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Chapter 30 • Red Eye
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359
A hordeolum (stye) produces redness at the base of
eyelashes and is usually unilateral. A chalazion is a
chronic granulomatous inammation of the meibomian
gland, which is in the middle of the eyelid, often on the
conjunctival side, and is usually unilateral. Some conditions can present with either unilateral or bilateral
symptoms. Conjunctivitis often starts in one eye and
then spreads to the other, sparing the limbal area of the
eyes. Subconjunctival hemorrhage is often unilateral
but may involve both eyes. Herpetic infection may be
unilateral or bilateral.
A unilaterally painful, inamed eye with photophobia and often a foreign body sensation and without a history of signicant trauma may indicate acute
glaucoma or keratitis with corneal ulceration.
What does the presence or absence of pain tell me?
Key Questions
l
Do you have pain in your eye?
l
How severe is the pain?
l
Does it feel like there is something in your eye?
Location of Pain
Decide whether the pain is coming from the eye itself
or is referred from surrounding structures. The ophthalmic nerve innervates the lid, conjunctiva, cornea,
and uveal tract. The retina, vitreous, and optic nerve
are less well innervated and seldom a source of pain.
Referred pain can originate from contiguous structures
or from inamed structures innervated by the meningeal branches of the ophthalmic nerve.
Severity of Pain
Bacterial conjunctivitis causes minimal pain; most patients report discomfort from the discharge and matting. There may be an itching or burning pain with allergy, moderate pain with iritis, and severe pain with
corneal abrasion or ulcer. Constant, boring, throbbing
pain, often severe enough to interfere with sleep, can
result from ocular inammation associated with iritis,
acute glaucoma, and scleritis.
Foreign Body Sensation
A foreign body in an eye is a likely cause of pain. Viral
causes of conjunctivitis produce a gritty sensation in
the eye. A scratchy sensation often accompanies conditions that lead to dry eye, such as Sjögren syndrome.
Patients who overwear contact lenses frequently report
pain in the eye, caused by corneal hypoxia, several
hours after removing the contacts.
Do I need to worry about vision changes?
Key Questions
l
Have you noticed any change in or loss of vision?
l
Have you had any blurred vision, double vision,
halos, or oaters?
Vision Loss
Distinguish vision loss from blurry vision caused
by the discharge associated with conjunctivitis. No
decrease in vision is seen with bacterial and allergic
conjunctivitis, beyond that reasonably related to
blurring from the heavy discharge. Vision is mildly
decreased in iritis but markedly decreased with acute
glaucoma, corneal abrasions, or ulcers. Box 30-1
lists symptom patterns of pain and vision loss (also
see Chapter 38).
Sudden diminution in or loss of visual acuity is an
ocular emergency and may indicate corneal or uveal
tract disorders, retinal tears or detachment, acute glaucoma, or orbital cellulitis.
Blurring
True blurring is caused by an ocular problem. When
the cornea, lens, aqueous humor, or vitreous is hazy,
vision blurs and often there is dazzle in bright light.
Some patients describe both refractive errors and double vision as blurred vision. Heavy discharge associated with conjunctivitis can also produce perceived
blurring of vision.
Double Vision
True double vision becomes single vision when one
eye is covered. Sudden onset usually indicates a
Box 30-1
Symptom Patterns of Pain and
Vision Loss
RED EYE (NO PAIN
OR VISION LOSS)
• Conjunctivitis
• Subconjunctival
hemorrhage
• Episcleritis
RED EYE (PAINFUL)
VISION NORMAL VISION IMPAIRED
• Episcleritis
• Keratitis
• Cluster
headache
• Corneal
abrasion
• Corneal ulcer
• Iritis
• Glaucoma
• Orbital
cellulitis
• Scleritis
• Corneal
abrasion
• Keratitis
• Corneal ulcer
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Chapter 30 • Red Eye
neurological problem. Chronic diplopia may be
caused by muscular problems. Monocular diplopia
usually indicates either corneal or lens changes.
Halos
Halos result from prismatic effects. They can be visual
signs of corneal edema caused by an abrupt rise in
corneal or intraocular pressure (acute glaucoma). Less
serious causes are water drops in the cornea or lens
(seen in corneal edema or cataract).
Floaters
Floaters and/or ashing lights occur with vitreoretinal traction. The traction may progress to a retinal tear or detachment. With a tear, patients may report spaghetti-like
strands oating in their vision. With a detachment, patients
will give a history of blurred or blackened vision over
several hours that progresses to complete or partial monocular blindness, often described as a curtain dropping.
