Red Eye
Red Eye: Excerpt from The Diagnostic Approach to Symptoms and Signs in Pediatrics
Most cases of a red eye are due to relativelyminor infectious or allergic causes. Some cases, however, reflectmore serious eye pathology, which must be investigated further.
Principal Causes of Red Eye
- Conjunctivitis
- Chemicalsand irritants
- Infectious conjunctivitis
- Neonatal
- Postneonatal
- Allergic conjunctivitis
- Trauma
- Corneal abrasion
- Foreign body
- Hemorrhage
- Burn
- Blunt or penetrating injury
- Contact lens problems
- Child abuse
- Lid disorders
- Hordeolum
- Blepharitis
- Nasolacrimal duct obstruction includingdacryocystitis
- Allergic reactions
- Preseptal and orbital cellulitis
- Keratitis
- Superficial keratitis
- Nonsuperficial keratitis
- Uveitis
Clinical Features and Diagnosis
Conjunctivitis
Inflammation of the conjunctivae lining eyelids(palpebral conjunctiva) and covering the exposed surface of sclera(bulbar conjunctiva) can be caused by chemicals, irritants, infections,and allergens.
Chemicals and Irritants
Instillationof silver nitrate drops in eyes after birth to prevent infectionwith N. gonorrhoeae may cause chemical conjunctivitis within 24hrs.Conjunctivitis also may occur withtopical use of erythromycin or tetracycline but is much less common.Conjunctivae are mildly inflamed withyellowish discharge for 1 or 2 days.Spray chemicals (household) are anothercause of chemical conjunctivitis.Smog and smoke also may produce conjunctivalredness and inflammation. Infectious Conjunctivitis
Neonatal
C. trachomatisis most common cause of neonatal infectious conjunctivitis.Acquired frominfected maternal genital tract secretions and commonly developsfew days to few weeks after birth.Discharge is mucopurulent or purulentand can be unilateral or bilateral. Inflamed conjunctivae, chemosis,and lid edema usually occur.Positive eye culture confirms diagnosis. N. gonorrhoeae may cause serious eyeinfection.Typicallypresents in first week of life with marked purulent eye discharge,chemosis, and lid edema. This pathogen may cause infection up until2 or 3 wks of age.Presence of gram-negative intracellulardiplococci on Gram stain of eye discharge is presumptive evidenceof this infection.Immediate inpatient treatment is mandatorybecause of serious complications (e.g., corneal ulceration withperforation leading to loss of vision or the eye itself).As with all bacterial infections, positiveculture of discharge is diagnostic. Infections with other bacteria usuallyoccur 2–10 days after birth. Pathogens include S. aureus,S. pneumoniae, H. influenzae, viridans streptococci, and, less often,gram-negative organisms (e.g., E. coli, K. pneumoniae, and P. aeruginosa).All produce inflamed conjunctivae and purulent discharge. Positivebacterial culture is diagnostic.Herpes simplex virus (HSV) is rarecause of isolated conjunctivitis in newborns but may occur at 1–2wks of age.Wheninfection is limited to eyelids or conjunctivae, it is usually notserious. Minute vesicles may be seen in these areas.Positive viral culture of eye lesionis diagnostic. Another method of diagnosis is polymerase chain reaction,which detects HSV DNA.Other manifestations of herpes infectionare discussed in Chap. 36, Jaundice,and Chap. 60, Skin Lesions andRashes. Postneonatal
