Red Eye

Differential Overview

❑ Viral conjunctivitis

❑ Allergic conjunctivitis

❑ Bacterial conjunctivitis

❑ Corneal abrasion

❑ Foreign body

❑ Subconjunctival hemorrhage

❑ Hordeolum

❑ Blepharitis

❑ Photophthalmia

❑ Acute angle closure glaucoma

❑ Chlamydial conjunctivitis

❑ Hypopyon

❑ Dacryocystitis

❑ Herpes simplex keratitis

❑ Iritis

❑ Scleritis

❑ Gonococcal conjunctivitis

❑ Keratoconjunctivitis sicca

❑ Measles

❑ Endophthalmitis

Diagnostic Approach

Decreased vision, pain, photophobia, and a history of trauma are important indicators of serious pathology.

In conjunctivitis, the anterior chamber is clear and the pupil active. There is great overlap in the clinical spectrum of bacterial and viral conjunctivitis. Ciliary flush (dilation of the fine capillaries around the iris border producing a violet-red halo) is a differentiating sign indicating anterior uveal inflammation caused by iritis/uveitis, infectious keratitis, or acute angle closure glaucoma, rather than conjunctivitis.

An active corneal process is indicated by a foreign body sensation with the patient unable to spontaneously open the eye or keep it open. These patients will also have photophobia. The eye is tender in patients with
scleritis, iritis, and glaucoma, but not in conjunctivitis. A pinpoint pupil is seen in cases of corneal abrasion, iritis, or infectious keratitis.

Clinical Findings

Viral conjunctivitis  Watery or mucoid discharge, common cold symptoms, follicular swelling of the lid, and tender preauricular lymph nodes are helpful clues.

Allergic conjunctivitis  Bilateral itching and tearing are associated with seasonal allergic rhinitis and atopic dermatitis. Vernal conjunctivitis (papillary hypertrophy of the underside of the lid) may develop in soft contact lens wearers. Edema without erythema suggests allergy.

Bacterial conjunctivitis  A unilateral mucopurulent discharge, with lids stuck together in the morning by a thick crust, is prominent. The conjunctival erythema is more intense than in viral or allergic conjunctivitis.

Corneal abrasion  Superficial eye irritation, a foreign body sensation without any foreign particle apparent, and excessive tearing are present. A history of trauma or of discomfort persisting after removal of a foreign body is usually elicited. Slit lamp examination or a patch of fluorescence with fluorescein confirms the diagnosis.

Foreign body  There is copious tearing with the sensation of a particle in the eye. The patient will be able to localize the source of the discomfort. If no foreign body is seen, evert the upper lid.

Subconjunctival hemorrhage  A painless, fixed, blood-red quadrantic lesion often occurs with minor trauma. If the patient is taking anticoagulants, the lesion may signal overdose.

Hordeolum  A painful, red, tender nodule appears at the lid margin (external) or under the lid (internal).

Blepharitis  Redness and crusting along the lid margins may be associated with a conjunctivitis and loss of eyelashes. A clue is associated seborrheic dermatitis of the face or scalp.

Photophthalmia  Redness occurs in the setting of excessive sun exposure or tanning booth use.

Acute angle closure glaucoma  The patient is in distress. Symptoms are unilateral headache or eye pain with nausea, colored halos surrounding lights, and cloudy vision. The pupil is 4 to 5 mm in size and poorly reactive to light. The cornea is cloudy as a result of edema. The globe feels hard on palpation. The anterior chamber does not transmit light with tangential illumination (light reaches less than one-third of the way to the nasal iris).

Chlamydial conjunctivitis  Early infection appears as conjunctivitis with small lymphoid follicles on the upper tarsal conjunctiva and a watery-to-mucoid discharge.

Hypopyon  A yellow, ragged corneal ulcer develops and is followed by pus in the anterior chamber, which layers out inferiorly.

Dacryocystitis  Swelling, redness, and tenderness develop at the inner canthus of the eye.

Herpes simplex keratitis  Ciliary flush and photophobia are present. A fine branching dendritic pattern or a broader geographic defect (also seen with zoster) is apparent with fluorescein staining.

Iritis  Deep pain (but without foreign body sensation), photophobia, blurred vision, and ciliary flush indicate iritis. When the ciliary body is involved (iridocyclitis), there are punctate precipitates on the inner surface of the cornea. A blue iris may become greenish as a result of vascular congestion. There may be contraction and irregularity of the pupil. Associated conditions include autoimmune disease (ankylosing spondylitis, Reiter syndrome, Behçet, or Crohn disease sarcoidosis, or sprue) and infections (tuberculosis, syphilis, HSV, or Lyme disease).

Scleritis  The eyes become tender and irritated with small purple corneal nodules on a red background. Inflammation often occurs in a quadrantic distribution. This may be seen in association with connective tissue disease (rheumatoid arthritis, lupus, PAN, Wegener granulomatosis or gout), allergic conditions, or psoriasis.

Gonococcal conjunctivitis  Urethritis is usually present, and the affected eye is ipsilateral to the dominant hand. Swelling, chemosis, pain, and purulent discharge are more prominent than with bacterial conjunctivitis.

Keratoconjunctivitis sicca  It occurs in geriatric patients, in patients who have connective tissue disease, or in those who have had corneal exposure due to Bell palsy. The eyes feel gritty and have a mucoid discharge.

Measles  Conjunctivitis occurs 3 to 4 days before the rash, during the phase characterized by fever, malaise, cough, and Koplik spots.

Endophthalmitis  Infection occurs from hematogenous seeding in immunosuppressed or diabetic patients, producing ocular pain and visual loss.  

Pictures

Book Source Details

• Book Title: Field Guide to Bedside Diagnosis
• Author(s): David S. Smith
• Year of Publication: 2007
• Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: Field Guide to Bedside Diagnosis Authors: David S. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-78178-165-5

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