What does the presence or characteristic of the
discharge tell me?
Key Questions
l
Do you have any discharge from your eye?
l
Is the discharge from one eye or both eyes?
l
What are the color, consistency, and characteristics
of this discharge?
Photophobia usually indicates ocular inammation or
irritation. Intraocular inammation (iritis or generalized uveitis) causes pain on pupillary changes and thus
leads to the avoidance of bright light. This symptom
may be mild and often is not reported unless the patient
is questioned specically about this symptom. There is
no photophobia with bacterial conjunctivitis. In infants
and young children, photophobia signals a serious condition, such as juvenile arthritis, intraocular tumors,
congenital glaucoma, keratitis, or trauma.
What other things do I need to consider?
Key Questions
l
Do you have excessive tearing?
l
Do your eyes itch?
l
Does the itching occur at different times of the year?
l
Have you had a cough or fever?
Tears
The lacrimal gland, which is situated in the upper lateral
orbit, produces tears that are then carried across the eye to
the puncta on the nasal side of the upper and lower lids.
Obstruction of the passage of tears via the nasolacrimal
duct to the nose causes regurgitation of uid down the
cheek (tearing). Epiphora (excessive production of tears)
is common with viral conjunctivitis, corneal abrasions,
infantile glaucoma, and nasal lacrimal duct stenosis.
Presence and Characteristics of Discharge
A watery, nonpurulent or mucoid discharge usually indicates allergic conjunctivitis. In allergic conjunctivitis, the
discharge is usually bilateral. Discharge that is purulent
or mucopurulent may indicate bacterial conjunctivitis
and often affects both eyes. Copious purulent discharge
may be caused by N. gonorrhoeae infection. Viral con-
junctivitis discharge is watery and may affect only one
eye. Corneal abrasions and ulcers also produce watery/
purulent discharge and are usually unilateral.
In the neonate who is 24 hours old, mucoid or purulent discharge indicates chemical conjunctivitis from
prophylactic instillation of erythromycin ophthalmic
ointment and other medications. Severe, bilateral purulent conjunctivitis 3 to 7 days after birth may indicate
gonococcal infection of the eye. Discharge 5 to 30 days
postpartum may indicate chlamydial conjunctivitis.
What does the presence of photophobia tell me?
Key Question
l
Does light bother you or hurt your eye(s)?
Itching and Tearing
The hallmark of an allergic conjunctivitis is itching
and tearing disproportionate to ndings. Vernal conjunctivitis is seasonal, recurrent, and bilateral. Itching
is intense in the spring and fall months.
Cough and Fever
Bacterial conjunctivitis is not associated with fever;
however otitis-conjunctivitis syndrome begins with a
low-grade to moderate fever, mucopurulent rhinorrhea, and cough. Three or four days after the onset of
fever, the individual wakes up with the eyelashes
crusted together. Ear complaints begin the same day as
eye symptoms. Viral conjunctivitis, seen as slight
crusting along the lid margins, may be seen with upper
respiratory tract infections.
DIAGNOSTIC REASONING: FOCUSED
PHYSICAL EXAMINATION
Before conducting specic assessment procedures, perform an overall assessment of the patient to determine
Chapter 30 • Red Eye
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361
if there is visible injury, asymmetry of eyes and lids, or
other abnormality, such as exophthalmia, to aid in
timely assessment and referral.
Test Visual Acuity
In adults and children older than 3½ years, use a
Snellen, Tumbling E, or Lippman chart. In children,
the referral standard is 20/40 or worse in both eyes or
a two-line difference between eyes. Retesting chil-
dren before referral is suggested because they may
perform better (within normal limits) on the second
examination.
For children younger than 3½ years, use an ophthalmoscope. Darken the room. Stay at arm’s length from
the child and look at the eyes at a distance of 1 m or
greater. When the child looks at the light, look at both
red reexes simultaneously and compare them. They
should be red and equal in coloration. This indicates
that the vision and binocular alignment are good and
that no major pathologic condition of the cornea, lens,
vitreous, or retina is present. If the reexes are not
equal, refer the child to an ophthalmologist.
Test Visual Fields
Testing of visual elds assesses the function of the
peripheral vision and the central retina, optic pathways, and cortex. The visual elds confrontation test
provides a gross assessment of peripheral vision. The
peripheral eld is damaged in glaucoma and by tumors
or vascular lesions involving the visual bers from the
chiasm to the occipital cortex.