Between1 and 3 mos of age, most common causes of infectious conjunctivitisare bacterial, viral, and chlamydial infections. After 3 mos ofage, most common causes are bacterial and viral infections.Most common bacterial pathogens causingpostneonatal conjunctivitis are nontypeable H. influenzae, S. pneumoniae,other streptococcal species, and M. catarrhalis. Less common pathogensinclude S. aureus, S. epidermidis, N. meningitidis, H. aegypticus,and gram-negative enteric bacteria. Conjunctivae are red and dischargeis purulent. Positive bacterial culture confirms diagnosis.Viral conjunctivitis may be causedby adenoviruses, enteroviruses, varicella-zoster virus, Epstein-Barrvirus, measles virus, rubella virus, and HSV. Epidemic keratoconjunctivitiscaused by adenovirus may produce marked conjunctival inflammation,tearing, photophobia, pain, lid swelling, and pseudomembranes. Adenovirusalso can cause pharyngoconjunctival fever, which is characterizedby fever, pharyngitis, and conjunctivitis.C. trachomatis (serotypes A–C)causes trachoma, which is major worldwide cause of blindness. Itis seen only sporadically in U.S.Pathogen invades conjunctival and cornealepithelium and produces lymphoid follicles. Their regression leavesareas of thinned cornea known as Herbert pits, which are pathognomonic.Chronic inflammation of conjunctivaecan lead to scarring and visual loss.Inclusion conjunctivitis in adolescentsis sexually transmitted disease due to C. trachomatis (serotypesD–K). It is passed from hand to eye or genitalia to eyewith subsequent development of mucopurulent discharge, eyelid swelling,and preauricular adenopathy.Positive culture is diagnostic. Allergic Conjunctivitis
Seasonalor perennial allergens may cause allergic conjunctivitis (see Chap. 41, Nasal Discharge).Also may be caused by contact allergy with topical eye medication.Most striking feature of allergic conjunctivitisis itching, which is often accompanied by tearing and nasal congestion.Conjunctival blood vessels are dilated bilaterally. Chemosis andmucous discharge are associated findings. Trauma
Corneal Abrasion
Usuallydue to trauma or foreign body.Inflamed conjunctiva, tearing, blepharospasm,and photophobia are usual findings.Abrasion or foreign body may be visualizedwith topical fluorescein. Wood's light exam reveals thegreenish stain, which indicates epithelial defect(s). Foreign bodyor abrasion also may be seen as shadow against red reflex. Foreign Body
Foreignbody (e.g., speck of dirt, other particulate matter, or eyelash)can cause acute eye pain.With frequent rubbing, conjunctivaebecome inflamed. Retained foreign body under upper lid may causevertical lines or scratches without obvious corneal foreign body.History and eye exam confirm diagnosis. Hemorrhage
Subconjunctivalhemorrhage may produce painless red eye. Most common cause is trauma,including birth trauma, but prolonged vomiting or coughing alsomay produce such hemorrhage.Redness is localized and sharply circumscribed.Underlying sclera is not visible and conjunctivae are not inflamed.Size of hemorrhage may increase slightlybefore it resolves due to spread between conjunctiva and sclera.Resolution usually occurs in 2–3 wks. Burn
May be dueto chemicals (acid or alkali), heat, or radiation. Toddlers maywalk into burning cigarettes. Adolescents may burn their eyes oreyelids with curling iron.Severe burns may produce corneal necrosis,scarring, perforation, and sometimes loss of eye.History and eye exam are diagnostic. Blunt or Penetrating Injury
Any significanttrauma to eye may produce conjunctival inflammation, pain, and bleeding.Blunt injury with rupture of bloodvessels of the iris or ciliary body causes hyphema that is usuallyreadily visible. Complications include recurrent bleeding and glaucoma.Penetrating injury may cause the vitreousto ooze from sclera or cornea.Following any traumatic eye injury,visual acuity should be measured.When significant injury has occurredwith possible loss of vision, ophthalmologic consultation is mandatory. Contact Lens Problems
Poorly fitted, overworn, or shared contactlens can cause irritation that may lead to an inflamed eye. Cornealabrasions and ulcers also may occur. Ulcers can lead to loss ofvision and sometimes the eye.
Child Abuse
Instillation of noxious substances into eyesor trauma may produce inflammation and eye injury.
