Red Eye
Red Eye: Excerpt from The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
John E. Sutherland
The most frequent causes of “red eye”—conjunctivitis, trauma, allergies, subconjunctival hemorrhage, and lid problems—are usually benign. Some conditions presenting with a red eye, however, require urgent evaluation and treatment. They include keratitis, episcleritis, scleritis, uveitis, orbital cellulitis, and acute angle-closure glaucoma (1–4).
Approach
The most important step in evaluating red eye is to distinguish which conditions can be treated by a primary care or emergency room physician and which should be referred to an ophthalmologist. Symptoms or findings requiring immediate referral to an ophthalmologist are pain, proptosis, perilimbal injection, tenderness, photophobia, and decreased or blurred vision.
Diagnostic eye instruments needed for a basic evaluation include topical anesthetic drops, Snellen’s chart for distant visual acuity (pediatric picture Snellen for young children), pinhole card for confirming reduced visual acuity, fluorescein paper strips for staining the cornea, a cobalt-blue penlight, an ophthalmoscope, a Schiotz tonometer, 0.9% saline for irrigation or to moisten fluorescein, and a magnifier instrument. A slit lamp, if available, can also be very helpful.
History
A. Overview. It is important to take a careful history, discriminating between mild discomforts such as itching, burning, and scratching versus severe pain or photophobia. A history of trauma or a foreign body is also helpful. Sudden diminution or loss of visual acuity should be considered an ocular emergency.
B. Conjunctivitis. Bacterial conjunctivitis presents with mild discomfort and a purulent discharge that becomes bilateral within 2 days. Viral conjunctivitis is usually bilateral and has a more watery discharge and a burning or gritty sensation, often associated with upper respiratory symptoms. Chlamydia conjunctivitis shows a mucopurulent discharge, whereas gonococcal conjunctivitis is markedly purulent. Both can be associated with symptoms of urethritis or vaginitis, most commonly during the sexually active years and associated with sexual abuse. Allergic conjunctivitis is characterized by bilateral itching and tearing, most frequently seasonal and often associated with other hay fever symptoms.
C. Painful red eye. Contact lenses can cause a corneal ulceration, which is painful and usually resolves with removal. Corneal abrasion, the most common urgent eye complaint seen in the primary care setting, is usually associated with a history of a known foreign body or direct trauma to the eye. Intense pain and tearing is usually associated with these injuries. Keratitis presents with pain, photophobia, reduced vision, and tearing. Episcleritis has only mild discomfort and is usually unilateral without discharge. Scleritis usually presents with a slowly progressive unilateral ocular pain. Primary acute angle-closure glaucoma presents with very acute, severe pain and profound visual loss, often with a history of the patient seeing halos around light as a result of corneal edema. Uveitis usually presents over 1 to 3 days of increasing, usually unilateral, pain with mildly decreased vision initially.
D. Other causes of red eye. Blepharitis, an inflammation of the eye lid margin, can be associated with conjunctival injection and a mucous discharge. Orbital cellulitis presents classically as a complication of sinusitis in febrile ill patients. Subconjunctival hemorrhage can come with coughing or straining but often has no associated history. Blood absorbs in 2 to 3 weeks.
Physical examination
A. Vision. Visual acuity should be checked; it is usually normal in episcleritis, scleritis, blepharitis, and conjunctivitis unless associated keratitis, such as in epidemic keratoconjunctivitis, is present. Decreased vision is demonstrable in keratitis and acute angle-closure glaucoma, but only mildly decreased in uveitis.
B. Inspection. The location of conjunctival redness is important. It is usually peripheral or diffuse in conjunctivitis, whereas in keratitis it is central or diffuse. It is localized in episcleritis or scleritis. In uveitis, it is central with a “ciliary flush.” In glaucoma there is a central perilimbal injection. Tenderness of the globe is usually only present in scleritis or uveitis. Pupillary reaction is normal, except in glaucoma where it is often a fixed mid-dilated pupil and in uveitis where a sluggish, miotic pupil is invariably present. Consensual photophobia is present in uveitis also, because of iris response and movement. The corneal appearance is normal except for scarring and ulceration of Chlamydia trachomatis and the haziness or edema of glaucoma.
C. Special tests. Staining of the cornea with fluoroscein is normal, except with corneal ulceration and abrasion, herpes zoster or simplex keratitis, or a bacterial corneal ulcer. Tonometry will demonstrate increased intraocular pressure in glaucoma. If a slit lamp is available, a narrow chamber angle will be seen with glaucoma. The slit lamp is also helpful to confirm the swelling and to inspect scleritis, not present in episcleritis.
Testing
A. Microbiology studies. Immunofluorescent tests on ocular scrapings for
C. trachomatis and culture for Neisseria gonorrhoeae are sometimes required. Bacterial cultures are generally reserved for infections of the neonate, in persistent conjunctivitis, or with keratitis if a break has occurred in the corneal epithelium (5). Viral cultures are rarely performed. Gram’s stain or Giemsa’s stain of epithelial scrapings may also be helpful. Urethral cultures may be indicated. Immunofluorescent detection of the herpes-specific antigen is also possible.
B. Other laboratory studies. Additional testing is primarily indicated for scleritis or uveitis because of a high frequency of associated rheumatologic disorders. Workup should include a complete blood count, sedimentation rate, C-reactive protein, antinuclear antibodies, rheumatoid factor, and a serologic test for syphilis (VDRL). A spine x-ray study can be helpful in diagnosing ankylosing spondylitis.
Diagnostic assessment
The red eye most commonly results from conjunctivitis, which is benign. Other causes can threaten sight, so a thorough evaluation must be done to prevent permanent visual impairment. Chlamydial conjunctivitis of a chronic nature causes trachoma, which is the leading cause of blindness in humans. The history and physical for both are very important. The history should include trauma, infectious exposure, and the length of symptoms. The examination should be thorough and methodical as stressed in the introductions. An immediate referral to an ophthalmologist should be made with severe deep pain, proptosis, perilimbal injection, tenderness, photophobia, and decreased vision.
References
1. Bertolini J, Pelucio M. The red eye. Emerg Med Clin North Am 1995;13(3):561–579.
2. Davey CC. The red eye. Br J Hosp Med 1996;55(3):89–94.
3. Morrow GL, Abbott RL. Conjunctivitis. Am Fam Physician 1998;57(4):735–746.
4. Hara JH. The red eye: diagnosis and treatment. Am Fam Physician 1996;54(8):
2423–2430.
5. Ruppert SD. Differential diagnosis of pediatric conjunctivitis (red eye). Nurse Practitioner 1996;21(7):12–26.
Book Source Details
- Book Title: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
- Author(s): Robert B. Taylor (editor)
- Year of Publication: 2000
- Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2000 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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