Adenoviral Keratoconjunctivitis Leads to Persistent Ocular Surface Damage

New data suggests patients with past AKC—even when the acute infection has clinically resolved—are at high risk for chronic mucin‑deficient dry eye. Researchers encourage clinicians to proactively assess tear film and ocular surface in patients with prior AKC, monitor and treat even asymptomatic patients (since reduced corneal sensitivity after AKC can blunt symptoms) and initiate early anti‑inflammatory management during acute infection and long‑term strategies (preservative‑free lubricants, anti‑inflammatory therapy or mucin‑targeted approaches) to reduce the burden of chronic ocular surface disease, though interventional trials are needed. Photo: Christine Sindt, OD. Click image to enlarge. Adenoviruses are the leading cause of viral conjunctivitis globally, responsible for roughly 65% to 90% of viral ocular infections. It’s known that ocular surface damage may persist after the acute infection is resolved, but the long-term effects of adenoviral keratoconjunctivitis (AKC) on conjunctival goblet cells and tear film stability are not as well understood. To investigate, researchers performed a prospective case-control study, in which patients with AKC demonstrated a 75% reduction in goblet cell density, more advanced squamous metaplasia and greater tear film instability than controls over an average 18-month follow-up.  Investigators enrolled 64 patients (95 eyes) with a documented history of AKC during institutional outbreaks in 2016 to 2017 and compared them with 55 healthy controls (92 eyes). Mean follow‑up after the acute episode was 18.3 months. Predefined clinical criteria for diagnosis required at least three of the following: follicular conjunctivitis, conjunctival hyperemia with watery discharge, ipsilateral preauricular lymphadenopathy, lid edema/chemosis or subepithelial corneal infiltrates. A virological subset (six patients sampled) yielded adenoviral DNA in five of the six samples, four of which were serotype 8. Regular use of preservative‑free artificial tears was reported by 65.6% of AKC patients at the time of assessment, while no control subjects reported such use.The data showed that patients with AKC had a conjunctival goblet cell density roughly 75% lower than that of controls (116 vs. 463 cells/mm2). AKC patients also showed clinically meaningful decreases in Schirmer test values (10.0mm vs. 14.0mm) and tear breakup time (8.16 seconds vs. 11.1 seconds) compared with controls. These changes were found to be independent of age and sex in stratified analyses.Epithelial changes, scored using the Nelson classification system, were also observed in the AKC cohort. Those patients had a higher median Nelson score than controls (2.0 vs. 1.0), indicating increased squamous metaplasia. “These findings support our hypothesis that AKC causes persistent damage to the ocular surface, contributing to chronic dry eye disease,” the researchers wrote in their paper. They noted that the markedly reduced goblet cell density in post-AKC patients observed in this study may help explain why approximately one-third of patients with epidemic keratoconjunctivitis report dry eye symptoms in the months and years following infection. Moreover, “The reduced tear breakup time in conjunction with decreased goblet cell density suggests that mucin deficiency is a major contributor to tear film instability in these patients.”Serotype 8—the most common found in the six sampled patients—targets conjunctival epithelial cells and is known to provoke intense ocular surface inflammation. According to the researchers, this “may partly explain the significant long-term ocular surface changes observed, as more virulent strains might cause greater tissue damage during the acute phase.”  Limitations of this study include its small sample size, single‑center, cross‑sectional design with limited serotyping and lack of systematic validated symptom scores, which restricts generalizability and prevents linking objective changes to patient‑reported symptoms. The authors conclude their paper by relaying the clinical implications of these findings for eyecare providers: “First, patients recovering from AKC should be counseled about the potential for long-term dry eye symptoms and the need for continued follow-up. Second, early and aggressive anti-inflammatory treatment during the acute phase might potentially reduce the degree of goblet cell loss and subsequent dry eye development, although this hypothesis requires further investigation.” Lastly, they wrote, “long-term management strategies, including artificial tears, antiinflammatory agents and mucin secretagogues, may be necessary in patients with persistent symptoms.”Click here for the journal source. Tas MM, Karabas VL, Yildiz DK, et al. Long-term effects of adenoviral keratoconjunctivitis on conjunctival goblet cell density and tear film parameters: a prospective case-control study. BMC Ophthalmol. April 27, 2026. [Epub ahead of print]. This article was developed by the editorial staff in conjunction with experts in the field. In the process, AI may have been among the editorial tools used to meet the goals of human editors, who approved all content.