Lid Disorders
Hordeolum
Infections of meibomian glands are calledhordeola. External hordeolum (stye) is acute inflammatory swellingat lid margin, whereas internal hordeolum (chalazion) is locatedwithin body of eyelid. When acute inflammation resolves, nodulemay persist for a few months within eyelid.
Blepharitis
Acute orchronic inflammation of eyelid, which is often associated with conjunctivitis andkeratitis.There is redness and crusting of eyelidmargins, especially upon awakening in morning.Most common causes include infectiousagents (particularly staphylococci) and allergens. Nasolacrimal Duct Obstruction Including Dacryocystitis
Congenitalnasolacrimal duct obstruction may produce persistent tearing andmucopurulent discharge that collects in medial aspect of 1 or botheyes. Conjunctival inflammation occurs occasionally. Expressionof discharge by compression of lacrimal sac is diagnostic.Infection of lacrimal sac (dacryocystitis)produces an area of inflammation and tenderness just below medialcanthus. Pressure over this area may cause extrusion of pus fromlacrimal puncta.Most common pathogens are S. pneumoniae,S. aureus, S. epidermidis, and H. influenzae. Less common are gram-negativeenteric bacteria and anaerobes. Bacterial culture reveals specificpathogen. Allergic Reactions
Often bee sting or insect bite around eyeproduces swollen, inflamed lid with mild pain. Pruritus is oftenprominent finding. Sometimes a central punctum is seen, which providesa clue to diagnosis.
Preseptal and Orbital Cellulitis
Preseptalcellulitis is infection of periorbital tissues anterior to orbitalseptum that usually arises from conjunctivitis, trauma, or insectbites, whereas orbital cellulitis usually results from contiguoussinusitis.Same pathogens that cause preseptalcellulitis also cause orbital cellulitis. Most common pathogensare S. aureus, S. pneumoniae, and group A Streptococcus. Since adventof H. influenzae type b vaccine, infection with this pathogen ismuch less common.Painful, swollen, inflamed eye andfever usually occur with both infections; however, presence of proptosis,chemosis, impaired extraocular movements, decreased vision, or opticnerve dysfunction (pupillary abnormalities, loss of color vision,visual field defects, papilledema) help distinguish orbital frompreseptal cellulitis.In some cases, blood culture may revealpathogen.CT should be performed with suspectedorbital cellulitis to detect orbital abscess, which may requiresurgical drainage in addition to intravenous antibiotics. Keratitis
Superficial Keratitis
May be causedby dry eyes, contact lenses, blepharitis, and viral conjunctivitis.Characteristic findings include superficialcorneal epithelial defects, inflammation of adjacent conjunctivaand superficial stroma, and conjunctival hyperemia. Punctate lesionsthat stain with fluorescein dye may produce hazy cornea with eyediscomfort and decreased vision. Nonsuperficial Keratitis
Most commoncauses are viral and bacterial infections. Usual viral pathogenin childhood is HSV, in which branching epithelial dendrites maybe seen with topical fluorescein. Less common viral pathogens includeadenoviruses (epidemic keratoconjunctivitis), enteroviruses, measlesvirus, mumps virus, and rubella virus.Severe eye pain, excessive tearing,photophobia, and decreased vision are usually found. When varicella-zostervirus involves ophthalmic division of cranial nerve V, conjunctivitisand keratitis usually occur during acute phase of skin eruption.Bacterial infection of cornea requiresprompt attention. Eye is acutely inflamed with grayish infiltrateand surface ulceration.Contact lens–associated ulcersare serious infections that may be seen in adolescents. Pathogensinclude S. aureus, S. epidermidis, S. pneumoniae, H. influenzae,M. catarrhalis, and P. aeruginosa. Appropriate cultures reveal specificpathogen. Uveitis
