Viral conjunctivitis

DEFINITION/OVERVIEW

A common misperception of conjunctivitis is that it is routinely secondary to viral and not bacterial infection. Even the most current version of the AAP Red Book lists viral conjunctivitis as the most common form of the disease in children.8 However, the literature does not support this assertion. Nevertheless, viral conjunctivitis is common and practitioners should be particularly attuned to its signs and symptoms since it should not be treated with antibiotics.

ETIOLOGY

Children with viral conjunctivitis are contagious for at least 7 days from the first appearance of their symptoms. Although the spread of the disease is thought to be caused mainly by direct contact with the virus by contaminated fingers to the eye, the virus may also be spread by coughing and sneezing of airborne particles. For this reason, the most important strategy to halt the spread of the virus is good hygiene and washing hands. The child should be isolated to prevent spread of the contagion. Adenovirus is the most common etiology of viral conjunctivitis, and as discussed previously, is seen more commonly in the fall and winter months.

CLINICAL PRESENTATION

Table 8 presents the signs and symptoms of viral conjunctivitis. There is an acute onset of unilateral symptoms that can rapidly spread to being bilateral through cross contamination of the fellow eye. A watery or serous discharge is present, along with the conjunctival injection (75). A hemorrhagic component may be seen in some cases (76). The presence of acute preauricular and/or submandibular lymphadenopathy may help to confirm the diagnosis. The child may be febrile and may have a pharyngitis associated with the conjunctivitis. Follicles of the conjunctiva can be seen if the lower lid is pulled down slightly (77). Acute follicular conjunctivitis is usually associated with a viral etiology (epidemic keratoconjunctivitis, herpes zoster keratoconjunctivitis, infectious mononucleosis, Epstein–Barr virus infection) or chlamydial infections (inclusion conjunctivitis), while chronic follicular changes can be seen in chronic chlamydial infection (trachoma, lymphogranuloma venereum) or as a toxic or reactive inflammatory response to topical medications and molluscum contagiosum. The follicles appear as gray-white, round to oval elevations which measure 0.5–1.5 mm in diameter and can be seen in the inferior and superior tarsal conjunctivae, and less often, on bulbar or limbal conjunctiva.

MANAGEMENT/TREATMENT

Supportive care and isolation of the child to decrease the spread of the contagion is the only treatment indicated for routine viral conjunctivitis. Because the necessity of isolation requires children to miss school, afterschool, and daycare, parents often request a ‘drop’ to get their child back into their daily routine. Most schools or daycare will only allow a child back if they are ‘on a drop’, but this is not even standardized from community to community.25 Nevertheless, the use of an antibiotic drop is inappropriate when the etiology is presumed to be viral in nature.

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75 Viral conjunctivitis.(Courtesy of Robert D. Gross,MD,MPH.)

The use of an antibiotic has no effect on the infection, other than to eradicate the normal bacterial flora of the conjunctiva. Moreover, the child is no less contagious, and may actually spread the virus quicker because good hygiene and hand washing may be less rigorous if the caregiver thinks that the antibiotic is having an effect on the disease process.

Most cases of viral conjunctivitis are selflimiting and overtreatment should be avoided. Corneal subepithelial infiltrates may be seen in some cases of epidemic keratoconjunctivitis (78).

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76 Hemorrhagic conjunctivitis.(Courtesy of Casey Eye Institute,Oregon Health Sciences University.)

77 Conjunctival follicles.(Courtesy of Casey Eye Institute,Oregon Health Sciences University.)

78 Adenoviral conjunctivitis,corneal infiltrates. (Courtesy of Casey Eye Institute,Oregon Health Sciences University.)

Herpes conjunctivitis

Viral conjunctivitis caused by the herpes simplex (HSV) or herpes zoster (HZV) viruses can cause serious and permanent damage to the eye and vision. Herpes zoster infections are not as common as herpes simplex in the pediatric patient. These infections can show periocular as well as ocular involvement, and are most often unilateral in nature. Herpes simplex infections can also be recurrent, causing repeated bouts of conjunctivitis, keratitis, and periorbital disease.

ETIOLOGY

Most cases of secondary conjunctivitis are caused by HSV-1 and are associated with recurrent orolabial infection (cold sores). HSV-2 is associated with genital infection and is the more common cause of neonatal eye infections.