Assess extraocular movements by testing the six
cardinal positions of gaze, assessing the corneal light
reex, and performing the cover-uncover test.
Inspect the Lids, Lid Margins, Periorbital Tissues,
and Orbital Tissues
Note redness or swelling of the lids. Look for lid
lesions. Inspect the lid margins. Evert the lids and
note appearance.
Unilateral inammation of the lids and periorbital
tissues without proptosis or limitation of eye movement characterizes periorbital cellulitis. If proptosis
and/or limitation of eye movement are present, orbital
cellulitis is a likely cause.
Erythematous swelling without systemic signs may
be caused by contact dermatitis. All exposed skin
should have the same coloring. A lid that is injected,
swollen, and irritated may be so because of an underlying disease process in the conjunctiva, cornea, sclera,
or intraocular area.
Examine for the presence of focal or diffuse inammation. Blockage of the glands along the lash line may
produce localized or diffuse redness or aking of the
skin as a result of staphylococcal or seborrheic causes.
With viral conjunctivitis, lids appear to have follicular changes (small aggregates of lymphocytes) in the
palpebral conjunctiva. Lids that have large, attened,
cobblestone-like papillary lesions of the palpebral conjunctivae are characteristic of vernal conjunctivitis.
Inammation of the lid margins in all four lids with
associated loss of eyelashes is common in children;
this condition is known as blepharitis. The lash line is
waxy, scaling, red, and irritated, and the eyes have
slightly swollen lid margins.
Eye pain with no external inammation suggests
referred causes, such as sinusitis, carotid artery aneurysm, temporal arteritis, migraine or cluster headache,
or trigeminal neuralgia. Optic neuritis can also cause
eye pain without inammation.
Observe for Entropion and Ectropion
The lacrimal puncta are turned backward slightly to
catch the pool of tears in the inner canthus and to prevent tears spilling over the cheeks. Anatomical changes
of the lid margins can develop into entropion, when the
eyelid margin turns inward. The eyelashes contact
the corneal and conjunctival surfaces, and the patient
reports discomfort. Scarring can occur.
Ectropion occurs when the eyelid margin turns
outward. A pool of stagnant tears results and does not
allow proper mechanical protection of the cornea and
conjunctiva. The exposed tarsal conjunctiva is also
susceptible to repeated trauma.
Evert the Eyelid
If there is a history of trauma, eversion of the eyelid
is necessary to detect a possible foreign body. This
is done by rst having the patient look down. Hold
the upper eyelashes straightforward. Push down on the
upper tarsal border with a cotton-tipped applicator. The
lid everts. Hold the eyelid in this position by moving
ngers to the brow. To undo, hold the lashes and pull
gently forward while asking the patient to look up.
Inspect the Conjunctiva
Note bilateral or unilateral redness and the location
of redness on the conjunctiva. Distinguish between
peripheral or circumcorneal injection (ciliary ush).
Ciliary ush is the deep conjunctival or episcleral
blood vessel injection around the limbus (junction between the cornea and conjunctiva), dilating in response
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Chapter 30 • Red Eye
to corneal disease or injury. It is frequently associated
with keratopathy, uveitis, and episcleritis/scleritis.
Abrasions and ulcers of the cornea cause increased
redness of the globe around the corneal limbus, appearing as a reddish ring surrounding the cornea. Note any
discharge. Look for visible lesions or foreign bodies on
the conjunctiva.
Conjunctival inammation as a result of infection
causes a red eye with peripheral injection that is maximal toward the fornix (the fold between globe and lid).
Peripheral injection involves the bulbar conjunctiva
without edema or exudate, and the cornea is spared.
Look for swelling of the conjunctiva (chemosis).
Fluid can accumulate beneath the loosely attached
bulbar conjunctiva, causing it to balloon away from the
globe. Chemosis occurs most frequently and dramatically with hyperacute bacterial conjunctivitis.
Subconjunctival hemorrhage causes a bright red
splash of blood that is visible on the conjunctiva and
sclera. Without a history of trauma or bleeding diathesis and no presence of retinal hemorrhage, the cause
may be intravascular pressure from coughing, sneezing, or straining.
Systemic autoimmune processes, such as juvenile
rheumatoid arthritis, serum sickness, and StevensJohnson syndrome, may cause conjunctivitis. Conjunctivitis around the limbus of the eye is seen in juvenile
rheumatoid arthritis.