Uveal tractconsists of iris, ciliary body, and choroid. Most useful classificationof uveitis is by site of involvement.Anterior uveitis refers to inflammation ofiris and ciliary body. Cells and flare are seen in anterior chamberof eye.Posterior uveitis refers to inflammationof choroid, and inflammatory cells are seen in the vitreous. Most common cause of anterior uveitisis idiopathic. Other causes include juvenile rheumatoid arthritis,herpes simplex, herpes zoster, sarcoidosis, and syphilis. Characteristicmanifestations include eye pain, photophobia, tearing, blurred vision,hyperemia in area surrounding cornea (limbal flush), and poorlyreactive or mid/fixed pupil.Toxoplasmosis and toxocariasis aremost common causes of posterior uveitis. Large chorioretinal scarmay be seen with toxoplasmosis. Diagnosis is confirmed by serologictests that demonstrate presence of Toxoplasma-specific antibodies.Toxocara infection may present with leukocoria, strabismus, or decreasedvision. Diagnosis is based on finding characteristic eye lesionin retina and positive ELISA. Other causes of posterior uveitisinclude histoplasmosis and tuberculosis. Diagnostic Approach
Historyand physical exam can distinguish many causes of red eye, includingconjunctivitis, trauma, lid disorders, nasolacrimal duct obstruction,allergic reaction, preseptal cellulitis, orbital cellulitis, keratitis,and uveitis.Age of child and presence of purulenteye discharge help narrow causes of conjunctivitis.If purulentdischarge occurs in neonates up to 3 wks of age, Gram stain andappropriate bacterial and chlamydial cultures should be performed.In this age group, it is especially important to determine whetherinfection is caused by N. gonorrhoeae.When infant presents with mucopurulentor purulent eye discharge between 3 wks and 3 mos of age, chlamydialeye culture should be performed.Because chlamydial infection is unusualafter 3 mos of age, infants with eye discharge may be presumed tohave bacterial infection, and broad-spectrum antimicrobial eye dropsmay be given as therapeutic trial without culture. If infectiondoes not resolve or is recurrent, bacterial culture should be performed.Presence of eosinophils on Wright stain from conjunctival scrapingsuggests allergic conjunctivitis. Fluorescein staining should be performedwith suspected corneal abrasion. Slit-lamp exam should be performedwith suspected keratitis or uveitis. Visual acuity should alwaysbe measured in anyone with significant eye pathology (e.g., trauma,keratitis, or uveitis).Ophthalmologic consultation is necessarywhenever significant eye pathology or injury occurs or is suspectedwith or without loss of vision. References
- Leibowitz HM. The red eye. N Engl J Med2000;343:345–351.
- Levin AV. Eye emergencies: acute management in thepediatric ambulatory setting. Pediatr Emerg Care 1991;7:367–377.
- Levin AV. Eye-Red. In: Fleisher GR, Ludwig S, eds.Textbook of pediatric emergency medicine, 4th ed. Philadelphia:Lippincott Williams & Wilkins, 2000:231–235.
- Long SS, et al., eds. Principles and practice of pediatricinfectious diseases. New York: Churchill Livingstone, 1997.
- Matoba A. Ocular viral infections. Pediatr Infect Dis1984;3:358–368.
- O'Hara MA. Ophthalmia neonatorum. PediatrClin North Am 1993;40:715–725.
- Pickering LK, ed. 2000 Red book: report of the Committeeon Infectious Diseases, 25th ed. Elk Grove Village, IL: AmericanAcademy of Pediatrics, 2000.
- Simon JW, Calhoun JH. A child's eyes: a guideto pediatric primary care. Gainesville, FL: Triad Publishing, 1998.
- Wright KW. Pediatric ophthalmology for pediatricians.Baltimore: Williams & Wilkins, 1999.
Book Source Details
- Book Title: The Diagnostic Approach to Symptoms and Signs in Pediatrics
- Author(s): Paul S. Bellet
- Year of Publication: 2006
- Copyright Details: The Diagnostic Approach to Symptoms and Signs in Pediatrics, Copyright © 2006 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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