CLINICAL PRESENTATION

Patients can exhibit a serous discharge, bulbar and tarsal conjunctival injection, photophobia, epiphora, lid edema, and vesicular eruptions of the lids. There may also be dendritic ulcerations of the cornea which can leave permanent scarring and visual acuity damage. The dendrites will stain with fluorescein and be visible with a

Wood’s light or cobalt blue light (79). They will also stain with Rose Bengal, which stains devitalized cells of the cornea, giving the classic dendrite appearance. A Wood’s light is not necessary to observe the staining with Rose Bengal. If herpetic involvement is suspected in a child with conjunctivitis, a referral to an ophthalmologist is warranted.26 The use by a primary care provider of any ophthalmic drop containing a steroid is contraindicated and it should only be prescribed by an ophthalmologist because of the possibility of herpetic involvement. The use of a steroid in a child with herpes can cause permanent and possibly devastating complications, including acute corneal perforation.

MANAGEMENT/TREATMENT

Treatment of viral conjunctival disease may shorten its duration but does not seem to otherwise alter the course of disease. Treatment is indicated when the cornea is involved. Oral acyclovir (aciclovir) has been shown to be effective for treatment of herpetic epithelial keratitis and for reducing the rate of recurrence when used prophylactically. Topical antiviral medications carry a risk of corneal toxicity and their use should be reserved for patients under the care of an ophthalmologist.

Giant papillary conjunctivitis

ETIOLOGY

GPC is a noninfectious condition that occurs when there is a chronic foreign body irritation of the eye. In the past, it was most frequently seen in children and young adults with an ocular prosthesis and in patients with exposed sutures or scleral buckles after retinal detachment surgery. GPC is also associated with patients who have undergone glaucoma filtering procedures with the formation of a conjunctival bleb, or elevation of the conjunctiva near or at the limbus, to allow the aqueous humor to escape the anterior chamber, therefore maintaining a controlled intraocular pressure.39 However, as the use of cosmetic contact lenses finds its way into younger and younger children, GPC is now commonly being seen with the use, and misuse, of contact lenses in both children and adults. Rigid, gas-permeable lenses as well as soft contact lenses have both been associated with GPC, although the incidence of GPC with the use of rigid gas-permeable lenses is less than with soft contact lens use.

The symptoms of GPC are low grade as the condition starts to evolve. There may be a mild amount of itching, or mild contact lens discomfort. However, since many of the patients are extremely motivated to continue their contact lens wear, the symptoms will worsen with increasing itching, blurring of vision, mucoid production, and then finally contact lens intolerance. Involvement of the cornea is rare, but with continued use of soft contact lenses, even in the presence of increasing conjunctival irritation, pannus formation can occur.

CLINICAL PRESENTATION

The symptoms of GPC can begin months or even years after the patient starts to wear his or her contact lenses. There is no sex or racial predilection, but the symptoms of GPC seem to be more aggressive in children who wear contact lenses. Papillae are seen on the superior tarsal conjunctiva and can measure up to 1 mm in diameter (80). The same type of papillae are seen in VKC, but the giant papillae in VKC are usually larger than in GPC, and the permanent ocular changes seen in VKC are not seen in GPC. However, pannus formation can be seen in

children from chronic misuse of their contact lenses. Itching on initial insertion of the contact lenses is an early symptom of GPC. If not treated properly, progression to complete contact lens intolerance may occur.

MANAGEMENT/TREATMENT

The only definitive treatment for patients who are experiencing signs and symptoms of GPC is removal of the foreign material from contact with the eye. This means removing exposed scleral buckles, altering an ocular prosthesis to create less conjunctival irritation, or discontinuation of the use of contact lenses until the symptoms resolve. Since, as previously mentioned, the motivation of these patients to continue their cosmetic contact lens wear is usually high, complete discontinuation may be very difficult to accomplish. In these cases, improving the patient’s compliance with hygiene in handling their lenses, decreasing the time that the contact lenses are inserted, the use of disposable lenses, or a different lens material should be employed. Since the primary care provider does not have expertise in this area, the importance of compliance should be stressed, and the patient should be referred back to the eye care professional providing the contact lenses.

PROGNOSIS

The symptoms of most patients can be controlled with topical medications. In those cases that cannot, removal of the offending agent is generally curative.

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80 Giant papillary conjunctivitis.(Courtesy of Casey Eye Institute,Oregon Health Sciences University.)