A localized degenerative process of the substantia
propria of the conjunctiva, known as pinguecula, may
invade the supercial cornea. These are yellow, elevated nodules of bropathic material that are usually
adjacent to the cornea on the nasal side.
Look at the palpebral conjunctiva and the fornices
for foreign bodies and pterygia, which are neovascularized structures that can encroach on the cornea and
form a pannus, an abnormal layer of brous tissue or
granulation tissue, which interferes with vision.
Inspect the Sclera
Note the color. The sclera gives the eye its white appearance. Inammation (scleritis) causes a dusky red
color.
foreign bodies. These imperfections of the corneal
surface will produce an abnormal light reex or a
break in the image as the light reects off the cornea.
The blood vessels around the limbus dilate in response
to corneal disease or injury.
When topical application of uorescein to the cornea reveals dendrite ulcers, you should suspect herpes
simplex virus.
Examine the Iris, Pupil, and Lens
Note pupil size and equality. Note transparency of lens.
Test pupillary reaction (direct and consensual). Note
any photophobia.
The anterior chamber should contain only clear
aqueous humor. Trauma may cause blood to accumulate in the chamber; this is known as a hyphema. The
shock wave produced by the sudden compression and
decompression of the cornea is transmitted through
the eye and may result in a tear in the ciliary
body. Disruption of the anterior arterial circle of this
structure produces bleeding that accumulates. The
hyphema appears as a bright red or dark red uid
level between the cornea and iris or as a diffuse
murkiness of the aqueous humor. Pus may also accumulate in this space in association with corneal infection. This is known as hypopyon. All hyphemas are
abnormal and must be referred to an ophthalmologist.
The pupil is the central aperture of the iris. It oats
in the aqueous humor and divides the anterior segment
into anterior and posterior chambers, which communicate throughout the pupillary aperture. It slides freely
on the anterior surface of the lens when dilating and
contracting. Conditions that affect this anatomy cause
pupil abnormalities. Inammation of the iris (iritis)
causes reduction in the reactive capacity of the iris
and inequality of pupils. Acute increased intraocular
pressure causes the space in the anterior chamber to
become very shallow, resulting in a dilated, xed, oval
pupil.
The lens is normally transparent and not visible
on inspection; however any visible clouding of the
lens seen through the pupil is indicative of cataract
formation.
Examine the Cornea
Test the corneal light (red) reex. Note if the cornea is
hazy or has opacities. Look for visible foreign bodies.
The normal cornea is transparent, with blood vessels only at the limbus (the junction between cornea
and conjunctiva). Illumination of the cornea tangentially may show abnormalities, such as abrasions or
Perform Ophthalmoscopy
When looking for the red reex, note any corneal opacity as well as the depth of the opacity. Corneal opacities
move in the opposite direction of the ophthalmoscope,
lens opacities stay still, and vitreous opacities move in
the same direction as the ophthalmoscope. Corneal
clouding (edema) is seen with glaucoma.
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Look for a large and deepened cup if you suspect
glaucoma. Early in the course of the disease, the ophthalmoscopic examination may be normal. Do not use
mydriatic agents if you suspect glaucoma.
Test Extraocular Movements
Test eye movement in all six elds of gaze. Note pain
or restriction. Inammation or underlying periostitis
and impaired venous drainage as a result of reactive
inammation cause restrictive eye movement and proptosis (exophthalmia). Decreased range of motion can
also occur with orbital cellulitis.
Palpate the Lid/Lacrimal Puncta
Note if gentle palpation of each lacrimal sac produces
any material that regurgitates into the eye. Unilateral
swelling over the lacrimal sac on the lid margin at the
side of the nose because of infection or obstruction
of the lacrimal drainage system is common. Infection
of the meibomian glands of the eyelids (hordeolum or
internal stye) and the glands of Zeis or Moll (hordeolum or external stye) produces pain on palpation. Internal styes are generally large and very tender and may
point to the conjunctiva or epidermis portion of the lid.
External styes are small and supercial and point only
to the epidermis side.
Granulomatous inammation of a meibomian gland
nodule that is rm and not tender and has no inammatory signs is a chalazion.
Examine the Tympanic Membranes
Examination of the tympanic membrane is necessary
because of the frequent association with atypical
H. inuenzae acute otitis media (otitis-conjunctivitis
syndrome).
