A 42-year-old white female came in on Friday with a red left eye and swollen eyelid. I put her on an antibiotic. But by Monday, the injection and swelling had progressed significantly, so I added a topical steroid. When I saw her again on Tuesday, her eye was even worse; the cornea was uninvolved but the conjunctiva was ballooning out. She’s miserable, so I’m referring her to you. Can you help her?

I can diagnose her, but only time will help her.

When I saw this patient on Wednesday, she had a palpable preauricular node on the left side, which told me what I already suspected: epidemic keratoconjunctivitis (EKC).

Oddly enough, this patient presented just a few days before Bob Costas made national news with his debilitating case of “pink eye” during the Winter Olympics.

Two problematic cases of epidemic keratoconjunctivitis: One in our patient (above) and one in sportscaster Bob Costas.

And, in both cases, the diagnosis was confounded by conjunctival chemosis and swelling of the lids, which is not unusual with EKC. This eyelid involvement and chemosis might steer you toward a diagnosis of allergy or preseptal cellulitis.
Don’t be fooled. In preseptal cellulitis, the eye is white and quiet. With EKC, it’s red and angry.

So, too, is the patient! Having had it myself, I can attest that EKC makes you miserable and desperate. Bob Costas went off the air, in part, because his photophobia made sitting in front of bright studio lights intolerable. When you have EKC, you’d pay someone a lot of money for the magic bullet to just make it all go away.

No Miracle Pill
Unfortunately, time is the only guaranteed cure. Of course, a miserable EKC patient doesn’t want to hear that. They’ll go from one doctor to the next, hoping for a better answer.

So, if you have a desperate and disbelieving patient—despite your best efforts to explain otherwise—send him or her for a friendly second opinion. The patient will hopefully stop shopping and let you follow the condition through to resolution on its own. Having said that, a couple treatments might be worth a try, and palliative measures for comfort are definitely in order.

Some doctors advocate an off-label, one-time, in-office instillation of Betadine 5% Sterile Ophthalmic Prep Solution
(povidone-iodine, Alcon), which potentially “nukes” the entire microbial load. Anecdotally, I’ve found mixed results; sometimes it makes the eye better, sometimes worse.

Early reports have suggested that Zirgan (ganciclovir 0.15%, Bausch + Lomb), which we use for herpetic keratitis, can reduce the recovery time of adenoviral conjunctivitis if used in the first few days.1 Again, I’ve found it helped some patients but not others.

More research is needed for both these treatments. Until we have those—or until a drug is approved specifically for adenoviral conjunctivitis—we can offer comfort and reassurance.

To that end, recommend cold compresses and artificial tears. Remove pseudomembranes in office. Because the virus is so contagious and is transmitted by direct contact, educate the patient about strict hygiene measures to prevent infection in the fellow eye as well as in other family members. (This goes for you, too. If you even remotely suspect EKC, use gloves during examination, and try to sterilize everything after the patient leaves.)

When my EKC got to the point that it involved the cornea, I used a bandage contact lens; it helped enough to get me through the day. Also, cycloplegic drops administered two or three times a day might help to reduce the pain and photophobia.

1. Tabbara OF. Ganciclovir effects in adenoviral keratoconjunctivitis. Poster (B253) presented at Annual Association for Research in Vision and Ophthalmology (ARVO); April 29-May 4, 2001; Fort Lauderdale, Fla.