; 59 (1): p.137-140. doi: 10.1016/j.jemermed.2020.04.060 . | Open in Read by QxMD
  11. Azari AA, Barney NP. Conjunctivitis. JAMA. 2013; 310 (16): p.1721. doi: 10.1001/jama.2013.280318 . | Open in Read by QxMD
  12. Burrell CJ, Howard CR, Murphy FA. Adenoviruses. Elsevier ; 2017 : p. 263-271
  13. Langford M, Anders E, Burch M. Acute hemorrhagic conjunctivitis: anti-coxsackievirus A24 variant secretory immunoglobulin A in acute and convalescent tear. Clin Ophthalmol. 2015 : p.1665. doi: 10.2147/opth.s85358 . | Open in Read by QxMD
  14. Cronau H, Kankanala RR, Mauger T. Diagnosis and management of red eye in primary care. Am Fam Physician. 2010; 81 (2): p.137-44.
  15. Lew DP, Waldvogel FA. Osteomyelitis. The Lancet. 2004; 364 (9431): p.369-379. doi: 10.1016/s0140-6736(04)16727-5 . | Open in Read by QxMD
  16. AAP Committee on Infectious Diseases. Red Book: 2021–2024 Report of the Committee on Infectious Diseases. American Academy of Pediatrics ; 2021 : p. 407-417
  17. Sundmacher, R. Color Atlas of Herpetic Eye Disease. Springer ; 2008
  18. Pihos AM. Epidemic keratoconjunctivitis: A review of current concepts in management. J Optom. 2013; 6 (2): p.69-74. doi: 10.1016/j.optom.2012.08.003 . | Open in Read by QxMD

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