Palpate Preauricular Nodes
The preauricular nodes are usually palpable with a viral
infection of the eyes. Palpable adenopathy is uncommon in acute bacterial conjunctivitis but may occur
in hyperacute infection caused by N. gonorrhoeae or
Neisseria meningitidis.
LABORATORY AND DIAGNOSTIC STUDIES
Fluorescein Staining
This is a test that uses orange dye (uorescein) and a
blue light to detect foreign bodies in the eye. This test
can also detect damage to the cornea. Under a blue
light, a corneal abrasion and foreign body will stain
bright green with uorescein. Dendrite etchings on the
anterior portion of the cornea are seen in herpes infection. Nodules near the limbus with surrounding hyperemia are seen in keratoconjunctivitis. Hypertrophy of
the dorsal conjunctiva with elevated grayish areas near
the limbus is consistent with vernal conjunctivitis.
Culture
Cultures are not usually required in patients with mild
conjunctivitis of suspected viral, bacterial, or allergic
origin. However, bacterial cultures should be obtained in
patients with severe, chronic, or recurrent conjunctivitis.
Moisten a sterile alginate (not cotton) swab with sterile
saline and wipe the lid margin or conjunctival culde-sac. The culture medium is then inoculated directly
with the swab tip. Place on solid medium, writing R for
right eye, L for left eye, and Z for another culture site.
The tip of the applicator may then be broken off and
dropped into the tube of liquid culture medium.
Cultures should be taken before instilling topical
anesthetics because preservatives will reduce the
recovery of some bacteria.
Gram Stain
Obtain a culture of any discharge. Gram-positive cocci
in pairs may indicate Streptococcus pyogenes. Gram-
negative diplococci indicate N. gonorrhoeae. Large
gram-negative diplobacilli indicate Moraxella catarrha-
lis; H. inuenzae stains as gram-negative coccobacilli.
Complete Blood Count
A complete blood count with differential can be done
to establish the presence of a systemic infection. An
increase in white blood cells and bands is seen with
systemic infection.
Blood Cultures
Blood cultures are obtained for any suspected orbital
cellulitis or when there is reason to suspect a clinically
signicant bacteremia. H. inuenzae, S. pneumoniae,
Staphylococcus aureus, Streptococcus pyogenes, or
anaerobes are possible infecting organisms.
Computed Tomography
A computed tomography scan can determine the presence and extent of an abscess and/or localize the site
of infection in the periorbital region as well as in the
sinuses.
Intraocular Pressure
Intraocular pressure can be measured using a variety of
tonometry instruments. It can also be used to screen for
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EVIDENCE-BASED PRACTICE
Is Antibiotic Treatment Needed For Acute Infective
Conjunctivitis?
The purpose of this meta-analysis was to determine the benefit
of antibiotic treatment for acute infective conjunctivitis in primary care and which subgroups benefit most. Three eligible
trials were identified and data were available for analysis in 622
patients. Eighty percent of patients who received antibiotics
and 74% of controls were cured at day 7. There was a significant benefit of antibiotics versus control for cure at 7 days in
all cases combined. Subgroups that showed a significant ben-
Data from Jefferis J, Perera R, Everitt H, et al: Acute infective conjunctivitis in primary care: Who needs antibiotics? An individual patient data
meta-analysis. J Gen Pract 61:e542, 2011.
open-angle glaucoma; however, many patients with
open-angle glaucoma do not have increased intraocular
pressure. Diagnosis is based on a combination of tests
showing characteristic degenerative changes in the
optic disc and defects in visual elds (often loss in
peripheral vision). Intraocular pressure is measured by
a specialist using dilated ophthalmoscopy and a slit
lamp to assess intraocular changes.
DIFFERENTIAL DIAGNOSIS
Lacrimal Sac
Dacryocystitis
Infection of the lacrimal sac occurs secondary to obstruction. In infants, it is a complication of congenital
dacryostenosis. In adults, duct obstruction results
from nasal trauma, deviated septum, hypertrophic
rhinitis, and mucosal polyps. The patient experiences
pain, swelling, and redness around the lacrimal sac
with tearing. Conjunctivitis, blepharitis, and leukocytosis are associated with an acute condition; with a
chronic condition, the only symptom may be slight
swelling of the sac. Pus may regurgitate through the
punctum.
