Corneal infiltrates seen in adenoviral keratoconjunctivitis

ICD-10 Diagnosis Code:

B30.0 — Keratoconjunctivitis due to adenovirus


Adenoviral Keratoconjunctivitis


Other Diseases Of The Conjunctiva Due To Viruses And Chlamydiae


Adenoviral keratoconjunctivitis is a type of adenoviral eye infection

Adenoviruses are unenveloped viruses with a linear, double stranded DNA genome.  Adenoviral keratoconjunctivitis is a clinical manifestation of adenovirus infection and is often accompanied by a variety of upper respiratory infections.  Although there are over 50 adenoviral serotypes that affect humans, adenoviral keratoconjunctivitis is usually caused by serotypes 3, 7, 8, 11, 19 or 37.

Adenoviral keratoconjunctivitis is a highly contagious ocular infection.  Transmission of the virus occurs because it is found in respiratory or ocular secretions, contaminated eye drop bottles, and make-up containers.  The infection usually starts in one eye and progresses to the other several days later. 

The incubation period for adenoviral keratoconjunctivitis is 2-14 days.  In addition, the patient may remain infectious for 10-14 days after symptoms develop.  Adenoviral infections may be preceded by any of the following symptoms:

  • Flu-like symptoms 
  • Fever
  • Malaise
  • Respiratory distress
  • Vomiting
  • Diarrhea
1a Adenoviral Keratoconjunctivitis

  • Dendritic ulcer is characterized by an epithelial defect that stains with fluorescein
  • Ulcers stain better with fluorescein
  • Terminal end bulbs of the dendrites stain better with lissamine green


Structural Damage to the Eye

  • Eyelid edema
  • Inferior conjunctival palpebral follicles
  • Conjunctival hyperemia
  • Conjunctival chemosis
  • Conjunctival hemorrhage
  • Conjunctival pseudomembrane
  • Punctate corneal epitheliopathy
  • Corneal infiltrates in the anterior to mid-stroma
  • Negative corneal staining associated with elevated corneal infiltrates

Functional Damage to the Eye

  • Decreased visual acuity can occur as a result of the compromised corneal epithelium
  • Decreased visual acuity can occur as a result of opaque corneal infiltrates in the visual axis

The main goal of the diagnostic evaluation in a patient with adenoviral keratoconjunctivitis is to accomplish the following:

  • To establish the diagnosis of adenoviral keratoconjunctivitis before the patient leaves your office
  • To educate the patient so that he/she avoids contaminating others
  • To prescribe appropriate therapy
  • Reduce unnecessary antibiotic prescriptions 
  • Help prevent antibiotic resistance

To obtain the information required to determine a clinical diagnosis of adenoviral keratoconjunctivitis and prescribe a treatment program, the following service components of a medical eye examination should be performed: 

  • Patient history
  • General medical observation
  • Adnexal examination
  • External ocular examination with biomicroscopy

Patient History

Patients with adenoviral keratoconjunctivitis may present with any of the following abnormal signs or symptoms:

  • Red eyes
  • Ocular itching
  • Ocular discomfort
  • Foreign body sensation
  • Watery eyes
  • Photophobia
  • Eyelid edema
  • Preauricular lymphadenopathy

External Ocular Examination with Biomicroscopy

Evaluate the eyelids, conjunctiva, and cornea.

Adenovirus (1) Clinical Appearance of the Cornea

  • Subepithelial infiltrates seen in adenoviral keratitis
  • Epithelial infiltrates progress through several stages as the infection continues
  • Subepithelial infiltrates develop in 30-80%of all adenoviral eye infections
  • The infiltrates are thought to represent a delayed hypersensitivity immune response to viral antigens in the corneal stroma
  • Lesions respond well to topical steroids, although the treatment does not shorten the natural course of the disease
Adenovirus (2) Clinical Appearance of the Cornea

  • Stage 1 occurs within 7-10 days of the onset of symptoms and is characterized by punctate epitheliopathy
  • Stage 2 is characterized by focal, white subepithelial infiltrates that are thought to represent an immune response to the virus
  • Stage 3 is characterized by subepithelial infiltrates that gradually fade over months to years
Adenovirus (3) Clinical Appearance of the Cornea

  • Subepithelial infiltrates may produce focal areas of elevation on the corneal surface that are revealed with negative fluorescein staining
  • When negative fluorescein staining is present, patients report an increase in abnormal symptoms such as photophobia, epiphora, and ocular discomfort

Adenoviral Conjunctivitis

The milder form of the disease usually presents with unilateral redness, epiphora, photophobia, and ocular discomfort.  The fellow eye is usually affected one to two days later with a milder presentation. 

  • Eyelid edema
  • Tender preauricular lymph node
  • Follicular conjunctivitis
  • Pseudomembranous conjunctivitis

Adenoviral Keratitis

The more severe form of the disease involves the cornea and can result in permanent visual impairment. 

  • Punctate epithelial keratitis
  • Subepithelial infiltrates
  • Permanent corneal opacities

Because the spectrum of adenoviral eye infection varies from sub-clinical disease to serious infection, a rapid screening procedure is a cost-effective way to exclude differential diagnoses and avoid unnecessary treatment with topical antibiotics.  In-office screening can be done with the Rapid Pathogen Screening (RPS) AdenoPlus Detector, a lateral flow immunoassay testing device that takes about ten minutes to perform.

Contact Lens Wear

Infiltrates and ocular redness associated with contact lens wear should be differentiated from those caused by adenoviruses.  For example, contact lens-related infiltrates are generally less severe and resolve faster.  Corneal infiltrates produced by adenoviral infection generally appear one to two weeks after the onset of symptoms.

Chlamydial Infections / Bacterial Infections

These conditions can present with corneal infiltrates similar to those found in adenoviral disease. 


Corneal disease secondary to ocular rosacea may produce punctate epithelial erosions that are similar in appearance to corneal infiltrates.

The key to treating adenoviral keratoconjunctivitis is making the correct diagnosis.  Treatment options vary depending upon the severity of the disease. 

Palliative Treatment

  • Artificial tears and cold compresses until spontaneous resolution occurs (e.g., up to 3 weeks)

Pharmacologic Treatment

  • Topical decongestant/anti-histamine for severe itching
  • Topical steroids for severe membraneous conjunctivitis
  • Topical steroids for subepithelial infiltrates
  • Topical antiviral agents (i.e., off-label use of Zirgan ophtahlmic gel)

Because steroids only suppress the corneal inflammation as long as they are used, a prolonged taper is recommended to prevent recurrence of the infiltrates.

Mechanical Treatment

  • Patients wearing contact lenses should discontinue contact lens wear until the condition resolves

Preventative Treatment

  • Frequent hand washing while the disease is active
  • Avoid contact with infected individuals
  • Restrict access to work and school during the first 10-12 days of the infection
  • Avoid sharing bedding, towels, make-up, or any objects that may come in contact with the eye

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2. Bawazeer A. Epidemic Keratoconjunctivitis Treatment and Management.  Available at http://emedicine.medscape.com/article/1192751-overview.  Last accessed February 20, 2014.
3.  Bowling E.  Russell GE.  Shovlin JP.  Sindt CW.  Adenoviral conjunctivitis.  RevOptom: The Corneal Atlas.  2009 Jan: 5.
4.  Dunbar MT.  Infectious ulcer or sterile infiltrate?  Rev of Cornea & Contact Lenses.  2007 Oct:  16-20.
5.  Shovlin JP.  Corneal infiltrates.  Rev of Cornea & Contact Lenses.  2007 Oct:  6.