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Dr M.Abdullah Younas
PGR Ophthalmology
DHQ Teaching Hospital
Gujranwala,Pakistan

Sources of study:-
 Kanski(90%)
 Oxford handbook of ophthalmology(4%)
 Wills eye manual(4%)
 Harpers(2%)

Introduction:-
 Common External Ocular infection.
 In 90% cases,Adenovirus is the causative agent.
 May be Sporadic,or occur in epidemics.

Causative Agents:-
 Adenovirus conjunctivitis(>90% cases).
 Herpes simplex keratoconjunctivitis.
 Herpes zoster conjunctivitis.
 Picorna viruses(Enterovirus and coxsackie virus).
 Poxvirus conjunctivitis.
 Myxovirus conjunctivitis.
 Parammyxovirus conjunctivitis.
 ARBOR virus conjunctivitis.

Symptoms:-
 Watering
 Redness
 Irritation(Radak).
 Itching.
 Photophobia(When Cornea is involved).

Signs(Anterior to posterior):-
 Eyelids :
edema,Ranging from mild to Severe.
 Lymphadenopathy:
Common.Tender Pre-auricular nodes.
 Conjunctiva:
Hyperemia,Follicles.May be Papillae(Particularly
superior tarsal conjunctiva).
 Severe Inflammation:
may be associated with conj.Hamorrhages, chemosis,
membranes(Rare) and pseudomembranes.Sometimes conj
Scarring.

Signs(Cont’d):-
 Keratitis(Adenoviral):
Epithelial microcysts in the early stage.
punctate epithelial keratitis:Usually occur in 7-10
days of onset of symptoms.Resolving in 2 weeks.
Anterior Stromal infiltrates/SEI:may persist for
months or years.
Anterior uveitis:
Usually mild.

Algorithm for Follicles:-
Follicles
Preauricular lymph nodes
Look for herpetic signs(e.g. dendrites,skin lesion)
Yes No
Source:Wills Eye Manual.
Yes No
HSV Adenovirus
Chlamydia
Toxic Conj.
Molluscum
Pediculosis

Adenoviral Conjunctivitis
 Non-enveloped, double stranded DNA viruses,
which replicate within the nucleus of host cells.
General reservoir is only human.

Type of adenoviral conjunctivitis:-
 Epidemic keratoconjunctivitis (EKC)
 Nonspecific acute follicular conjunctivitis
 Pharyngoconjunctival fever (PCF)
 Chronic /relapsing adenoviral conjunctivitis

Spread of infection:-
 Facilitated by
i)virus can survive on dry surfaces for weeks.
ii)Viral shedding may occur for many days before
clinical features are apparent.
 Transmission by
i)Contact with Respiratory or ocular secretions.
ii)Via Contaminated Fomites such as Towels.
iii)Route of transmission is usually Eye-Hands-Eyes.
In Clinical setting,Eye-Instruments-Eye.

I)Epidemic Keratoconjunctivitis:-
 Most severe presentation.
 Caused by adenoviruses type 8,19 and 37.It is
markedly contagious.
 incubation period after infection (8 days) & virus shed
from the inflamed eye for 2-3 weeks.
 Keratitis occurs in 80% cases.

II)Non-specific acute follicular Conj.
 Most common form of acute follicular conjunctivitis
 Caused by adenovirus serotypes 1 to 11 & 19
 Milder form of acute follicular conjunctivitis.
 Unilateral symptoms, Other eye involved 1-2 days later,
but less severely.
 Patient may have systemic symptoms such as sore
throat or common cold.

III)Pharyngoconjunctival fever:-
 adenoviral infection commonly associated with
subtypes3,4 & 7.
 Acute follicular conjunctivitis, associated with
pharyngitis.
 Fever & pre-auricular lymphadenopathy.
 Cornea : superficial punctate keratitis. (30%)

IV)Chronic/relapsing adenoviral
conj.
 Rare
 Gives a clinical picture of chronic non-specific
follicles/papillas.
 Can persist over years, but eventually self limiting.

Herpes simplex Virus:-
 Causes Follicular conjunctivitis particularly in
primary disease.
 Usually unilateral.
 Often Associated skin lesions.
 Minute,Micro dendrites may be mistaken for punctate
epithelial keratitis,But Corneal sensation is reduced
in HSV (Source:Harper).

Acute hemorrhagic conjunctivitis:-
 Usually occurs in tropical areas.
 Caused by Enterovirus and coxsackie virus(Picorna
virus family).
 Rapid onset,resolves within 1-2 weeks.

Molluscum Contagiosum:-
 Caused by dsDNA pox virus.
 Peak incidence of getting the virus is 2-4years.
 Typically,Virus causes a skin lesion.
 When skin lesion is on the lash line area of eyelid,it
causes viral shedding and follicular conjunctivitis.
 Examine eyelash line carefully when
Chronic,unilateral eye irritation and mild discharge is
present.

Systemic viral infections Causing
Conjunctivitis:-
 Measles , mumps , Varicella ,HIV etc.

Investigations:-
 Giemsa stain.
 PCR
 Viral culture.
 Immunochromatography.
 Serology.
 For other causes in non-resolving cases.

TREATMENT
Adenoviral conjunctivitis:-
 Supportive treatment for amelioration of symptoms is
the only treatment required and includes:
I)Artificial tears 4x/d.Preferably preservative free.
II)Topical Anti Histamines and vasoconstrictors.
III)Cold Compresses
IV)Discontinuation of contact lens wear.

(Cont’d)
V)Removal of membranes/pseudomembranes.
VI)Topical antibiotics.
VII)Povidone-Iodine:kills free adenoviruses.
VIII)Topical Steroids:For severe Membranous or
Pseudo-membranous conjunctivitis and SEIs.

Reduction of Transmission Risk:-
 Meticulous hand hygiene.
 Avoiding eye rubbing and towel sharing.
 Disinfection of instruments and clinical surfaces after
examining an infected person.

Acute Haemorrhagic Conjunctivitis
Treatment:-
 Prophylactic measures similar to EKC.
 Supportive measures same as Adenoviral.
 Usually the disease has a self-limiting course of 7 days.

Molluscum treatment:-
 Usually the lesion is self-limiting in
immunocompetent patient.
 Removal is needed to address secondary Conjunctivitis
or for Cosmetic reasons.
 Expression by making a nick in the skin by a needle is
usually effective.

Herpes Simplex Treatment:-
 Usually self limiting.
 Topical antiviral drugs control the infection effectively
and prevent recurrences.
 Supportive measures are similar with Adenoviral.

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Viral conjunctivitis

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