Eyelids
Blepharitis
Blepharitis is the most common inammation of the
eyelids associated with bacterial infection, dry eyes,
or a skin condition called acne rosacea. It usually
involves the lid margins (anterior blepharitis) but can
also affect the meibomian glands in the eyelid (posterior blepharitis) and frequently is associated with conjunctivitis. It is bilateral and not painful and has no
associated photophobia. The lids are inamed, and
efit from antibiotics were patients with purulent discharge and
patients with mild severity of red eye. The type of control used
(placebo drops versus nothing) showed a statistically significant
interaction (P 5 0.03). The authors concluded that acute conjunctivitis seen in primary care is a self-limiting condition, with
most patients getting better regardless of antibiotic therapy.
Patients with purulent discharge or a mild severity of red eye
may obtain a small benefit from antibiotics.
scaling of the lid margins is seen. Loss of eyelashes
occurs late. Visual acuity is unimpaired.
Hordeolum
Hordeolum is caused by infection of the glands of
Zeis or Moll along the lash line. It develops acutely
and manifests as a palpable indurated area along the
lid margin, with a purulent center and surrounding
erythema. It spontaneously drains within 1 to 2
weeks. Patients experience swelling of the eyelid and
localized lid pain.
Chalazion
A chalazion is a granulomatous reaction in the meibomian gland on the tarsal plate of the lid. This is
usually a chronic condition. The lesion is usually
painless and indurated. When symptoms are present,
they include pruritus and redness of the involved eye
and eyelid.
Conjunctiva
Bacterial Conjunctivitis
S. aureus, S. pneumoniae, group A streptococci,
H. inuenzae, and N. gonorrhoeae most commonly
cause bacterial conjunctivitis. The onset is gradual,
begins unilaterally, and often becomes bilateral. The
patient usually reports a scratchy sensation instead of
pain. There is generally no photophobia. Examination
reveals peripheral injection, purulent discharge, and
matted eyelids. Visual acuity is not affected, although
the presence of discharge may produce “blurring” of
vision.
Viral Conjunctivitis
Occurring most commonly in young adults, viral conjunctivitis is caused by such viruses as adenovirus,
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picornavirus, rhinovirus, and herpesvirus. The onset is
gradual and unilateral early in the course and then may
become bilateral. The patient reports a scratchy, rather
than painful, sensation. On examination, peripheral
injection with watery discharge is apparent. Visual
acuity is intact. Lids may have follicular changes
(small aggregates of lymphocytes) in the palpebral
conjunctiva.
Allergic Conjunctivitis
Allergic conjunctivitis is a chronic, seasonal condition
caused by a hypersensitivity reaction to a specic allergen. It is bilateral, itchy, and painless. The conjunctival injection is peripheral. There is ropy, mucoid
discharge. The palpebral conjunctiva has a cobblestone
appearance. Visual acuity is unaffected.
Neisseria gonorrhoeae Conjunctivitis
The N. gonorrhoeae organism can produce a bacterial
conjunctivitis in newborns. It is bilateral, with very
purulent discharge 48 to 72 hours after birth. Although rare in adults, it can occur through direct
transmission via nger contact or via contact of the
eyes with water in a nonchlorinated swimming pool.
The infection has an abrupt onset and is characterized
by copious purulent discharge that reaccumulates
after being wiped away. In addition to redness and
irritation, the patient has marked conjunctival injection, chemosis, lid swelling, and tender preauricular
adenopathy. The condition warrants immediate ophthalmic referral.
Chemical Conjunctivitis
Chemical conjunctivitis occurs with instillation of
chemical prophylaxis in the neonate. A bilateral reaction occurs within the rst 24 hours.
Subconjunctival Hemorrhage
Subconjunctival hemorrhage is usually the result of a
small blood vessel rupture in the conjunctival tissue
and frequently develops after episodes of coughing or
straining. It is painless, although often frightening to
the patient. Visual acuity is not impaired.
Anterior Chamber
Hyphema
Hyphema is caused by blood in the anterior chamber
of the eye, usually produced by trauma to the eye.
The patient has a marked decrease in vision, with red
blood cells present diffusely throughout the anterior
chamber. A settled layer of blood present inferiorly
or a complete lling of the anterior chamber is
possible, obscuring the visual examination of the
posterior chamber. The pupil is irregular and poorly
reactive.
Sclera
Episcleritis
Often a benign inammatory condition of the covering
of the sclera, episcleritis is bilateral, with mild stinging. Peripheral injection is present. There is no discharge, but some lacrimation and photophobia may be
present. Visual acuity is unimpaired.
