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Acute Hemorrhagic Conjunctivitis: Causes, Diagnosis, and Treatment

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Acute hemorrhagic conjunctivitis is a highly contagious infection and sudden inflammation of the conjunctiva caused by viruses. Read the article to know more.

Written by

Dr. Monisha. G

Medically reviewed by

Dr. Gopal R. Damani

Published At May 22, 2023
Reviewed AtDecember 22, 2023


Acute hemorrhagic conjunctivitis is an epidemic (sudden and rapid outbreak of a disease to a large population of a specific region) disease. It was first detected in Ghana, Africa. But now, it has been widely spread to other parts of the world. This is known as Apollo disease. It is commonly seen in developing countries and affects more than fifty percent of the local population.

What Is Acute Hemorrhagic Conjunctivitis?

Conjunctivitis is the inflammation of the conjunctival layer covering the inner surface of the upper eyelid and the outer surface of the eyeball. There are two types of conjunctiva, namely palpebral conjunctiva, which lines the inner surface of the upper eyelids, and bulbar conjunctiva, which covers the front part of the sclera. In acute hemorrhagic conjunctivitis, both types of conjunctiva are affected.

What Causes Acute Hemorrhagic Conjunctivitis?

The main etiological agents for hemorrhagic conjunctivitis are viruses. The group of viruses which are the main cause is picornaviruses. Enterovirus 70, coxsackievirus A24 variant, and adenoviruses. The spread of infection is through direct contact with eye tars or secretions of an infected person, using the objects and things that have been used or touched by them. The incubation period (the time interval from exposure to the virus to the appearance of the first symptoms) is around five to fourteen days.

Enterovirus 70:

  • It belongs to the family Picornaviridae.

  • The structure of this virus is not known. So, the altered particle (genetically modified virus) of the virus (EV70 virion) is observed under a cryo-electron microscopy technique.

  • The capsid (the space containing the virus's genetic material) has four subunits called VP1, VP2, VP3, and VP4.

Coxsackie Virus A24:

  • Coxsackie virus belong to the family Picornaviridae and are subclassified under enterovirus.

  • They contain a single-stranded RNA (ribonucleic acid) genetic material covered by an icosahedral capsid.

  • They are small, about 22-30 nanometers, and non-enveloped.

  • The capsid comprises proteins responsible for controlling cell entry and immune reactions.

  • The viral particle lacks an enzyme.


  • They are composed of an icosahedral capsid which is made up of 252 capsomeres.

  • The genetic material is a double-stranded linear DNA (deoxyribonucleic acid).

  • Two main proteins make up the core particle: polypeptide Ⅴ and polypeptide Ⅶ.

What Are the Signs and Symptoms of Acute Hemorrhagic Conjunctivitis?

The infection affects the conjunctival layer, a thin, delicate mucous membrane rich in small blood vessels, and helps lubricate eyes by producing mucus and tears and protects the eyes from injury and microbe entry. Acute conjunctivitis causes the blood vessels to dilate, and there is an increase in blood supply (hyperemia). Also, with hyperemia, the eyes get swollen (edema), and there are watery secretions from the eyes. The dilated blood vessels break and start bleeding into the conjunctiva. The risk of infection is estimated to range from ten to fifty percent. This pathophysiology of acute hemorrhagic conjunctivitis gives rise to the following signs and symptoms:

  • Pain in the affected eyes.

  • Red-colored eyes.

  • Discharge of secretions.

  • Swelling of the eyelids.

  • The feeling of some foreign particle in the eyes.

  • Eye irritation.

  • Sensitive to light (photophobia).

  • Paralysis of the body similar to polio.

  • Fever.

  • Blurred vision.

  • Lymphadenopathy.

How Is Acute Hemorrhagic Conjunctivitis Diagnosed?

  • Patient History and Clinical Examination: A brief history of the patient's symptoms can help suspect acute hemorrhagic conjunctivitis in addition to clinical evaluation by a clinician. The typical signs of red, watery eyes with pain and swelling will most likely comfort the diagnosis.

  • Viral Culture: It is a method of diagnosis that uses a small sample from the infected area or secretions from an infected person collected using a cotton swab. The collected sample is grown in different cell lines and a culture media that supports the viral growth. The culture is tested for viral infection after the growth p period. If there is a cytopathic (killing of cells) infection of other cells by the virus, the culture is positive, and if a viral infection is absent, the culture is negative.

  • Reverse-Transcription Polymerase Chain Reaction: It combines two techniques- a reverse transcription of RNA into DNA and polymerase chain recon, which is the production of million copies of a sample DNA material to enlarge its size and study in detail its structure and sequence.

How Is Acute Hemorrhagic Conjunctivitis Treated?

There is no specific treatment for hemorrhagic conjunctivitis. The infection is self-limiting and usually resolves in five to seven days without major treatment. So the primary concern is to prevent the spread of infection. The infection spreads very rapidly, so following a few preventions practices is essential, which include:

  1. To avoid contact with eyes.

  2. To avoid sharing objects that you touch, like towels, pens, and bottles.

  3. To wash hands often.

  4. To avoid shaking hands with each other.

  5. To disinfect things touched and used on patients with acute hemorrhagic conjunctivitis in hospitals.

  6. To stay in isolation till the symptoms resolve (usually for 10 to 15 days).

  7. Medical treatment is given to manage the symptoms and to relieve pain and irritation in the patient. It includes:

    • Cold compression can be given to the eyes, which will constrict the blood vessels and reduce the redness and swelling, giving symptomatic relief.

    • The use of artificial tears can manage dry and irritated eyes. However, tear production by conjunctiva is affected, so artificial lubrication is required to control the symptoms.

    • Antibiotics will not be useful for viral infections.

    • Use of steroids is not advised since it can cause a secondary infection of the cornea., which will then require antibiotics to treat it.


Acute hemorrhagic conjunctivitis does not have a definitive treatment since the disease is self-limiting. But awareness to stop the rapid spread of the infectious virus should be created among people, especially the school-going children population, since the chances of infection are very high among them. The primary preventive remedy is to stay in isolation and not to share personal belongings with anyone. The disease has no complications but may rarely have a sequel called radiculomyelitis, which is inflammation of the spinal cord and nerve roots. It causes weakness, sensory impairment, pain, and the inability of bowel and bladder control.

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Dr. Gopal R. Damani
Dr. Gopal R. Damani

Ophthalmology (Eye Care)


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