found in sexually active teenagers in association with chlamydial urethritis or cervicitis. Patients present with follicular conjunctivitis, scant mucopurulent discharge, and preauricular adenopathy. There is no membrane formation. This condition can be diagnosed by culture of conjunctival scrapings, polymerase chain reaction, direct fluorescent antibody tests, and enzyme immunoassays. If untreated, inclusion conjunctivitis resolves spontaneously in 6–18 months. The recommended treatment is oral tetracycline, doxycycline, or azithromycin. The clinician should consider whether the patient has been sexually abused, especially if adult inclusion conjunctivitis is found in a young child.
Viral Conjunctivitis
Adenovirus
Viral conjunctivitis is most often caused by adenovirus, a DNA virus that can cause a range of human diseases, including upper respiratory tract infection and gastroenteritis. The following adenovirus diseases are listed with their associated serotypes: epidemic keratoconjunctivitis (serotypes 8, 19, and 37), 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).
Epidemic keratoconjunctivitis 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 adenopathy. 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 under 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, medical personnel who become infected should be excluded from patient contact for up to 2 weeks, and 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 steroids may be used judiciously to decrease symptoms in severe cases and in cases of decreased vision secondary to subepithelial opacities; however, such agents may prolong the time to full recovery. Steroid use in adenovirus infection is seldom indicated in children.
Pharyngoconjunctival fever 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 adenopathy develop. Symptoms may last for 2 weeks or more. Treatment is supportive because no topical or systemic treatment alters the course of the disease.
Herpes simplex virus
Conjunctivitis caused by HSV type 1 is covered in BCSC Section 8, External Disease and Cornea. Neonatal HSV infection is discussed in Chapter 28.
Varicella-zoster virus
Varicella-zoster virus (VZV) is a herpesvirus that can cause varicella and herpes zoster.
Varicella Varicella (chickenpox) is a contagious viral exanthem of childhood caused by primary infection with VZV. It presents with fever and vesicular eruptions of the skin and mucous membranes. Varicella vaccine is very effective in preventing severe disease, but immunized children exposed to VZV may develop mild symptoms. Clinical manifestations of primary VZV infection include fever and characteristic skin lesions. Except for eyelid vesicles and follicular conjunctivitis, ocular involvement is uncommon. Treatment of conjunctival disease is usually not necessary. Intravenous or oral acyclovir may be considered in the treatment of immunocompromised children with varicella.
Herpes zoster Reactivation of latent VZV from dorsal root and cranial nerve ganglia results in herpes zoster. Vesicular lesions may erupt on the periorbital skin in a dermatome configuration, with subsequent ocular involvement (Fig 21-3). Keratitis and anterior uveitis are most likely 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 patients with severe disseminated disease. Antiviral medications should be started within 72 hours of onset of symptoms.
Figure 21-3 Herpes zoster.
Epstein-Barr virus
Epstein-Barr virus is a herpesvirus that can cause infectious mononucleosis. This disease usually occurs between ages 15 and 30 years and is benign and self-limited. Findings include fever, widespread adenopathy, pharyngitis, hepatic involvement, and the presence of atypical lymphocytes in the circulating blood. Conjunctivitis is the most common ocular finding. Nummular keratitis may also be seen. Diagnosis is confirmed with detection of immunoglobulin M (IgM) antibodies to viral capsid antigens or with a positive heterophile antibody test. Ocular treatment is cool compresses to the eyes.
Molluscum contagiosum
Molluscum contagiosum is caused by a DNA poxvirus and usually presents as numerous umbilicated skin lesions (Fig 21-4A). Lesions on or near the eyelid margin can release viral particles onto the conjunctival surface, resulting in a follicular conjunctivitis (Fig 21-4B). Most lesions do not require