Scleritis
Inammation of the sclera can result in severe destructive disease. It is usually a unilateral inammatory
condition associated with rheumatoid arthritis, systemic immunologic disease, or other autoimmune disorders. There is pain and ciliary injection. Lacrimation
is present and visual acuity is variable.
Cornea
Keratitis
Bacterial, fungal, and viral organisms can cause infection of the cornea, which leads to corneal ulceration
and potential destruction of the cornea. Moderate to
severe eye pain is present, there is some discharge, and
visual acuity is decreased. Pupils are equal and normal,
but the cornea appears cloudy. Peripheral injection
is present and diffuse. A ciliary ush is also present.
All corneal ulcers require immediate ophthalmology
referral.
Corneal Abrasion
Corneal abrasion may be supercial, lying on top of
the anterior surface of the cornea, or it may be subtarsal and become implanted on the palpebral conjunctiva, causing the cornea to become irritated when the
patient blinks. The patient usually has a history of a
foreign body on the anterior surface of the eye. The
abrasion causes moderate to severe pain with discharge
present. Visual acuity may be normal or decreased,
photophobia is present, and pupil size and reaction are
normal. Fluorescein stain is taken into the ulcer and
can be seen under a Wood lamp.
Herpetic Infection
Caused by the herpes simplex virus, this infection occurs unilaterally or bilaterally. The patient’s presenting
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symptoms are pain, photophobia, and diffuse or ciliary
injection. Discharge is variable, and visual acuity is
markedly decreased. Dendritic lesions are seen on uorescein staining.
Herpes zoster can cause inammation and scarring
of the cornea with conjunctivitis and iritis. In some
cases the retina and optic nerve are involved. Severe or
chronic outbreaks of herpes zoster may cause glaucoma, cataract formation, double vision, and scarring
of the cornea. Patients with suspected ocular herpes
infection (simplex or zoster) should be referred to an
ophthalmologist.
Orbit
Periorbital Cellulitis
The patient’s presenting symptoms include unilateral
lid swelling, redness, fever, and hotness. The conjunctiva is clear, the eye moves freely, and vision is not
impaired.
Orbital Cellulitis
The patient’s symptoms include unilateral lid swelling,
fever, and pain. Examination reveals proptosis, chemosis, and conjunctivitis. There is limitation of eye motion on testing of extraocular movements. The patient
appears ill. This is a life-threatening condition and
requires immediate intervention.
Uveal Tract
Iritis
Characterized by inammation of the iris and ciliary
body, iritis may be idiopathic and develop in response
to coexistent conjunctivitis, keratitis, or eye trauma, or
it may occur with chronic inammatory or infectious
processes. Eye pain is moderate and aching, visual
acuity is decreased, and photophobia is present. There
is minimal eye discharge, the affected pupil is smaller,
and the cornea appears normal. There is central redness
of the eye, with ciliary ush present.
Glaucoma
The two main types of glaucoma are open-angle glaucoma, which is a chronic condition, and angle-closure
glaucoma, which may be a sudden (acute) condition or
a chronic disease. Open-angle glaucoma is the most
common type; its frequency increases greatly with age.
In acute closed-angle glaucoma, the patient’s presenting symptoms include unilateral, deep eye pain and
photophobia. There may be a report of halos around
visualized objects. There is ciliary injection with tears
and decreased visual acuity. The pupil is mid-dilated
and has decreased reactivity to light. The cornea is
cloudy. There is diffuse redness of the eye with an
intraocular pressure of greater than 21 mm Hg. This
condition requires emergency referral.
