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Adenoviral Infection (EKC)

Subjective
A 32-year-old white female with acute onset of left red eye beginning three days prior thinks her right eye is also becoming involved (Fig. 1). Her roommate had red eyes two weeks prior. She complains of a watery discharge and her left eye hurts.

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Fig. 1 Note that the left eye has a subconjunctival hemorrhage overlying generalized conjunctival injection. This hemorrhage results from inflammation caused by the primary infectious process.

Objective

  • Visual acuity (VA): OD 6/6 (20/20); OS 6/7.5 (20/25)
  • Corneas: clear and do not stain with fluorescein
  • OD: 1+ conjunctival injection; clear lacrimal lake
  • OS: 3+ conjunctival injection; multiple petechial hemorrhages are seen within the injected conjunctiva
  • Palpation of the left preauricular area is positive for lymphadenopathy

Assessment

  • Classic adenoviral conjunctivitis (epidemic keratoconjunctivitis), left eye much more involved than the right

Plan

  • The nature of her condition and its contagious nature are discussed at length with the patient
  • Furthermore, she was shown pre-highlighted pages from a textbook supporting what was shared with her verbally

Specific Tx

  • Her left eye was treated in the office with several drops of 5% Betadine ophthalmic prep solution following proparacaine topical anesthesia. After one minute of Betadine exposure, both eyes were thoroughly lavaged with a sterile saline rinse. Click here for more specific details of "off-label" use of povidone iodine.
  • Cold compresses p.r.n.
  • Loteprednol etabonate 0.5% ophthalmic suspension q.i.d. OS
    • GenTeal artificial tears q.2h. OU
    • Keep hands away from face/eyes
    • Wash hands regularly throughout the day
    • Instructed in proper household hygiene
    • Re-evaluate in 3 to 5 days

Comments: If the patient is a contact lens wearer, wait two or three more days beyond clinical renormalization before resuming wear. The presence of subepithelial infiltrates does not influence the precorneal tear film or contact lens wear. However, if the infiltrates are limiting visual performance to the point steroid therapy is indicated, it is strongly recommended that contact lens wear be delayed until the cessation of medical therapy.

General Observations Regarding Epidemic Keratoconjunctivitis (EKC)

  • Common cause of acute follicular (often hemorrhagic) conjunctivitis in children and adults
  • Can be bilateral or unilateral: if unilateral, the fellow eye is generally involved in a few days and is usually less affected
  • Usually seen in adults with isolated conjunctivitis (often hemorrhagic)
  • Can be so severe as to cause pseudomembrane formation (Fig. 2). Removal of these pseudomembranes decrease the extent of ocular surface irritation (Fig. 3)

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    Fig. 2 An advanced tarsal conjunctival membrane in EKC. Since these are pathologic and uncomfortable for patients, they should be removed with jeweler's forceps or a cotton swab after a drop of proparacaine 0.5%.
    Fig. 3 Removing tarsal conjunctival membranes often causes minor bleeding, which stops rapidly following repositioning of the eyelidto its normal anatomic position against the globe.

  • Highly contagious by direct contact for as long as the eye is red and the watery discharge persists:
    • use gloves to evert lid(s), or be sure to wash hands thoroughly
    • use Q-tips to manipulate lid(s)
    • disinfect any instrument touching patient
    • do not let dropper tip touch tissues
  • Most patients present with a watery, serous discharge and often have foreign body sensation and/or photophobia
  • Palpable preauricular lymphadenopathy is almost invariably present and is an extremely helpful diagnostic sign (Fig. 4)

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    Fig. 4 Palpation of the preauricular lymph nodes, especially on the side of the first affected eye, is of paramount importance in the diagnostic workup of adenoviral patients.

  • Secondary bacterial infection is rare
  • Adenoviral infections generally run a two-to three week self-limiting course
  • Because of the infectious/contagious nature of adenoviral disease, the history often reveals recent exposure to other persons having "red eyes"
  • Two major types: pharyngoconjunctival fever (PCF) and epidemic keratoconjunctivitis (EKC)
  • Superficial keratitis is commonly seen during the first 10 to 14 days and tends to resolve as the primary infection resolves. By the second or third week, subepithelial infiltrates may begin to form
  • Subepithelial infiltrates:
    • considered pathognomonic of prior adenovirus infection
    • occur in 50% to 75% of all cases
    • occur around the third week of infection, once the active disease process has abated and can be few or many, central or peripheral, rarefied or dense (Fig. 5)

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      Fig.5 These classic subepithelial corneal infiltrates always ultimately resolve. Most clear in several weeks to few months. However, the immune complexes can linger for a few years.

    • can cause variable decrease in vision from mild to severe; usually persist for weeks to months, but can do so for two to three years and are steroid-responsive; however, the need for mild steroid therapy must be evaluated on a case-by case basis. If indicated, chronic, low-dose administration may need to be tapered over weeks to months
  • If the acute phase (first week or two) is severe and causing significant patient discomfort and/or decreased vision, corticosteroid therapy can be quite helpful and is indicated. However, because of the self-limited nature of adenovirus infections, in mild to moderate cases it is preferable to use mild vasoconstrictors, cold compresses, and/or artificial tears as supportive therapy. When indicated, proper treatment with an effective topical ophthalmic corticosteroid is sound and compassionate therapy

  • As discussed in the above link, in-office treatment with 5% Betadine Ophthalmic Prep Solution is rational therapy, and has become our approach when treating moderate to severe cases. We still use Lotemax or other effective steroid qid for a few days to address any residual inflammation.

  • Recent studies reflect our experience that topical nonsteroidal anti-inflammatories are no more effective than artificial tears in relieving patient symptoms in adenoviral conjunctivitis

 
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