DIFFERENTIAL DIAGNOSIS OF
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
EYELIDS/LACRIMAL SAC
Dacryocystitis
Blepharitis Bilateral, gradual onset; no
Hordeolum/stye
Chalazion Unilateral, chronic; painless Indurated lesion on tarsal plate of
CONJUNCTIVA
Bacterial conjunctivitis Gradual onset, unilateral
Common Causes of Red Eye
Unilateral, acute onset; pain Swelling and redness around
lacrimal sac; tearing; may
have pus through punctum
Lids inflamed; scaling on visual
pain
Unilateral; pain Swelling of eyelid; indurated
early, bilateral late;
scratchy (no pain);
photophobia
acuity okay; loss of margins,
lashes (late)
lesion with central pus and
surrounding erythema
lid; may have pruritus and redness of involved eye and eyelid
Peripheral injection; purulent
discharge; matted eyelids;
visual acuity okay
CBC, leukocytosis
None
None initially; if repeated,
screen for diabetes
None
None initially; if not
better with treatment,
obtain culture and sensitivities; Gram stain
Chapter 30 • Red Eye
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367
DIFFERENTIAL DIAGNOSIS OF
Common Causes of Red Eye—cont’d
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
Viral conjunctivitis Gradual onset, unilateral
early, bilateral late;
scratchy (no pain)
Allergic conjunctivitis Chronic; seasonal; bilateral;
itchy (no pain)
N. gonorrhoeae
conjunctivitis
Chemical conjunctivitis Bilateral Neonate: within first 24 hours None
Subconjunctival
hemorrhage
ANTERIOR CHAMBER
Hyphema
SCLERA
Episcleritis
Scleritis
Keratitis Unilateral or bilateral;
Corneal abrasion/
foreign body
Herpetic keratitis Unilateral or bilateral; pain;
Bilateral; newborn Purulent discharge 48-72 hr after
Unilateral; painless; coughing
or straining
Unilateral; trauma to eye Red blood cells in anterior
Bilateral; mild stinging Peripheral injection; no dis-
Unilateral; deep, boring pain Ciliary injection, teary; visual
moderate to severe pain;
photophobia
Unilateral; pain; photophobia Diffuse injection; tears; visual
photophobia
Peripheral injection; watery
discharge; visual acuity okay;
follicular changes (small
aggregates of lymphocytes)
in palpebral conjunctiva
Peripheral injection; ropy, mucoid
discharge; cobblestone-like
mucosa; visual acuity okay
birth
Splash of blood in conjunctiva or
sclera; visual acuity okay
chamber; visual acuity
decreased; pupil irregular
and poorly reactive
charge; visual acuity okay
acuity variable; photophobia
Discharge; ciliary flush; cornea
cloudy; visual acuity decreased
acuity variable
Ciliary flush; discharge; visual
acuity markedly decreased
Same as for bacterial
conjunctivitis
Fluorescein staining;
hypertrophy of dorsal
conjunctiva with
elevated gray areas
near limbus with
vernal conjunctivitis
Culture on Thayer-Martin
plate; Gram stain
None
Refer to ophthalmologist
None
Associated with systemic
immunological disease
Refer to ophthalmologist
Fluorescein stain positive
Fluorescein stain shows
dendritic lesions
ORBIT
Periorbital cellulitis Unilateral Swelling of lid; fever, redness;
Orbital cellulitis Unilateral; pain Proptosis; lid swelling; chemosis;
UVEAL TRACT
Iritis
GLAUCOMA
Acute closed-angle
glaucoma
CBC, Complete blood count; CT, computed tomography.
Unilateral; moderate aching
pain; photophobia
Unilateral; deep pain;
photophobia; halos
conjunctiva clear; eye moves
freely; vision not impaired
conjunctivitis; limitation of eye
motion
Tearing; affected pupil smaller;
cornea normal; ciliary flush
Ciliary injection; tears; visual
acuity decreased
CBC, leukocytosis, blood
cultures
CBC, blood cultures; CT
scan; life-threatening
Refer
Tonometry; emergency
referral
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Chapter 30 • Red Eye
References and Readings
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Brower E: Corneal abrasions, Pediatr Rev 33:6, 2012.
Buchanan M, Muen W, Heinz P: Management of periorbital and
orbital cellulitis, Paediatr Child Health 22:72, 2012.
Cronau H, Kankanala RR, Mauger T: Diagnosis and management of
red eye in primary care, Am Fam Physician 81:137, 2010.
Deibel JP, Cowling K: Ocular inammation and infection, Emerg
Med Clin North Am 31:387, 2013.
Leibowitz HM: The red eye, N Engl J Med 343:345, 2000.
Rietveld RP, ter Riet G, Bindels PJ, et al: Predicting bacterial cause
in infectious conjunctivitis: Cohort study on informativeness of
combinations of signs and symptoms, BMJ 329:206, 2004.
Simon JW, Kaw P: Commonly missed diagnoses in the childhood
eye examination, Am Fam Physician 64:623, 2001.
Wagner RS, Aquino M: Pediatric ocular inammation, Immunol
Allergy Clin North Am 28:169, 2008.
Watts P: Preseptal and orbital cellulitis in children: A review, Paediatr
Child Health 22:1, 2011.
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